Faculty Bibliography

BACKGROUND:Individuals with posttraumatic stress disorder (PTSD) face symptoms that can hinder access to treatment, such as avoidance and guilt. Telemedicine offers a technological solution to increase access to mental health care and overcome barriers to treatment. Although an increasing body of literature focused on synchronous telehealth (eg, live video), no studies have examined the delivery of PTSD treatment via two-way multimedia messages (ie, texting or messaging). OBJECTIVE:The aim of this study was to conduct a longitudinal observation of treatment for PTSD delivered using two-way asynchronous messaging. We also sought to identify individual and treatment characteristics that could predict the observed outcome differences. METHODS:Outpatients diagnosed with PTSD (N=475) received interventions from licensed therapists, which were delivered via messaging once or more than once per day, 5 days a week for 12 weeks. PTSD symptoms were assessed every 3 weeks using the PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders-5. Trajectories of PTSD symptoms were identified using growth mixture modeling (GMM). Using logistic regression, the demographic, treatment, and messaging characteristics of patient groups that improved were compared with the characteristics of patient groups that did not improve. RESULTS:The GMM identified 4 trajectories of PTSD symptoms: moderate improvement (197/475, 41.4%), high symptoms (197/475, 41.4%), chronic symptoms (61/475, 12.9%), and acute improvement (20/475, 4.3%). Patients with a clinically significant reduction in PTSD symptoms (231/475, 48.6%) were more likely to communicate via video (odds ratio [OR] 1.01, 95% CI 1.01-1.05; P=.03), have a higher working alliance with their therapist (OR 1.03, 95% CI 1.01-1.05; P=.02), and be at their first treatment experience (OR 2.03, 95% CI 1.18-3.54; P=.01). Treatment adherence was associated with greater therapeutic alliance (OR 1.07, 95% CI 1.03-1.10; P<.001), education (OR 2.13, 95% CI 1.13-4.03; P=.02), and more patient-generated messages per week (OR 1.08, 95% CI 1.04-1.13; P<.001). CONCLUSIONS:Multimedia message delivery for PTSD treatment showed symptom-reduction rates similar to traditional forms of treatment delivery, suggesting further study of messaging as a treatment medium. Most patients completed an 8-week course, reflecting the acceptability of messaging interventions. Delivering treatment via two-way messaging offers increased opportunities for widespread access to mental health care.

The ability to accurately perceive cues to contextual demands across different situations has been identified as a crucial component of successful self-regulation. However, previous attempts to measure context sensitivity have suffered from serious methodological limitations, most notably the possibility that respondents may not possess sufficient knowledge of their own abilities, the confounding of perception of context with response to context, the use of only one or two contextual variations, and the failure to consider the abilities to both accurately detect contextual cues and accurately determine cue absence. This article reports a new, easy-to-administer scenario-based questionnaire measure, the Context Sensitivity Index (CSI), that addressed each of these limitations. The 20-item CSI was iteratively developed and normed using data from five studies to create separate indices to capture sensitivity to the presence of contextual cues (Cue Presence index) and to the relative absence of cues (Cue Absence index). We validated these indices against measures of flexibility, psychopathology, and other scales. Results are discussed in terms of the CSI's implications, limitations, and future applications.

BACKGROUND:Diagnostic criteria for prolonged grief have appeared in the Diagnostic and Statistical Manual of Mental Disorders ( DSM-5; persistent complex bereavement disorder, PCBD) and in the ICD-11 (prolonged grief disorder, PGD), and the question of which diagnosis is most clinically useful has been hotly debated. This study provides the first longitudinal comparison of PCBD and PGD in their ability to capture symptom change over time and their relation to long-term outcomes. METHODS:A community sample was recruited consisting of 282 individuals who had recently lost a spouse. Structured clinical interviews were conducted at 3, 14, and 25 months postloss for symptoms corresponding to PCBD and PGD criteria. Outcomes at 25 months included PCBD and PGD caseness, depression, global functioning, and interviewer ratings of participant suffering. RESULTS:PCBD and PGD trajectories determined by growth mixture modeling, each captured three primary outcomes: resilience, moderate-improving symptoms, and prolonged-stable symptoms. The PGD solution also identified trajectories of increasing and decreasing distress: prolonged-worsening and acute-recovering symptoms. Prediction of 25-month outcomes indicated differences conforming to the severity of PGD symptoms, and the prolonged-worsening trajectory was associated with the worst adjustment. CONCLUSIONS:PGD symptoms were more differentiated, better-captured psychopathology, and other outcomes and were more sensitive to change over time compared to PCBD.

