The Utility of Quantile Regression in Disaster Research

Following disasters, population-based screening programs are routinely established to assess psychological consequences of exposure. These data sets are highly skewed as only a small percentage of trauma-exposed individuals develop adverse mental health outcomes. Commonly used statistical methodology in disaster research generally involves population-averaged models, such as linear and logistic regressions. However, these models offer only a partial explanation of the complex relationships between the extent of disaster exposure, individual characteristics and adverse mental health outcomes. The aim of this report is to illustrate the benefits of using quantile regression in disaster research by analyzing the effects of a selected exposure variable, perceived threat to one’s life, and education level on post-traumatic stress symptomatology among n=2960 non-rescue disaster workers exposed to the World Trade Center (WTC) disaster in New York City on 9/11. The findings of the study are in line with previous WTC research that documented the link between perceived danger associated with disaster work, low education level and elevated post-traumatic stress symptomatology. However, the use of quantile regression demonstrates the robust and differential association between these variables throughout the entire distribution of post-traumatic stress symptomatology. Specifically, we show that the effect of high perceived danger and low education level were more strongly associated with post-traumatic stress symptoms in the upper tail of the distribution, after adjusting for covariates. Quantile regression methodology has the potential to enrich disaster research by tackling research questions that were previously unanswered. This method may be particularly useful in analyzing large population-based screening programs

D-cycloserine augmentation of exposure-based cognitive behavior therapy for anxiety, obsessive-compulsive, and posttraumatic stress disorders: a systematic review and meta-analysis of individual participant data

Importance: Whether and under which conditions D-cycloserine (DCS) augments the effects of exposure-based cognitive behavior therapy for anxiety, obsessive-compulsive, and posttraumatic stress disorders is unclear. Objective: To clarify whether DCS is superior to placebo in augmenting the effects of cognitive behavior therapy for anxiety, obsessive-compulsive, and posttraumatic stress disorders and to evaluate whether antidepressants interact with DCS and the effect of potential moderating variables. Data Sources: PubMed, EMBASE, and PsycINFO were searched from inception to February 10, 2016. Reference lists of previous reviews and meta-analyses and reports of randomized clinical trials were also checked. Study Selection: Studies were eligible for inclusion if they were (1) double-blind randomized clinical trials of DCS as an augmentation strategy for exposure-based cognitive behavior therapy and (2) conducted in humans diagnosed as having specific phobia, social anxiety disorder, panic disorder with or without agoraphobia, obsessive-compulsive disorder, or posttraumatic stress disorder. Data Extraction and Synthesis: Raw data were obtained from the authors and quality controlled. Data were ranked to ensure a consistent metric across studies (score range, 0-100). We used a 3-level multilevel model nesting repeated measures of outcomes within participants, who were nested within studies. Results: Individual participant data were obtained for 21 of 22 eligible trials, representing 1047 of 1073 eligible participants. When controlling for antidepressant use, participants receiving DCS showed greater improvement from pretreatment to posttreatment (mean difference, -3.62; 95% CI, -0.81 to -6.43; P = .01; d = -0.25) but not from pretreatment to midtreatment (mean difference, -1.66; 95% CI, -4.92 to 1.60; P = .32; d = -0.14) or from pretreatment to follow-up (mean difference, -2.98, 95% CI, -5.99 to 0.03; P = .05; d = -0.19). Additional analyses showed that participants assigned to DCS were associated with lower symptom severity than those assigned to placebo at posttreatment and at follow-up. Antidepressants did not moderate the effects of DCS. None of the prespecified patient-level or study-level moderators was associated with outcomes. Conclusions and Relevance: D-cycloserine is associated with a small augmentation effect on exposure-based therapy. This effect is not moderated by the concurrent use of antidepressants. Further research is needed to identify patient and/or therapy characteristics associated with DCS response.2018-05-0

Virtual Reality Exposure Therapy for World Trade Center Post-traumatic Stress Disorder: A Case Report

