Negative psychometric outcomes: Self-report measures and a follow-up telephone survey

To assess the effectiveness of the Koach project, two groups of subjects, comprising the 40 Koach participants and 40 PTSD veterans who served as controls, were examined 1 year before Koach and 9 months afterwards. In addition, the Koach participants were also assessed immediately before and immediately following the project. The self-report measures focused on PTSD symptomatology, post-traumatic intrusion and avoidance, general psychiatric symptomatology, social functioning and perceived self-efficacy in combat. Participation in Koach led to improvement in one area only: perceived self-efficacy in combat. The measures of emotional distress and psychiatric symptomatology indicated that patients treated in Koach fared worse than untreated PTSD controls. In addition, in order to assess the long-term impact of the program, 36 Koach participants were surveyed by phone approximately 2 years after the residential stage of the project. Military functioning, family life, work, and psychiatric symptomatology were assessed. Findings indicate that most of the participants had not returned to their prewar level of functioning.     

The use of individual goal-setting and ongoing evaluation in the treatment of combat-related chronic PTSD

The Koach project included not only assessments before and after the residential phase, but also an ongoing evaluation of the therapeutic process. A systematic self-evaluation of achievement by the Koach trainees, and a concurrent evaluation by the commander/therapists was built into the Koach project as one of its key elements. Each trainee formulated with his commander/therapist a broad outcome area in which he wished to gain therapeutic improvement, and then broke it down into specific target behaviors which they contracted to work on during the project. Progress on each target behavior was monitored every two days. Results indicate a linear pattern of improvement and a high degree of agreement between the ratings of the trainees and those of the therapists/commanders. These findings are congruent with the subsequent impressions of both the participants and the therapists regarding the overall effects of the project.     

Positive clinical impressions: I. Therapists' evaluations

In this study, the therapists who participated in the Koach project were interviewed regarding their assessment of the project. The therapists expressed a high degree of overall satisfaction with Koach. The significance of one group of combat veterans (the therapists) treating another group of veterans (the PTSD casualties) is discussed.     

The “Koach” project for treatment of combat-related PTSD: Rationale,aims, and methodology

The Koach project was designed and implemented by the Mental Health Department of the IDF (Israel Defense Forces) Medical Corps as a treatment program for chronic PTSD veterans, aimed at reducing the prevalence and severity of PTSD and accompanying psychiatric symptomatology and improving functioning in the military, the family, and the community. It was comprised of a 1-month residential phase on an army base, followed by mutual self-help groups in the veterans' communities. The project combined behavioral, cognitive, and group approaches into an integrated therapeutic program. This article presents the rationale behind the project and describes the treatment approaches that were utilized.     

Anthropological impressions of Koach: Participant observations

The Koach Project was conceived by the Department of Mental Health of the Israel Defense Forces to find a means to improve treatment for chronic battle related PTSD. Having described the rationale and method for the project (Solomonet al., 1991) the enthnography of the residential stage is introduced and analyzed from an anthropological perspective.     

PTSD: Theoretical and practical considerations as reflected through Koach—An innovative treatment project

This article summarizes the achievements of the Koach project and attempts to draw conclusions regarding the treatment of chronic PTSD. It also attempts to reconcile the apparent contradictions between the participants' and therapists' positive impressions of the project and the less encouraging findings of the systematic assessment of its effectiveness.     

Effectiveness of Cognitive Processing Therapy for Male and Female U.S. Veterans With and Without Military Sexual Trauma

Military sexual trauma (MST) affects approximately 2% and 36% of male and female veterans, respectively, (e.g., Allard, Gregory, Klest, & Platt, 2011). Although the deleterious consequences of MST have been clearly established, few studies have explored treatment effectiveness for this population. Using archival data from a residential treatment program, the current study explored the effectiveness of cognitive processing therapy (CPT) in treating full or subthreshold posttraumatic stress disorder (PTSD) to compare U.S. veterans reporting an MST index trauma (MST‐IT) to those without MST‐IT. Of the 481 participants, 40.7% endorsed MST‐IT. Multiway frequency analyses were utilized to compare men and women with and without MST on baseline demographic variables. Hierarchical linear models were constructed to investigate treatment outcome by MST status and sex. Results showed that 44.8%, 23.8%, and 19.6% of the variation in clinician‐ and self‐reported PTSD and depression symptoms were explained by three models. Scores on all outcome measures significantly decreased over time for both groups. Additionally, women demonstrated a sharper decrease in PTSD symptoms over time than men. Lastly, men who reported MST‐IT had higher PTSD symptoms than men without MST‐IT on average. With no control group or random assignment, preliminary findings suggest residential treatment including CPT may be effective for MST‐IT regardless of sex.     

