Showing papers by "Charles W. Hoge published in 2015"

Psychotherapy for Military-Related PTSD: A Review of Randomized Clinical Trials.

Abstract: Importance Posttraumatic stress disorder (PTSD) is a disabling psychiatric disorder common among military personnel and veterans. First-line psychotherapies most often recommended for PTSD consist mainly of “trauma-focused” psychotherapies that involve focusing on details of the trauma or associated cognitive and emotional effects. Objective To examine the effectiveness of psychotherapies for PTSD in military and veteran populations. Evidence Review PubMed, PsycINFO, and PILOTS were searched for randomized clinical trials (RCTs) of individual and group psychotherapies for PTSD in military personnel and veterans, published from January 1980 to March 1, 2015. We also searched reference lists of articles, selected reviews, and meta-analyses. Of 891 publications initially identified, 36 were included. Findings Two trauma-focused therapies, cognitive processing therapy (CPT) and prolonged exposure, have been the most frequently studied psychotherapies for military-related PTSD. Five RCTs of CPT (that included 481 patients) and 4 RCTs of prolonged exposure (that included 402 patients) met inclusion criteria. Focusing on intent-to-treat outcomes, within-group posttreatment effect sizes for CPT and prolonged exposure were large (Cohen d range, 0.78-1.10). CPT and prolonged exposure also outperformed waitlist and treatment-as-usual control conditions. Forty-nine percent to 70% of participants receiving CPT and prolonged exposure attained clinically meaningful symptom improvement (defined as a 10- to 12-point decrease in interviewer-assessed or self-reported symptoms). However, mean posttreatment scores for CPT and prolonged exposure remained at or above clinical criteria for PTSD, and approximately two-thirds of patients receiving CPT or prolonged exposure retained their PTSD diagnosis after treatment (range, 60%-72%). CPT and prolonged exposure were marginally superior compared with non–trauma-focused psychotherapy comparison conditions. Conclusions and Relevance In military and veteran populations, trials of the first-line trauma-focused interventions CPT and prolonged exposure have shown clinically meaningful improvements for many patients with PTSD. However, nonresponse rates have been high, many patients continue to have symptoms, and trauma-focused interventions show marginally superior results compared with active control conditions. There is a need for improvement in existing PTSD treatments and for development and testing of novel evidence-based treatments, both trauma-focused and non–trauma-focused.

The ritual of hyperbaric oxygen and lessons for the treatment of persistent postconcussion symptoms in military personnel.

