Treatment for Posttraumatic Stress Disorder in Military and Veteran Populations Final Assessment (2014) / Chapter Skim
Currently Skimming:
9 Research on PTSD
9 Research on PTSD
Pages 175-214
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From page 175... ...
Other attributes of a high-performing system are fostering new research on innovative approaches for PTSD management; expediting translation of new research findings to people who have PTSD and to their health care settings; striving to anticipate future research directions to address knowledge gaps; and exploring new ways to reduce stigma and promote access to and dissemination of evidence-based treatment. In its phase 1 report, the committee presented an overview of the current knowledge base on PTSD prevention, assessment, diagnosis, and treatment, including comorbidities and rehabilitation.
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From page 176... ...
National Research Action Plan for Improving Access to Mental Health Services for Veterans, Service Members, and Military Families On August 31, 2012, President Obama issued Executive Order 13625, which directs DoD, VA, the Department of Health and Human Services, the Department of Education, and the Department of Homeland Security to "take steps to meet the current and future demand for mental health and substance abuse treatment services for veterans, service members, and their families." In response, those departments developed a national research
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From page 177... ...
As part of the National Research Action Plan, DoD, VA, and NIH have identified several PTSD research goals (Castro et al., 2013)
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From page 178... ...
. To identify PTSD research projects, the committee looked at several publicly available research databases.
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From page 179... ...
The committee then provides a broad description of why each research category in this chapter is important for understanding and treating for PTSD in DoD and VA. It also provides a general summary of the ongoing research from the NIH RePORT database, the VA Health Services Research and Development database, the ClinicalTrials.gov database, and the information provided by DoD.
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From page 180... ...
Treatment 78 101 31 26 104 Identify and understand effective pharmacotherapies, somatic treatments, psychotherapies, and treatments that combine psychotherapies and pharmacotherapies; complementary and
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From page 181... ...
Long-Term Outcomes Associated with PTSD 9 10 4 5 0 Understand long-term health outcomes and the development of comorbidities such as cardiovascular disease in people diagnosed with PTSD. Intimate Partner Violence 0 4 2 2 1 Understand risks for intimate partner violence or interpersonal violence in people diagnosed with PTSD.
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From page 182... ...
Thus, the table should be considered as a general representation of currently or recently funded PTSD research. Physiology, Neurobiology, and Behavior As detailed extensively in the committee's phase 1 report (IOM, 2012)
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From page 183... ...
. Some people diagnosed with PTSD overgeneralize their fears and exhibit substantial avoidance symptoms, so animal research on passive and active avoidance is helpful.
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From page 184... ...
. Although exploring means to enhance those techniques is useful, the committee identified relatively few ongoing studies of the mechanisms of fear resilience or fear-control techniques beyond extinction or cognitive regulation.
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From page 185... ...
However, because brain tissue from living people cannot be assayed, brain-focused studies to identify differentially expressed genes are generally conducted in animal models. The committee identified human studies that are investigating whether epigenetic and expression differences observed in peripheral tissues are associated with PTSD.
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From page 186... ...
Establishing best practices for recruiting people into studies immediately after trauma and improving basic research techniques for early behavioral or neural interventions could result in new methods to prevent PTSD symptoms. The committee identified some research projects that explore methods for increasing resilience and reducing adverse effects after exposure, such as investigations of early interventions (for example, intervening in the emergency room or as soon as the event occurs)
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From page 187... ...
Equally important but less studied is the question of whether psychological, social, or environmental variables may increase or decrease the likelihood of PTSD. Prevention research is examining risk and protective factors for the development of PTSD symptoms.
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From page 188... ...
, and the characterization of speech patterns in people who have PTSD compared with those who do not have PTSD. The committee identified a research gap in the area of diagnosis -- one potentially useful approach that is not being studied is the use of advanced statistical procedures, such as random forest classification and functional magnetic resonance imaging, to develop a neurobiologically based approach to diagnosis PTSD and to evaluate it against standard (that is, clinically based)
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From page 189... ...
The combination of various clinical approaches to address the complexity of PTSD issues (for example, concurrent treatment for PTSD and comorbidities or treatments that combine psychotherapies, pharmacotherapies, and complementary and alternative therapies) needs to be studied further in military and veteran populations.
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From page 190... ...
Examples are controlled studies to assess the value of adding components to evidence-based treatments. Various new treatments are being tested in randomized controlled trials, such as acceptance and commitment therapy, adaptive disclosure therapy, behavioral activation therapy, interpersonal psychotherapy, trauma-management therapy, and relatively new and untested cognitive training approaches to enhance modulation of emotion.
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From page 191... ...
(2014b) found no reduction in overall PTSD symptoms in OEF and OIF veterans who were given a combination of DCS and virtual-reality exposure therapy but did find a significant decrease in cortisol and psychophysiological startle response in general.
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(2012) found that this couple therapy model reduced PTSD symptoms and enhanced relationship satisfaction.