Clinically Significant Change in Posttraumatic Stress Disorder Symptoms Is Associated With Lower Levels of Aggression After Residential Treatment Discharge

Although the link between posttraumatic stress disorder (PTSD) and aggression has been repeatedly demonstrated, to our knowledge no research has examined whether PTSD symptom reductions are linked to less aggression after treatment. The current study aimed to address this gap in the literature by examining the association between reductions in PTSD symptoms and posttreatment aggression among 2,275 veterans in residential treatment for PTSD across 35 Veterans Health Administration sites. We estimated a multilevel model that examined the effect of clinically significant PTSD symptom change on aggression at 4‐month posttreatment follow‐up, and found significant within‐site and between‐site contextual effects of clinically significant changes in PTSD symptoms on follow‐up aggression. Findings revealed that veterans who reported clinically significant changes in their PTSD symptoms had lower levels of aggression at follow‐up than veterans at the same treatment site who did not report clinically significant PTSD change. After we controlled for individual clinically significant PTSD change, participants in treatment sites where the rates of clinically significant PTSD change were higher overall had lower levels of aggression at follow‐up. The model explained over one‐fourth of the variability in aggression, R² = .26. Findings from the current study extend previous research that has shown associations between PTSD and aggression, by revealing that clinically significant change in PTSD during residential treatment is associated with less aggression at follow‐up. These findings suggest that interventions that effectively reduce PTSD symptoms may also help reduce risk for aggression.     

Outcomes of Prolonged Exposure Therapy for Veterans With Posttraumatic Stress Disorder

Prolonged Exposure (PE) is an evidenced‐based psychotherapy for posttraumatic stress disorder (PTSD) that is being disseminated nationally within the U.S. Department of Veterans Affairs (VA) with promising initial results. Empirical evidence, however, regarding the effectiveness of PE for treatment of PTSD in military veterans is limited. Building on previous treatment outcome research, the current study investigated the effectiveness of PE in a diverse veteran sample. One‐hundred fifteen veterans were enrolled in PE at an urban VA medical center and its surrounding outpatient clinics. PTSD and depression symptoms as well as quality of life were measured before and after treatment. Several baseline patient characteristics were examined as predictors of treatment response. Eighty‐four participants completed treatment. Participants experienced a 42% reduction in PTSD symptoms, a 31% reduction in depression symptoms, and an increase in quality of life following PE. Veterans not prescribed psychotropic medication reported greater PTSD symptom reduction than veterans prescribed such medication. The implications of these results for treatment programs targeting PTSD in veterans are discussed.     

Prolonged Exposure Therapy With Veterans and Active Duty Personnel Diagnosed With PTSD and Traumatic Brain Injury

The present study used archival clinical data to analyze the delivery and effectiveness of prolonged exposure (PE) and ancillary services for posttraumatic stress disorder (PTSD) among Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn veterans (N = 69) with histories of mild to severe traumatic brain injury (TBI). Data from standard clinical assessments of veterans and active duty personnel treated in both inpatient and outpatient programs at 2 Department of Veteran Affairs medical centers were examined. Symptoms were assessed with self‐report measures of PTSD (PTSD Checklist) and depression (Beck Depression Inventory‐II) before and throughout therapy. Mixed linear models were utilized to determine the slope of reported symptoms throughout treatment, and the effects associated with fixed factors such as site, treatment setting (residential vs. outpatient), and TBI severity were examined. Results demonstrated significant decreases in PTSD, B = ?3.00, 95% CI [?3.22, ?2.78]; t(210) = ?13.5; p < .001, and in depressive symptoms, B = ?1.46, 95% CI [?1.64, ?1.28]; t(192) = ?8.32; p < .001. The effects of PE treatment did not differ by clinical setting and participants with moderate to severe injuries reported more rapid gains than those with a history of mild TBI. The results provide evidence that PE may well be effective for veterans with PTSD and TBI.     