Abstract: During the past decade, unprecedented clinical and research resources have been directed toward addressing 2 conditions considered “silent” and “signature injuries” of the Iraq and Afghanistan wars, namely, posttraumatic stress disorder (PTSD) and concussion (m i l d t r auma t i c b r a i n injury). This investment is increasingly paying dividends in knowledge and interventions that are changing the standards of clinical practice. Notable examples include emerging trauma-focused psychotherapies and the antihypertensive prazosin hydrochloride for PTSD.1 However, along with these successes have also come seemingly promising interventions that in due course are shown to lack efficacy when tested in clinical trials such as the multicenter trial of risperidone augmentation for PTSD.1 This issue of JAMA Internal Medicine publishes results of a clinical trial that illuminates the challenges in designing effective interventions for silentwar-related injuries.2While the sample size was modest, this unique well-designed 3-arm double-blindstudyofhyperbaricoxygen (HBO) treatmentprovides compelling results with broad implications. Seventytwo service members who experienced concussions (including at least 1 concussion during war-zone deployment) and werehavingpersistentpostconcussionsymptoms (≥4months’ duration) were randomized to receive 40 HBO treatments (100%oxygenat1.5atmospheresabsolute for60minutes5days per week), a sham procedure (40 equivalent sessions involving slightly pressurized room air, sufficient to induce a feeling of inner ear pressure), or routine postconcussion care. Results showed that both the HBO and sham procedures were associated with significant improvements in postconcussion symptoms and secondary outcomes, including PTSD (which most participants had), depression, sleep quality, satisfactionwith life, andphysical, cognitive, andmental health functioning. However, there were no significant differences betweenHBOand the shamprocedure, and change scores for all secondary outcomes favored sham. Although this trialwas technically apilot investigationdesigned to produce data necessary for a pivotal study and will not likely end debate on this topic (given tenacious advocacy byHBOproponents3), these results are consistentwith 2other sham-controlledclinical trialsamongservicemembersandveterans involving a range ofHBOdoses.2 Given the outstanding methods, consistency in results, and lack of dose response across thesestudies, it is increasinglyhard toargue thataphase 3 trial of HBO for the treatment of postconcussion symptoms (or PTSD) is warranted. This conclusion is disappointing for servicemembers and veterans experiencing war-related symptoms but offers important lessons and anopportunity to engage in reneweddialogue concerning the priorities for future interventions. This dialogue requires us to begin by acknowledging that no new treatments for persistent blast or impact–related postconcussion symptomshavebeen identified, despite the extensive investment to date. The evidence remains weak and inconsistent for both pharmacological (eg, stimulant or cholinergic augmentation) and nonpharmacological (eg, cognitive rehabilitation) interventions.4,5 The only evidence-based treatment shown to be effective in attenuating persistent symptoms after concussion, based on clinical trials in civilian populations, is cognitive education to promote expectations of recovery.4,5However,despite thisbeingemphasizedasacornerstone of treatment guidelines,4 research is lacking to replicate or refine educational interventions in military or veteranpopulations.Furthermore, concernshavebeenraised that current screening approaches, combined with a specialtydriven structure of concussion care in the Veterans Health Administration and Department of Defense, may inadvertently promote negative, rather than positive, recovery expectations.5,6 ThisHBOclinical trial highlights a principal barrier to successful concussion-related interventions,namely, the fact that the condition of persistent postconcussion symptoms is such an elusive target for treatment that effective interventions will likely not be identified until this condition is reconceptualized.4-6 Postconcussion symptoms typically involve headaches, fatigue, cognitive and memory problems, sleep disturbance, irritability, dizziness and balance problems, andothers.However, these symptoms areubiquitous in general medical practice, they are associated with numerous different conditions, and no validated clinical case definition exists, oneofmany reasonswhy thisHBOpilot studywas conducted. Multiple studies amongmilitary and veteran populationshave shown thatpersistent cognitive andphysical symptoms attributed to concussion in the postdeployment period are much more likely to be associated with conditions other than concussion, including PTSD, depression, grief, nonconcussive injuries, or associated comorbidities (eg, chronic pain andsleepdysfunction).5-7Underlyingneuroendocrineandautonomic nervous system dysregulation likely mediates these multisymptom trauma-spectrum responses.1,5 Two-thirdsof servicemembers in thisHBOstudyhadadiagnosis ofPTSD (basedonstructuredclinical interviews), 44% were taking daily pain medication, and the mean depression scores were in the depressed range (with more than half takRelated article page 43 Hyperbaric Oxygen in Postconcussion Service Members Original Investigation Research

Measuring the Long-term Impact of War-Zone Military Service Across Generations and Changing Posttraumatic Stress Disorder Definitions.