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From page 193... ...
. The committee identified a research gap with regard to the use of mobile communication devices and their applications.
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From page 194... ...
The committee identified current research that is aimed at assessing the potentially different needs of men and women who have PTSD and alcohol or substance use disorders, or who have experienced military sexual trauma. Some studies are focused on making PTSD treatment more accessible to members of minority groups, on adapting manualized PE for Hispanic patients, and on developing culturally relevant treatment for American Indians.
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From page 195... ...
Other treatment approaches included physiological response-tailored exposure therapy, imagery rehearsal with or without CBT, and group CBT. The diversity of the study targets and clinical approaches suggests that DoD and VA recognize the importance and challenge of treating for PTSD and comorbid conditions.
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From page 196... ...
, but there are still few empirically supported interventions. The committee identified promising innovative studies that focused on racial and ethnic factors associated with PTSD and intimate partner violence; the intersections of TBI, intimate partner violence, and PTSD; and the effects of PTSD and intimate partner violence on children in military and veteran families.
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From page 197... ...
The committee recognizes the importance of conducting basic research that translates from animal models to healthy humans and to clinical and trauma-exposed populations. Basic research on physiological and biologi TABLE 9-3 The Continuum of Translation Research Translational Phase Notation Types of Research 1 Discovery to candidate health Phases I and II clinical trials; applications observational studies 2 Health application to evidence- Phase III clinical trials; observational based practice guidelines studies; evidence synthesis and guidelines development 3 Practice guidelines to health Dissemination research; practice implementation research; diffusion research Phase IV clinical trials 4 Practice to population health Outcomes research (includes many impact disciplines)
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From page 198... ...
Unless a broad range of researchers can access relevant populations to conduct studies on how trauma exposure and PTSD influence the brain or behavior, the applicability of basic research to treatments for PTSD will continue to be limited. New research models -- for example, pragmatic trials, practical clinical trials, and hybrid effectiveness–implementation trials -- may be useful for addressing the common translational gap between randomized controlled trials and clinical practice (Curran et al., 2012; Tunis et al., 2003)
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From page 199... ...
. Technology-based advances in mental health care include telehealth, informational and self-help websites, mobile smartphone applications, virtual reality and online virtual worlds, intelligent health care agents, and interactive clinical training systems.
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From page 200... ...
Often termed cognitive remediation therapy, this approach is a standardized intervention that involves performing cognitive exercises to improve attention, processing speed, executive function, and memory through practice by using various software packages. The committee identified six projects that evaluate cognitive remediation therapy programs as an alternative intervention for PTSD in combat veterans.
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From page 201... ...
Thus, virtual-reality exposure therapy offers a way to circumvent a natural avoidance tendency by directly delivering multisensory and contextrelevant cues that aid in the confrontation and processing of traumatic memories. Favorable outcomes have been reported in several PTSD populations treated with virtual reality therapy (Difede and Hoffman, 2002; Difede
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From page 202... ...
. In addition to providing more and better options for PTSD treatment, virtual-reality exposure therapy may be useful for overcoming barriers to care by improving treatment appeal, acceptability, and adherence.
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From page 203... ...
Online Clinical Training and Virtual Patients Although human "actor" patients are the gold standard for training in medical schools, such live standardized patients are rarely available for clinical training with psychologists, social workers, and other mental health care providers. In most training, direct patient-interaction skills are acquired via role-playing with supervising clinicians, fellow graduate students, and closely supervised "on-the-job" training.
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From page 204... ...
However, if found to be effective, virtual patient technology could have a considerable impact by supplementing existing in-person training approaches. SUMMARY Executive Order 13625 and The National Research Action Plan for Improving Access to Mental Health Services for Veterans, Service Members, and Military Families established PTSD as a high national research priority.
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From page 205... ...
2004. A survey of psychologists' attitudes to wards and utilization of exposure therapy for PTSD.
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From page 206... ...
2007. Virtual reality exposure therapy for the treatment of posttraumatic stress disorder following September 11, 2001.
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From page 207... ...
2012. Potentially modifiable pre-, peri-, and postdeployment characteristics associated with deployment-related posttraumatic stress disorder among Ohio Army National Guard soldiers.
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2012. Treatment for posttraumatic stress disorder in military and veteran populations: Initial assessment.
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2012. A randomized placebo-controlled trial of D-cycloserine and exposure therapy for posttraumatic stress disorder.
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2009. Neurobiological basis of fail ure to recall extinction memory in posttraumatic stress disorder.
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2001. Virtual reality exposure therapy for Vietnam veterans with posttraumatic stress disorder.
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2014b. A randomized, double-blind evaluation of D-cycloserine or alprazolam combined with virtual reality exposure therapy for posttraumatic stress disorder (PTSD)
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2012. A sham controlled study of repeti tive transcranial magnetic stimulation for posttraumatic stress disorder.
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