A Novel Posttraumatic Stress Disorder Treatment for Veterans with Moral Injury

针对道德受伤退伍军人的一种新型创伤后应激障碍治疗方法

• 批准号: 10399986
• 负责人: Shira Maguen
• 金额: --
• 依托单位: VETERANS AFFAIRS MED CTR SAN FRANCISCO
• 依托单位国家: 美国
• 财政年份: 2019
• 资助国家: 美国
• 起止时间: 2019-04-01 至 2024-03-31
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/10399986
• 关键词: Address; Aftercare; Alcohol abuse; Anger; Area; Attention; Behavior; Belief; Caring; Cessation of life; Clinical Treatment; Clinical assessments; Cognition; Cognitive; Communities; Complex; Conflict (Psychology); Control Groups; Development; Diagnosis; Evaluation; Exposure to; Family; Feeling; Funding; Generations; Goals; Grant; Guilt; Healthcare Systems; Impairment; Individual; Injury; Intervention; Learning; Measures; Mediator of activation protein; Mental Health; Modeling; Morals; Outcome; Participant; Patients; Performance; Physiology; Post-Traumatic Stress Disorders; Psychotherapy; Quality of life; Randomized; Randomized Controlled Trials; Rehabilitation therapy; Risk; Sample Size; San Francisco; Self-Injurious Behavior; Severities; Shame; Signs and Symptoms; Site; Social isolation; Suicide; Symptoms; Target Populations; Testing; Thinking; Time; Trauma; Treatment Cost; Veterans; Veterans Health Administration; Visit; Waiting Lists; War; Work; active control; care systems; combat; combat veteran; design; diagnostic criteria; efficacy testing; efficacy trial; evidence base; expectation; experience; follow up assessment; follow-up; forgiveness; functional disability; functional gain; functional improvement; improved; improved functioning; novel; pilot trial; prevent; primary outcome; psychiatric symptom; psychological distress; psychological trauma; psychosocial; response; secondary outcome; skills; stem; suicide rate; symptomatic improvement; treatment group

Post-traumatic stress disorder (PTSD) is now the most common mental health diagnosis among the youngest generation of Veterans receiving treatment from the Veterans Health Administration (VHA), necessitating the need for diverse types of targeted care. Although there are two evidence-based psychotherapies (EBP) for PTSD, the vast majority of combat Veterans who receive these treatments still meet diagnostic criteria for PTSD and their functioning continues to be impacted. Furthermore, Veterans that have experienced trauma related to killing have high rates of suicide and more severe PTSD symptoms. Although there have been few studies examining predictors of poor outcomes in EBPs, one area that has recently begun to receive growing attention is moral injury. A recent study found that PTSD and moral injury were distinct constructs with unique signs and symptoms, and preliminary evidence indicates that the feelings of guilt and anger that characterize moral injury associated with trauma such as killing in war may contribute to worsening symptoms over the course of existing treatments. Although PTSD may be one manifestation of psychological trauma related to killing, conceptualization of the impact of killing requires a broader framework. The emerging concept of moral injury offers an alternative context to better understand the many possible outcomes of exposure to killing. For these reasons, the development of targeted moral injury interventions is critical. We designed and received VA funding to conduct a pilot randomized controlled trial (RCT) of the Impact of Killing (IOK) treatment, which can be seamlessly added as a standalone treatment following existing EBPs for PTSD. IOK focuses on key themes including physiology of killing responses, moral injury, self-forgiveness, and improved post-deployment reintegration. The treatment was designed to fit well into already existing systems of care and has been shown to improve functioning, PTSD symptoms, and general psychiatric symptoms following EBP. Whereas the IOK RCT pilot was initially conducted at the San Francisco VA Healthcare System, our goal is to conduct a fully- powered, multi-site efficacy trial at two regionally-diverse sites with a larger sample size and active control condition. Consequently, the objective of this project is to test the efficacy of an individual treatment for PTSD stemming from moral injury called IOK, compared to a present-centered therapy (PCT) control condition, and to determine the rehabilitative utility of IOK for Veterans seeking treatment for PTSD. Our primary outcome is psychosocial functioning. The target population is Veterans who have initiated or completed Cognitive Processing Therapy or Prolonged Exposure Therapy, two EBPs for PTSD, and continue to have PTSD symptoms and moral injury related to killing. Veterans will be randomly assigned to receive either: 1) IOK (10 individual therapy sessions lasting 60-90 minutes) or 2) PCT (sessions of equal duration to IOK). Our first aim is to test the efficacy of IOK through measures of psychosocial functioning (primary outcome) and PTSD severity (secondary outcome). Our second aim is to determine whether IOK gains made by Veterans are durable. Given that moral injury treatment is a new and burgeoning area, we have two exploratory aims that can help move the field forward. Our first exploratory aim is to conduct post-treatment evaluations with a subset of the IOK treatment group to better understand how to support continued improvement in functioning among participants. Our second exploratory aim is to evaluate mediators of functional improvement, such as self-forgiveness, among Veterans completing IOK. If the aims of this grant are achieved, we will be able to have a moral injury intervention following EBP that can be seamlessly integrated into existing care for one of the most commonly occurring mental health problems in Veterans. Furthermore, suicide is a national priority for VHA, and expanding treatment for PTSD and moral injury has the potential to decrease suicide and improve functioning in Veterans. Finally, IOK offers skills and ways of understanding warzone experiences that can be mastered and can continue to be implemented by Veterans over time.

