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）现在是最年轻的心理健康诊断 从退伍军人卫生管理局（VHA）接受治疗的退伍军人的产生，需要 需要各种类型的目标护理。尽管有两个基于证据的心理治疗（EBP） PTSD，获得这些治疗方法的绝大多数战斗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，经历了创伤的退伍军人 与杀戮有关的自杀率很高，PTSD症状更为严重。虽然很少 研究了EBP中结果不佳的预测指标，该领域最近开始接受增长 注意是道德伤害。最近的一项研究发现，PTSD和道德损伤是独特的不同构造 体征和症状以及初步证据表明，特征的内gui和愤怒感 与创伤相关的道德伤害，例如战争中的杀戮可能导致症状恶化 现有治疗过程。尽管PTSD可能是与 杀戮，杀戮影响的概念化需要更广泛的框架。道德的新兴概念 伤害提供了另一种环境，可以更好地了解接触杀戮的许多可能结果。为了 这些原因，有针对性的道德伤害干预措施的发展至关重要。我们设计并收到了VA 进行杀戮影响（IOK）治疗影响的飞行员随机对照试验（RCT）的资金，可以 在现有的PTSD现有EBP之后，将无缝添加为独立治疗。 IOK专注于关键主题 包括杀人反应，道德伤害，自我宽恕和改善后部署的生理学 重新整合。该处理旨在很好地适合已经存在的护理系​​统，并已显示 为了改善EBP之后的功能，PTSD症状和一般精神病症状。而iok RCT飞行员最初是在旧金山VA医疗保健系统进行的，我们的目标是进行一次 在两个区域多样性地点，具有较大样本量和主动控制的区域多样性位点有能力的多站点功效试验 健康）状况。因此，该项目的目的是测试个人治疗对PTSD的功效 与以现为中心的治疗（PCT）控制条件相比，由称为IOK的道德伤害，以及 确定IOK对退伍军人寻求PTSD治疗的康复效用。我们的主要结果是 社会心理功能。目标人群是已经发起或完成认知的退伍军人 加工疗法或长时间暴露疗法，两种用于PTSD的EBP，并继续具有PTSD 症状和与杀戮有关的道德伤害。退伍军人将被随机分配要接收：1）IOK（10 持续60-90分钟的个体治疗课程）或2）PCT（与IOK相同持续时间的课程）。我们的第一个目标 是通过心理社会功能（主要结果）和PTSD来测试IOK的功效 严重程度（次要结果）。我们的第二个目的是确定退伍军人的IOK收益是否 耐用的。鉴于道德伤害待遇是一个新的新兴领域，我们有两个探索性目标 可以帮助向前推进场地。我们的第一个探索目的是用 IOK治疗小组的子集，以更好地了解如何支持持续改进功能 在参与者中。我们的第二个探索目的是评估功能改进的调解人，例如 在完成IOK的退伍军人中，自负。如果实现了这笔赠款的目标，我们将能够 在EBP之后进行道德伤害干预措施，可以将其无缝整合到现有的护理中之一 退伍军人中最常见的心理健康问题。此外，自杀是国家优先事项 对于VHA，以及扩大PTSD和道德损伤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式 随着时间的推移，可以掌握退伍军人，可以继续由退伍军人实施。