BACKGROUND:Complicated grief (CG) is a bereavement-specific syndrome distinct from but commonly comorbid with posttraumatic stress disorder (PTSD). While bereavement is common among military personnel (Simon et al., 2018), there is little research on the impact of CG comorbidity on PTSD treatment outcomes. METHODS:To evaluate the impact of comorbid CG on PTSD treatment outcomes we analyzed data from a randomized trial comparing prolonged exposure, sertraline, and their combination in veterans with a primary diagnosis of combat-related PTSD (n = 194). Assessment of PTSD, trauma-related guilt, functional impairment, and suicidal ideation and behavior occurred at baseline and weeks 6, 12, and 24 during the 24-week trial. RESULTS:CG was associated with lower PTSD treatment response (odds ratio (OR) = 0.29, 95% confidence interval (CI) [0.12, 0.69], p = 0.005) and remission (OR = 0.28, 95% CI [0.11, 0.71], p = 0.007). Those with CG had greater severity of PTSD (p = 0.005) and trauma-related guilt (<0.001) at baseline and endpoint. In addition, those with CG were more likely to experience suicidal ideation during the study (CG: 35%, 14/40 vs. no CG 15%, 20/130; OR = 3.01, 95% CI [1.29, 7.02], p = 0.011). CONCLUSIONS:Comorbid CG is associated with elevated PTSD severity and independently associated with poorer endpoint treatment outcomes in veterans with combat-related PTSD, suggesting that screening and additional intervention for CG may be needed.

The death of a loved one is one of life's greatest stressors. Most bereaved individuals experience a period of acute grief that diminishes in intensity as they adapt to the changes brought about by their loss. Over the past four decades, a growing body of research has focused on a form of prolonged grief that is painful and impairing. There is a substantial and growing evidence base that supports the validity and significance of a grief-related disorder, including the clinical value of being able to diagnose it and provide effective targeted treatment. ICD-11 will include a new diagnosis of prolonged grief disorder (PGD). DSM-5 called this condition persistent complex bereavement disorder (PCBD) and included it in Section III, signaling agreement that a diagnosis is warranted while further research is needed to determine the optimal criteria. Given the remaining uncertainties, reading this literature can be confusing. There is inconsistency in naming the condition (including complicated grief as well as PGD and PCBD) and lack of uniformity in identifying it, with respect to the optimal threshold and timeframe for distinguishing it from normal grief. As an introductory commentary for this Depression and Anxiety special edition on this form of grief, the authors discuss the history, commonalities, and key areas of variability in identifying this condition. We review the state of diagnostic criteria for DSM-5 and the current ICD-11 diagnostic guideline, highlighting the clinical relevance of making this diagnosis.