A Randomized Clinical Trial of Cognitive Processing Therapy for Veterans With PTSD Related to Military Sexual Trauma

In this randomized controlled clinical trial, the authors evaluated the effectiveness of cognitive processing therapy (CPT) in the treatment of self‐reported and clinician‐assessed posttraumatic stress disorder (PTSD) related to military sexual trauma (MST), along with depressive symptoms. Eighty‐six veterans (73 female, 13 male) randomly assigned to receive 12 individual sessions of either CPT or present‐centered therapy (PCT) were included in analyses. Blinded assessments occurred at baseline, posttreatment, and 2, 4, and 6 months posttreatment. Mixed‐effects model analysis revealed a significant interaction between groups (p = .05, d = ?0.85): At posttreatment, veterans who received CPT had a significantly greater reduction in self‐reported, but not clinician‐assessed, PTSD symptom severity compared to veterans who received PCT. All three primary outcome measures improved significantly, both clinically and statistically, across time in both treatment groups. Pre‐ and posttreatment effect sizes were mostly moderate to large (d = 0.30–1.02) and trended larger in the CPT group. Although the study was impacted by treatment fidelity issues, results provide preliminary evidence for the effectiveness of CPT in reducing self‐reported PTSD symptoms in a population of veterans with MST, expanding on established literature that has demonstrated the effectiveness of CPT in treating PTSD related to sexual assault in civilian populations.     

A pilot study of behavioral activation for veterans with posttraumatic stress disorder

A pilot study was conducted to investigate the feasibility and effectiveness of behavioral activation (BA) therapy for veterans with posttraumatic stress disorder (PTSD). Eleven veterans seeking treatment at a Veterans Administration outpatient PTSD clinic were enrolled in the study protocol, consisting of 16-weekly individual sessions of BA. Nine veterans completed the protocol, one participant completed 15 sessions, and one dropped out after one session. Clinician-rated PTSD symptom severity showed significant pre- to posttreatment improvement and was associated with a moderate effect size. A number of participants also were improved on measures of depression and quality of life, but changes did not reach statistical significance. Findings suggest that BA is a well-tolerated, potentially beneficial intervention for veterans with chronic symptoms of PTSD.     

Decisional regret and quality of life after participating in medical decision-making for early-stage prostate cancer

OBJECTIVE: To determine the effect of men's reported levels of involvement in medical decision-making and quality of life (QoL) on their levels of decisional regret after definitive treatment. PATIENTS AND METHODS: Men referred to a hospital-based resource centre completed QoL and decisional-regret measures after definitive treatment for localized prostate cancer. Data from these questionnaires were linked with a previous study conducted to determine if providing individualized information to men newly diagnosed with prostate cancer would lower their levels of psychological distress and enable them to become more active participants in treatment decision-making. The preferred role in medical decision-making and QoL had previously been measured at the time of diagnosis and the assumed role at 4 months after the definitive treatment decision. This postal survey was conducted approximately 18 months after diagnosis. RESULTS: Of 74 men, 67 (91%) responded; the mean (sd) time since definitive treatment was 10.3 (4.7) months and the mean age of the men 62.5 (6.9) years. Radical prostatectomy was the most frequent treatment (72%). Most (94%) patients participated in medical decision-making either actively or collaboratively and did not regret their treatment choice. The type of definitive treatment received had no effect on decisional regret; patients' QoL scores were similar to the levels before treatment. Levels of sexual function were significantly lower after definitive treatment, but urinary incontinence was not significantly affected. Men who had neoadjuvant hormone therapy reported having significantly more treatment-related symptoms. CONCLUSIONS: There is no evidence that providing information to facilitate participation in medical decision-making causes decisional regret or psychological distress within the first year after definitive treatment. A longitudinal follow-up of these patients is required to adequately assess the long-term effects of treatment on QoL and decisional regret.     