Abstract: The neuropsychiatric impact of World War I, World War II, and the Korean War was described in terms such as shell shock, neurasthenia, psychoneurosis, and battle fatigue. For the Vietnam generation, readjustment problems were initially attributed to alcohol or substance use, followed by growing acceptance of persistent stress responses or post-Vietnam syndrome. In 1979, the US Congress directed the Veterans Administration to establish Readjustment Counseling Centers (Vet Centers) to provide community-based counseling options for combat veterans. By 1980, consensus was reached on the first definition for posttraumatic stress disorder (PTSD). However, scientific and political debate raged as to whether PTSD was a legitimate disorder and Vietnam service a legitimate cause; members of Congress called for closure of Vet Centers. The Congressionally funded National Vietnam Veterans Readjustment Study (NVVRS) emerged from this landscape. Completed between 1984 and 1988, the NVVRS provided the first representative study using newly available structured diagnostic interviews based on DSM-III-R. The 17-symptom PTSD definition established by the DSM-III-R would remain largely unchanged for the next 25 years. The NVVRS researchers concluded that 30% of Vietnam veteransmet PTSD criteria during their lifetime, and 15% still had PTSD.1 Although the NVVRS did not end debate, it paved the way for countless future studies that characterized PTSD epidemiology and neurobiology, the debilitating comorbidities associatedwith this condition, and evidence-based treatment strategies, many of which were first tested in Vietnam veterans. A 2006 NVVRS reanalysis by Dohrenwend et al2 addressed lingering concerns that original estimates were inflated by inaccurate self-reports of war-zone stressors or lack of a criterion for functional impairment (added in 1994 to the PTSDdefinition inDSM-IV).Drawingonoriginal diagnostic interviews and verifiable military records, lifetime and current war-zone–attributedPTSDprevalenceswererevisedto19%and 9%, respectively, with documentation of a strong combat exposuredose-response.2 Althoughmore conservative, these estimates confirmed the considerable burden of PTSD. This issue of JAMA Psychiatry brings another remarkable chapter tounderstanding the impactof theVietnamWar—a report from the National Vietnam Veterans Longitudinal Study (NVVLS).3Thismethodologically superb follow-upof theoriginal NVVRS cohort offers a unique window into the psychiatric health of these veterans 40 years after the war’s end. No other studyhas achieved this quality of longitudinal information, and the sobering findings tell us asmuch about theVietnam generation as about the lifelong impact of combat service in general, relevant to all generations. Like the NVVRS, theNVVLS comes at a historicwatershed after 14 years ofwar in IraqandAfghanistanandshortly afterpublicationofDSM-5, the first substantial revision of the PTSD definition since DSM-III-R (including marked wording changes, restructuring, and additional symptoms). Themost importantNVVLS finding is confirmationof the chronic anddebilitating courseofwar-relatedPTSD.Using the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5), Marmar and colleagues3 found lifetime and currentwar-zone PTSDprevalencesof 17.0%and4.5%, respectively, inmaleveterans (15.2% and 6.1%, respectively, in female veterans). Although lower than the estimates by Dohrenwend et al,2 these figures likely do not reflect the full disease burden owing to potential psychometric concerns with the CAPS-5 (discussed below) and because nearly a quarter of the cohort died in the interim between the NVVRS and NVVLS (PTSD is strongly associated with mortality). The full disease burden may be best represented by the definition that incorporates subthreshold PTSD, which the NVVLS researchers brilliantly measured using a stringent definition consistent with the need for treatment and which effectively encompasses previous (DSM-IV) criteria.3 This measurement raised the lifetime and current CAPS-5 estimates to 26.2% and 10.8%, respectively, in male theater veterans (25.7% and 8.7%, respectively, in female theater veterans). For additional confirmation, the NVVLS used an appended version of the PTSD Checklist for DSM-IV (PCL), scored using DSM-5 criteria plus impairment, and found nearly identical current prevalences (12.2% for male and 8.5% for female theater veterans). Because of ease of administration and diagnostic validity, the DSM-IV version of the PCL has become the backbone of epidemiologic research throughout the Iraq and Afghanistan wars.4,5 The NVVLS decision to rely on the DSM-IV version (appendedwith newDSM-5 symptoms) allows for direct comparisons across generations. The NVVLS documented a 10.3% prevalence using the original 17-item, 50-point cutoff, which is considered optimal for population research.5 This prevalencecompareswithaweightedmeanof6%acrosspopuRelated article page 875 Opinion

Hyperbaric Oxygen Treatment for Persistent Postconcussion Symptoms—Reply

Abstract: older homeless adults is a long-term issue in need of longterm solutions. Approaches to managing functional impairment among older homeless adults might include referral to medical respite for individuals with short-term impairments and, for persons with longer-term impairments, promoting access to permanent supportive housing with appropriately tailored environmental adaptations and personal care services. Because few factors measured in standard practice predict whose impairments will persist vs improve, monitoring older homeless individuals over time will be necessary to understand their functional trajectory and identify appropriate services.

