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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

基本信息

批准号：
10705560
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
项目类别：
财政年份：
2019
资助国家：
美国
起止时间：
2019-04-01 至 2024-12-31
项目状态：
已结题

来源：
https://reporter.nih.gov/project-details/10705560
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 Education Evaluation Exposure to Family Feeling Funding Generations Goals Grant Guilt Healthcare Systems Impairment Individual Intervention Learning Measures Mediator Mental Health Modeling Moral injury 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 Spirituality Suicide Symptoms Target Populations Testing Thinking Time Trauma Veterans Veterans Health Administration Visit Waiting Lists War Work active control care systems combat combat veteran cost design diagnostic criteria efficacy testing efficacy trial evidence base expectation experience follow up assessment follow-up forgiveness functional disability functional gain functional improvement improved novel pilot trial prevent primary outcome psychiatric symptom psychological distress psychological trauma psychosocial response secondary outcome skills stem suicidal suicide rate symptomatic improvement treatment group

项目摘要

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）现在是最常见的心理健康诊断中最年轻的一代退伍军人接受退伍军人健康管理局（VHA）的治疗，需要需要多种类型的针对性护理。虽然有两种循证心理疗法（EBP）， PTSD，绝大多数接受这些治疗的退伍军人仍然符合诊断标准， 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人有关的人自杀率高，PTSD症状更严重。虽然很少有研究检查EBPs不良结局的预测因素，这是一个最近开始受到越来越多关注的领域。注意力是道德伤害。最近的一项研究发现，创伤后应激障碍和精神伤害是不同的结构，具有独特的迹象和症状，初步证据表明，内疚和愤怒的感觉，特点是与创伤有关的精神伤害，如战争中的杀戮，可能会导致症状恶化，现有的治疗方法。虽然创伤后应激障碍可能是心理创伤的一种表现，杀害，杀害的影响的概念化需要一个更广泛的框架。新兴的道德概念伤害为更好地理解接触杀戮的许多可能后果提供了另一种背景。为因此，制定有针对性的精神伤害干预措施至关重要。我们设计并接收了VA 资助进行一项关于杀伤作用（IOK）治疗的试点随机对照试验（RCT），无缝地添加为一个独立的治疗后，现有的EBP创伤后应激障碍。IOK专注于关键主题包括杀人反应的生理学、道德伤害、自我宽恕和改进后部署重新融入社会这种治疗方法的设计是为了很好地适应现有的护理系统，改善EBP后的功能、PTSD症状和一般精神症状。而IOK RCT试点最初在旧金山弗朗西斯科医疗保健系统进行，我们的目标是进行全面的- 在两个地区不同的研究中心进行的具有更大样本量和活性对照的把握度、多中心疗效试验条件因此，本项目的目的是测试PTSD个体治疗的有效性与以现在为中心的治疗（PCT）对照条件相比，以确定IOK对寻求创伤后应激障碍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的退伍军人处理治疗或延长暴露治疗，两种创伤后应激障碍的EBP，并继续患有创伤后应激障碍与杀人有关的症状和精神伤害退伍军人将被随机分配接受：1）IOK（10 个体治疗疗程持续60-90分钟）或2）PCT（疗程持续时间与IOK相同）。我们的首要目标是通过测量心理社会功能（主要结果）和PTSD来测试IOK的疗效严重程度（次要结局）。我们的第二个目标是确定退伍军人的IOK收益是否耐用.鉴于精神伤害治疗是一个新兴的领域，我们有两个探索性的目标，可以帮助推动这一领域的发展我们的第一个探索性目标是进行治疗后评估， IOK治疗组的一个子集，以更好地了解如何支持功能的持续改善在参与者中。我们的第二个探索性目标是评估功能改善的介质，如在完成IOK的退伍军人中，自我宽恕。如果这笔赠款的目标得以实现，我们将能够在EBP之后进行道德伤害干预，可以无缝地整合到现有的护理中，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扩大对创伤后应激障碍和精神伤害的治疗有可能减少自杀，改善退伍军人的工作。最后，IOK提供了理解战区经验的技能和方法，可以掌握，并可以继续实施的退伍军人随着时间的推移。