创伤后应激障碍 (PTSD) 现在是最年轻人群中最常见的心理健康诊断 一代退伍军人接受退伍军人健康管理局 (VHA) 的治疗，因此需要 需要多种类型的有针对性的护理。尽管有两种基于证据的心理治疗（EBP） 创伤后应激障碍（PTSD），绝大多数接受这些治疗的退伍军人仍然符合以下诊断标准： 创伤后应激障碍（PTSD）及其功能继续受到影响。此外，经历过创伤的退伍军人 与杀戮有关的自杀率很高，创伤后应激障碍症状也更严重。虽然已经很少有 研究检查 EBP 不良结果的预测因素，这一领域最近开始受到越来越多的关注 关注就是道德伤害。最近的一项研究发现，创伤后应激障碍（PTSD）和道德伤害是不同的结构，具有独特的特征。 体征和症状，初步证据表明，内疚感和愤怒感是 与战争中杀戮等创伤相关的精神伤害可能会导致症状恶化 现有治疗过程。尽管 PTSD 可能是与以下相关的心理创伤的一种表现 杀戮，杀戮影响的概念化需要一个更广泛的框架。道德观念的兴起 伤害提供了另一种背景，可以更好地理解杀戮造成的多种可能后果。为了 出于这些原因，制定有针对性的道德伤害干预措施至关重要。我们设计并收到了 VA 资助开展一项关于杀戮影响（IOK）治疗的试点随机对照试验（RCT），该试验可以 可以无缝添加为现有 PTSD EBP 的独立治疗方法。 IOK 聚焦关键主题 包括杀戮反应的生理学、精神伤害、自我宽恕和部署后的改善 重新融入社会。该治疗方法旨在很好地适应现有的护理系统，并且已被证明 改善 EBP 后的功能、PTSD 症状和一般精神症状。而 IOK RCT 试点最初是在旧金山 VA 医疗保健系统进行的，我们的目标是进行全面的 在两个不同区域的地点进行有动力的多地点疗效试验，样本量较大，并采用主动对照 健康）状况。因此，该项目的目标是测试针对 PTSD 的个体治疗的功效 与以当下为中心的治疗 (PCT) 控制条件相比，源自称为 IOK 的道德伤害，以及 确定 IOK 对于寻求 PTSD 治疗的退伍军人的康复效用。我们的主要成果是 心理社会功能。目标人群是已经开始或完成认知课程的退伍军人 处理疗法或延长暴露疗法，两次针对 PTSD 的 EBP，并继续患有 PTSD 与杀戮有关的症状和精神伤害。退伍军人将被随机分配以获得：1）IOK（10 个体治疗疗程持续 60-90 分钟）或 2）PCT（与 IOK 持续时间相同的疗程）。我们的首要目标 是通过心理社会功能（主要结果）和 PTSD 的测量来测试 IOK 的功效 严重程度（次要结果）。我们的第二个目标是确定退伍军人获得的 IOK 收益是否 耐用的。鉴于精神伤害治疗是一个新兴的新兴领域，我们有两个探索性目标： 可以帮助推动该领域向前发展。我们的第一个探索性目标是进行治疗后评估 IOK 治疗组的子集，以更好地了解如何支持功能的持续改善 参与者之间。我们的第二个探索性目标是评估功能改善的中介因素，例如 完成 IOK 的退伍军人中的自我宽恕。如果这笔赠款的目标得以实现，我们将能够 在 EBP 后进行道德伤害干预，可以无缝地融入以下患者之一的现有护理中： 退伍军人中最常见的心理健康问题。此外，自杀是国家的优先事项 对于 VHA，扩大对 PTSD 和精神伤害的治疗有可能减少自杀和 改善退伍军人的功能。最后，IOK 提供了理解战区体验的技能和方法， 随着时间的推移，退伍军人可以掌握并继续实施。