Posttraumatic Stress Disorder Screening in the US Military and VA Populations

Abstract: For 14 years, the US military has sent more than 2 million service members to Iraq and Afghanistan. Based on lessons learned from the first Persian Gulf War, US military personnel now undergo post-deployment medical and mental health screening for posttraumatic stress disorder (PTSD). Over the last 20 years, multiple studies have aided in refining this process to include adapting the questionnaires, including evidence-based screening tools, modifying the scheduled screening times, and identifying cutoff scores. However, this current process and the screening tools have their limitations, dominantly based on the requirement for self-report of symptoms. Future developments will focus on continued screening refinement, the application of screening tools in treatment monitoring, and developing PTSD measures which are not dependent on self-report measures.

Posttraumatic Stress Disorder: Developments in Assessment and Treatment

Abstract: Diagnostic discordance between posttraumatic stress disorder definitions, treatment dropout rates, comorbidities, and varying policy approaches leave VA and DoD clinicians with unique concerns in providing effective treatment for many postwar health problems.

Medication for ADHD and accidental injury

Abstract: www.lancet.com/psychiatry Vol 2 August 2015 669 Soren Dalsgaard and colleagues present data in The Lancet Psychiatry that indicate higher rates of accidental injury in children with attention defi cit hyperactivity disorder (ADHD) than in controls without ADHD and document the amelioration of this risk by medication treatment (primarily with the psychostimulant, methylphenidate). This research is extremely important because accidental injury has long been considered a serious functional consequence of ADHD, which persists in various forms across the lifespan, though it has never been examined as extensively as it is here. Moreover, studies examining the eff ects of treatment in mitigating this outcome in children have produced inconclusive fi ndings. By documenting the increased risk for accidental injury in children with ADHD in a very large birth cohort obtained and followed up through national health registers, the investigators provide compelling evidence that ADHD is a disorder that can be associated with potentially serious medical outcomes. Further, their fi nding that medication treatment lowers risk for accidental injury to levels noted in controls without ADHD provides a strong rationale for considering such treatment in children deemed to be at high risk. These data add to the potential benefi ts of medication treatment for ADHD in academic and behavioural domains of function, which are more commonly discussed in relation to ADHD in children. The study includes data from a prodigious number of individuals identifi ed through a series of personal and health registers, which were linked to provide comprehensive information regarding demographic characteristics, medical history, and treatment. All school-age children in Denmark born between 1990 and 1999 were included in the registers; the population with ADHD was restricted to those diagnosed between the ages of 5 and 10 years. In all, 710 120 children were examined in this report, including 4557 diagnosed with ADHD before age 10 years, 1457 (32%) of whom were treated with medication. The prevalence of accidental injury varied between 11% and 19%, depending on age, ADHD status, and treatment history. The prevalence of accidental injury at age 5 years was nearly twice as high in children with ADHD (19·3%) compared with those whether in-home video technology provides any greater eff ectiveness and clinical use than does simpler, more available (and potentially more cost eff ective) traditional telephone interfaces. However, if telephone therapy is deemed to be on par with videobased therapy, then health-care policies would have to further adapt; for many health settings, care delivered via telephone is not included in the defi nition of telemedicine and is handled under diff erent regulatory and insurance reimbursement guidelines. The Egede and colleagues study is a vanguard demonstration of safety and effi cacy of in-home telemental health. Although the study underscores the many challenges in this discipline, it also paves the way for future research and refi nements in the many ways in which evidence-based mental health treatments can be eff ectively delivered.