Relationship between self-reported residential indoor remodeling and semen quality: a case-control study

The present study examined the association between residential indoor remodeling and poor semen quality. Sperm donors aged 18–45 years old were recruited in Shanghai, China. Semen specimens were collected and analyzed. An in-person interview was conducted to obtain information on the history of indoor remodeling and potential confounders. A total of 70 participants with abnormal semen quality (case group) and 68 controls were examined. A total of 20 subjects reported indoor remodeling in the recent 24 months, and among them 17 subjects reported indoor remodeling in the recent 12 months. Compared with participants with no history of indoor remodeling, participants with a history of indoor remodeling in the recent 24 months were more than three times as likely to have poor sperm quality (adjusted odds ratio = 3.8, 95% confidence interval: 1.3–12.0) after controlling for potential confounders. The association was strengthened when the analysis was restricted to those who had indoor remodeling in the recent 12 months. Our findings provide preliminary evidence that indoor remodeling has an adverse effect on semen quality.     

Aggressive and unsafe driving in male veterans receiving residential treatment for PTSD

Aggressive and unsafe driving was examined in 474 male veterans receiving Veterans Affairs residential treatment for posttraumatic stress disorder (PTSD). Specifically, the authors evaluated if PTSD was associated with aggressive and unsafe driving and if Iraq and Afghanistan War veterans were at higher risk than other war veterans. Approximately two thirds of the sample reported lifetime aggressive driving and one third reported current aggressive driving. Posttraumatic stress disorder severity was associated with aggressive driving, but not other forms of unsafe driving. Iraq and Afghanistan veterans endorsed higher rates of and more frequent aggressive driving than did other veterans. After accounting for PTSD severity, age, income, and marital status being an Iraq and Afghanistan War veteran predicted aggressive driving frequency and infrequent seatbelt use.     

Response to the 2004-2005 influenza vaccine shortage in veterans with spinal cord injuries and disorders and their providers

BACKGROUND/OBJECTIVES: To assess patient and provider behaviors regarding influenza vaccination, diagnosis, and testing strategies and the availability of influenza vaccine during the 2004-2005 nationwide influenza vaccine shortage. DESIGN/METHODS: Multisite, anonymous, cross-sectional surveys of patients and providers and qualitative interviews after the 2004-2005 influenza season. SETTING: Department of Veterans Affairs (VA) health care facilities with spinal cord injury centers or clinics. PARTICIPANTS: Stratified random sample of 3,958 veterans with spinal cord injuries and disorders (SCI & D; 31% response rate), 177 providers who treat persons with SCI&D, and 17 key informants. RESULTS: Most patient respondents (96.1%) reported awareness of a vaccine shortage (n = 938). When asked whether the shortage affected their ability to get the vaccine, 64.8% said they had no problem, whereas 12.1% reported an inability to get the vaccine. The vaccination rate was 71.8%; most veterans received the vaccine early (October-November) at the VA, and vaccination rates increased with age (P < 0.0001). Although vaccine shortages were reported by 47.5% of provider survey respondents (n = 177), most reported that the vaccine shortage did not affect availability of vaccine for patients with SCI&D. Few clinicians conducted diagnostic tests for influenza more often than in past years (4.9%). Although providers reported shortages at 12 centers (n = 23), patients with SCI&D had priority at 11 of 12 centers. CONCLUSIONS: Most patients were aware of the vaccine shortage, and the vaccination rate remained high and comparable with previous years. VA providers and facilities targeted SCI&D as a high-risk group and prioritized use of the limited vaccine supply for them.     

肾上腺皮质癌9例报告

目的：探讨肾上腺皮质癌的诊断和治疗方法。方法：回顾性分析9例肾上腺皮质癌患者的临床资料,其中男7例,女2例。年龄5个月～63岁,平均39岁。术前全部行B超及CT检查,有内分泌异常者2例,分别为Cushing syndrome及原发性醛固酮增多症。无内分泌异常者7例。结果：手术完整切除9例。术后病理检查：I期1例;Ⅱ期4例;Ⅲ期3例;Ⅳ期1例。随访4～60个月,平均生存30个月,1例因肺部转移而术后26个月死亡,1例失去随访,其余7例均存活至今。结论：肾上腺皮质癌恶性程度较高,预后较差,根治性切除是治疗肾上腺皮质癌最有效的方法。化疗及放疗可作为术后辅助治疗。早期诊断和早期治疗可提高患者生存率。     