Background: Complicated grief (CG) is hypothesized to include both attachment and traumatic distress symptoms, and a preliminary diagnosis has been placed in the trauma and stressor related DSM-5 category (APA, 2013). Posttraumatic stress disorder (PTSD) and CG often present comorbidly, and both result from a major stressor (Simon et al., 2007; Marques et al., 2013; Lenferink et al., 2018). Preliminary data suggest posttraumatic stress symptoms (PTSS) may be present across patients with CG, and not vary by whether the loss is violent or accidental in nature such as required for PTSD diagnoses (Simon et al., 2013; Kersting et al., 2011). Much less is known about how PTSS changes with CG targeted treatment, whether this change is impacted by the nature of the death, or whether it may be necessary to target PTSS separately from grief to improve functional outcomes.
Method(s): Participants were 395 individuals (mean age +/- SD = 53.0 +/- 14.5 years; 78.0% women) with a primary diagnosis of CG based on structured clinical interviews and an Inventory of Complicated Grief (ICG) score>=30. Data were derived from the previously published 20-week multi-center RCT of complicated grief therapy plus pill placebo (CGT + PLA), CGT plus citalopram (CGT + CIT), citalopram (CIT), or placebo (PLA) (Shear et al., 2016). DSM-IV PTSS were assessed using the 17-item self-report Davidson Trauma Scale (DTS). DTS total score of 40 was proposed by the developers of the scale as a cut-off for a diagnosis of PTSD, and has been frequently used as a threshold in previous studies (Davidson et al., 1997; Kastello et al., 2016; Khitab et al., 2013). Our primary analysis examined the adjusted mean difference from baseline in the DTS total and subscale scores (i.e., intrusion, avoidance-numbing, hyperarousal) over three follow-up periods (week 12, 16, and 20) by treatment arm using longitudinal mixed effects regression with participant specific random intercepts. In follow-up analyses, we investigated whether cause of death (violent vs. nonviolent) moderated the relationship between treatments and DTS total score by introducing interaction terms between cause of death and treatment arms in the mixed effects regression model.
Result(s): In the full sample, the mean DTS total score at baseline was 63.2 +/- 27.2, and 77.7% (n = 307) had DTS>=40. There was a general decreasing trend of mean DTS total scores over the 20-week period with a mean adjusted reduction of 27.4 points (d = 0.6) from baseline to week 12 (p < 0.001), and a reduction of 30.7 points (d = 0.7) from baseline to week 20 (p < 0.001). There was no significant difference in change in DTS total score at week 12 by treatment group. However, at weeks 16 and 20, CGT + PLA and CGT + CIT were each associated with a significant DTS reduction compared to placebo alone, while CIT was not. For CGT + PLA vs. PLA, there was 8.8 point (d = 0.14) greater reduction in DTS total score from baseline to week 16 (p = 0.01), and 12.5 point (d = 0.19) greater reduction from baseline to week 20 (p < 0.001). For CGT + CIT vs PLA, there was a 10.0 point (d = 0.15) greater reduction in adjusted DTS total score from baseline to week 16 (p < 0.001), and 10.7 point (d = 0.16) greater decrease from baseline to week 20 (p < 0.001). Similar trends were observed for DTS subscales-CGT + PLA and CGT + CIT demonstrated consistent reduction compared to PLA. In the model with interaction terms between treatments and cause of death, the decrease in DTS score for CGT + CIT compared to PLA was 9.5 points (d = 0.12) greater for those who had violent death compared to those who did not experience violent death (p = 0.04). For CGT + CIT vs CGT + PLA, however, the reduction in DTS total score was 4.2 points (d = 0.04) greater in those who experienced violent death compared to those who did not, but the difference was not statistically significant (p = 0.53).
Conclusion(s): Adults with primary CG assigned to CGT with or without medication demonstrated a significantly larger reduction in PTSS compared to pill placebo, whereas citalopram alone did not. These data parallel findings from the primary study findings for grief (Shear et al., 2016), and demonstrate that CGT may be an effective intervention for PTSS in those with CG. A high level of PTSS were present in this primary CG sample, and PTSS were comparable at baseline for those with violent and non-violent losses. For those who lost someone to violent death, while these data found initial support for greater PTSS reduction for combination therapy with CGT and citalopram compared to placebo, we did not find evidence for a significant benefit of combined therapy over CGT alone for CG due to violent loss. More research is needed to fully understand the role of traumatic distress and its optimal treatment in CG

BACKGROUND:Complicated and persistent grief reactions afflict approximately 10% of bereaved individuals and are associated with severe disruptions of functioning. These maladaptive patterns were defined in Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) as persistent complex bereavement disorder (PCBD), but its criteria remain debated. The condition has been studied using network analysis, showing potential for an improved understanding of PCBD. However, previous studies were limited to self-report and primarily originated from a single archival dataset. To overcome these limitations, we collected structured clinical interview data from a community sample of newly conjugally bereaved individuals (N = 305). METHODS:Gaussian graphical models (GGM) were estimated from PCBD symptoms diagnosed at 3, 14, and 25 months after the loss. A directed acyclic graph (DAG) was generated from initial PCBD symptoms, and comorbidity networks with DSM-5 symptoms of major depressive disorder (MDD) and post-traumatic stress disorder (PTSD) were analyzed 1 year post-loss. RESULTS:In the GGM, symptoms from the social/identity PCBD symptoms cluster (i.e. role confusion, meaninglessness, and loneliness) tended to be central in the network at all assessments. In the DAG, yearning activated a cascade of PCBD symptoms, suggesting how symptoms lead into psychopathological configurations. In the comorbidity networks, PCBD and depressive symptoms formed separate communities, while PTSD symptoms divided in heterogeneous clusters. CONCLUSIONS:The network approach offered insights regarding the core symptoms of PCBD and the role of persistent yearnings. Findings are discussed regarding both clinical and theoretical implications that will serve as a step toward a more integrated understanding of PCBD.