Done properly by experienced therapists, re-exposure to memories of traumatic events via imaginal exposure therapy can lead to a reduction of Post-traumatic Stress Disorder (PTSD) symptoms. Exposure helps the patient process and habituate to memories and strong emotions associated with the traumatic event: memories and emotions they have been carefully avoiding. But many patients are unwilling or unable to self-generate and re-experience painful emotional images. The present case study describes the treatment of a survivor of the World Trade Center (WTC) attack of 9-11-01 who had developed acute PTSD. After she failed to improve with traditional imaginal exposure therapy, we sought to increase emotional engagement and treatment success using virtual reality (VR) exposure therapy. Over the course of six 1-h VR exposure therapy sessions, we gradually and systematically exposed the PTSD patient to virtual planes flying over the World Trade Center, jets crashing into the World Trade Center with animated explosions and sound effects, virtual people jumping to their deaths from the burning buildings, towers collapsing, and dust clouds. VR graded exposure therapy was successful for reducing acute PTSD symptoms. Depression and PTSD symptoms as measured by the Beck Depression Inventory and the Clinician Administered PTSD Scale indicated a large (83%) reduction in depression, and large (90%) reduction in PTSD symptoms after completing VR exposure therapy. Although case reports are scientifically inconclusive by nature, these strong preliminary results suggest that VR exposure therapy is a promising new medium for treating acute PTSD. This study may be examined in more detail at www.vrpain.com

Virtual Iraq: Initial Case Reports from a VR Exposure Therapy Application for Combat-Related Post Traumatic Stress Disorder

reported to be caused by traumatic events that are outside the range of usual human experience including (but not limited to) military combat, violent personal assault, being kidnapped or taken hostage and terrorist attacks. Initial data suggests that at least 1 out of 6 Iraq War veterans are exhibiting symptoms of depression, anxiety and PTSD. Virtual Reality (VR) delivered exposure therapy for PTSD has been used with reports of positive outcomes. The aim of the current paper is to present the rationale and brief description of a Virtual Iraq PTSD VR therapy application and present initial findings from two successfully treated patients. The VR treatment environment was created via the recycling of virtual graphic assets that were initially built for the U.S. Army-funded combat tactical simulation scenario and commercially successful X-Box game, Full Spectrum Warrior, in addition to other available and newly created assets. Thus far, Virtual Iraq consists of a series of customizable virtual scenarios designed to represent relevant Middle Eastern VR contexts for exposure therapy, including a city and desert road convoy environment. User-centered design feedback needed to iteratively evolve the system was gathered from returning Iraq War veterans in the USA and from a system deployed in Iraq and tested by an Army Combat Stress Control Team. Clinical trials are currently underway at Camp Pendleton and at the San Diego Naval Medical Center and the results from two successfully treated patients are presented along with a delineation of our future plans for research and clinical care using this application. I

A proof-of-concept randomized crossover clinical trial of a first-in-class vasopressin 1a receptor antagonist for PTSD: Design, methods, and recruitment

Background: Almost eight million Americans suffer from Posttraumatic Stress Disorder (PTSD). Current PTSD drug therapies rely on repurposed antidepressants and anxiolytics, which produce undesirable side effects and have recognized compliance issues. Vasopressin represents a promising and novel target for pharmacological intervention. Logistical issues implementing a clinical trial for a novel PTSD pharmaceutical are relatively uncharted territory as trials concerning a new agent have not been published in the past several decades. All published trials have repurposed FDA-approved psychoactive medications with known risk profiles. Our recruitment challenges are discussed in this context. Methods: An 18-week proof-of-concept randomized crossover clinical trial of a first-in-class vasopressin 1a receptor antagonist (SRX246) for PTSD was conducted. All participants received SRX246 for 8 weeks, the placebo for 8 weeks, and the drug vs. placebo arms were compared. Participants were assessed every 2 weeks for PTSD symptoms as well as other medication effects. Results were expected to provide an initial demonstration of safety and tolerability in this clinical population and potentially clinical efficacy in SRX246-treated patients measured by Clinician Administered PTSD Scale (CAPS) score changes, clinical impression, and other indices compared to placebo. The primary hypothesis was that SRX246 would result in a clinically meaningful 10-point reduction in mean CAPS score compared to placebo. Discussion: This study is the first to investigate an oral vasopressin 1a receptor antagonist for PTSD. As a wave of PTSD clinical trials with new pharmaceutical compounds are beginning now, lessons learned from our recruitment challenges may be invaluable to these endeavors