Compensation and Treatment: Disability Benefits and Outcomes of U.S. Veterans Receiving Residential PTSD Treatment

The U.S. Department of Veterans Affairs (VA) provides specialized intensive posttraumatic stress disorder (PTSD) programs to treat trauma‐related symptoms in addition to providing service‐connected disability to compensate veterans for injury sustained while serving in the military. Given the percentage of veterans who are receiving treatment for PTSD, in addition to seeking compensation for PTSD, a debate has emerged about the impact of compensation on symptom recovery. This study examined the associations among status of compensation, treatment expectations, military cohort, length of stay, and outcomes for 776 veterans who were enrolled in 5 VA residential PTSD programs between the years of 2005 and 2010. Mixed model longitudinal analyses, with age, gender, and baseline symptoms nested within treatment site in the model, found that treatment expectations were modestly predictive of treatment outcomes. Veterans seeking increased compensation reported marginally lower treatment expectations (d = .008), and did not experience poorer outcomes compared to veterans not seeking increased compensation with the effect of baseline symptoms partialled out. Veterans from the era of the Iraq and Afghanistan conflicts reported lower treatment expectations (d = .020) and slightly higher symptoms at intake (d = .021), but had outcomes at discharge equivalent to veterans from other eras with baseline symptoms partialled out. These findings help further inform the debate concerning disability benefits and symptom changes across time.     

Response to Cognitive Processing Therapy in Veterans With and Without Obstructive Sleep Apnea

Recent studies have called attention to the need for enhancing treatment outcome in trauma‐focused psychotherapies, such as cognitive processing therapy (CPT), with veterans. Given the prevalence of posttraumatic‐related sleep disturbances, and the role of sleep in emotional learning and processing, sleep quality may be a target for improving CPT outcome. Elevated rates of obstructive sleep apnea (OSA) have been reported in samples of veterans with posttraumatic stress disorder (PTSD); however, the impact of OSA on response to CPT is unclear. In this study, CPT outcome was examined in veterans with and without a diagnosis of OSA. Following chart review, 68 OSA‐positive and 276 OSA‐negative veterans were identified. Generalized estimating equations were used to compare between‐group differences in weekly self‐reported PTSD symptomatology. The OSA‐positive veterans reported greater PTSD severity over the course of treatment and at posttreatment compared with veterans without OSA (B = −0.657). Additionally, OSA‐positive veterans with access to continuous positive airway pressure (CPAP) therapy reported less PTSD severity relative to OSA‐positive veterans without access to CPAP (B = −0.421). Apnea appears to be a contributing factor to the reduced effectiveness of evidence‐based psychotherapy for veterans with PTSD; however, preliminary evidence indicates that CPAP therapy may help mitigate the impact of OSA on treatment outcome.     

米氮平治疗早泄106例临床观察

目的 研究米氮平(mitrazapine)治疗早泄(premature ejaculation,PE)的有效性和安全性.方法 选择门诊早泄患者106例,予以每晚口服米氮平30mg,连续使用一个月为一个疗程.治疗1～2个疗程后接受复诊或电话随访,进行疗效和安全性评估,分别记录治疗前、治疗一个疗程后阴道内射精潜伏时间(intravaginal ejaculation latency time,IELT)、治疗后性生活质量改善满意度,并详细记载药物治疗期间出现的不良反应.结果 随诊的106例PE患者,自行停药9例,其中因药物副作用不能耐受而停药的有6例(嗜热睡4例,头晕2例),其他(离异及经济因素等)原因3例.97例PE患者完整接受至少一个疗程的米氮平治疗,治疗前IELT为(1.19±0.09)min,治疗后为(4.72±2.53)min,治疗前、后差异比较,具统计学意义(P<0.001).IELT改善总有效率为68.04%,治疗后患者自我满意度达到75.26%.其他抗抑郁药物治疗无效的32例PE患者,米氮平治疗后早泄改善自我满意度调查结果满意度43.75%(14/32).结论 米氮平治疗早泄有效且安全,对于其他抗抑郁药物治疗无效的PE患者也可以尝试米氮平治疗.