Publications by authors named "Sean Cowlishaw"

49 Publications

Modelling the relationship between poor sleep and problem anger in veterans: A dynamic structural equation modelling approach.

J Psychosom Res 2021 11 8;150:110615. Epub 2021 Sep 8.

Phoenix Australia - Centre for Posttraumatic Mental Health, Centenary of Anzac Centre, Department of Psychiatry, University of Melbourne, Australia.

Objective: Problem anger and poor sleep are common, particularly in military and veteran populations, but the nature of the relationship is poorly understood, and treatment approaches would benefit from improved understanding of how these constructs interact. Ecological momentary assessment (EMA) is suitable for monitoring day-to-day fluctuations in symptoms, and modelling dynamic relationships between variables.

Methods: This study aimed to examine these fluctuations and relationships involving sleep quality and anger experiences among veterans. A sample of n = 60 veterans with problem anger as assessed by the recommended cut off on the Dimensions of Anger Reactions 5 scale (DAR-5) completed daily assessments of sleep quality and four times daily assessments of anger frequency, over a 10-day period.

Results: A Dynamic Structural Equation Model (DESM) estimated and revealed a unidirectional relationship across daily measurements, in that previous night poor sleep quality was associated with more frequent anger on the next day (φASi Estimate -0.791, one-tailed p = .075), but not the reverse.

Conclusions: These are the first longitudinal, naturalistic findings in relation to anger and sleep in a sample self-identifying with significant anger problems. The observed patterns point to the need for further research on mechanisms underpinning this relationship, and raises potential for early intervention for problem anger to include a focus on improving sleep quality.
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http://dx.doi.org/10.1016/j.jpsychores.2021.110615DOI Listing
November 2021

Cross-lagged analyses of anger and PTSD symptoms among veterans in treatment.

Psychol Trauma 2021 Aug 26. Epub 2021 Aug 26.

Phoenix Australia Center for Posttraumatic Mental Health.

Objective: Anger is a salient feature of posttraumatic mental health which is linked to posttraumatic stress disorder (PTSD) and may have implications for treatment. However, the nature of associations involving anger and PTSD remains unclear. The aim of the present study was to examine bidirectional influences involving anger and International Classification of Diseases (ICD)-11 PTSD symptom clusters over time among treatment-seeking veterans.

Method: Current or ex-serving members ( = 742; 92.4% male) who participated in an accredited outpatient PTSD treatment program were administered measures of PTSD symptoms (PTSD checklist for 5th edition [PCL-5]) and anger (Dimensions of Anger Reactions Scale-5 [DAR-5]) at treatment intake, discharge, and three-month follow-up. Bidirectional influences were assessed using cross-lagged panel analyses.

Results: The majority of participants (78%) exhibited significant anger problems at intake. Cross-lagged analyses showed anger was associated with relative increases in PTSD symptoms of intrusive reexperiencing and avoidance at posttreatment, whereas no reverse effects of any PTSD symptoms on anger were observed. Anger continued to influence changes in heightened sense of threat and avoidance symptoms at three-months posttreatment.

Conclusions: Anger influences change in specific PTSD symptoms over time among military veterans in treatment and may interfere with treatments for PTSD. Veterans who present to clinical services with anger problems may benefit from anger interventions prior to commencing trauma-focused treatment. The findings have additional implications for conceptual models of the relationship between anger and PTSD. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
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http://dx.doi.org/10.1037/tra0001084DOI Listing
August 2021

Piloting a scalable, post-trauma psychosocial intervention in Tuvalu: the Skills for Life Adjustment and Resilience (SOLAR) program.

Eur J Psychotraumatol 2021 6;12(1):1948253. Epub 2021 Aug 6.

Phoenix Australia Centre for Posttraumatic Mental Health, The University of Melbourne, Carlton, VIC, Australia.

Background: The Skills for Life Adjustment and Resilience (SOLAR) programme is a brief, scalable, psychosocial skill-building programme designed to reduce distress and adjustment difficulties following disaster.

Objectives: We tested the feasibility, acceptability, efficacy and safety of a culturally adapted version of SOLAR in two remote, cyclone-affected communities in the Pacific Island nation of Tuvalu.

Method: This pilot adopted a quasi-experimental, control design involving 99 participants. SOLAR was administered to the treatment group ( = 49) by local, non-specialist facilitators (i.e. 'Coaches') in a massed, group format across 5 consecutive days. The control group ( = 50) had access to Usual Care (UC). We compared group differences (post-intervention vs. post-control) with psychological distress being the primary outcome. We also examined whether changes were maintained at 6-month follow-up.

Results: Large, statistically significant group differences in psychological distress were observed after controlling for baseline scores in favour of the SOLAR group. Mean group outcomes were consistently lower at 6-month follow-up than at baseline. SOLAR was found to be acceptable and safe, and programme feedback from participants and Coaches was overwhelmingly positive.

Conclusions: Findings contribute to emerging evidence that SOLAR is a flexible, culturally adaptable and scalable intervention that can support individual recovery and adjustment in the aftermath of disaster. RCTs to strengthen evidence of SOLAR's efficacy are warranted.
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http://dx.doi.org/10.1080/20008198.2021.1948253DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8354170PMC
August 2021

A Longitudinal Exploration of Self-Reported Hearing Loss, Tinnitus, and Posttraumatic Stress Disorder Treatment Outcomes in Australian Veterans.

Psychosom Med 2021 10;83(8):863-869

From the Phoenix Australia Centre for Posttraumatic Mental Health, Department of Psychiatry, The University of Melbourne, Melbourne, Australia.

Objective: Tinnitus, hearing loss, and posttraumatic stress disorder (PTSD) are common conditions among veterans. Shared underlying symptoms, such as hypervigilance and heightened sense of threat, may interfere with talk-based psychological treatments. The aim was to investigate the prevalence and risk factors for self-reported tinnitus and hearing loss among Australian treatment-seeking veterans, as well as links with PTSD symptoms and quality of life (QOL) after treatment.

Methods: Australian veterans participating in hospital-based PTSD treatment (n = 523) completed self-report measures of subjective hearing impairment, service-related factors, PTSD symptoms, and QOL at treatment intake and discharge, as well as 3- and 9-month follow-ups. Univariate analyses of covariance modeled symptom change over time.

Results: More than half of veterans on PTSD treatment self-reported doctor-diagnosed hearing loss or tinnitus, whereas 43% reported both. However, 75% reported subjective mild to moderate hearing impairment, and only 1% reported severe impairment. Service-related factors, such as longer length of service and exposure to explosions, were risk factors for having any hearing condition. After controlling for intake scores, there were no significant differences on PTSD or QOL outcomes over time between those with and without hearing conditions.

Conclusions: Although self-reported tinnitus and hearing loss are prevalent among veterans, those with severe hearing impairments are unlikely to be represented in this context. There is a need for psychological treatments that are accessible to patients with severe hearing impairments, which should be examined routinely among military members accessing psychological treatments.
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http://dx.doi.org/10.1097/PSY.0000000000000978DOI Listing
October 2021

Cross-Lagged Relationships Between Insomnia and Posttraumatic Stress Disorder in Treatment-Receiving Veterans.

Behav Ther 2021 07 5;52(4):982-994. Epub 2021 Jan 5.

Phoenix Australia-Centre for Posttraumatic Mental Health and University of Melbourne.

Insomnia is a risk factor for the development of posttraumatic stress disorder (PTSD) while it is also plausible that PTSD symptoms can maintain insomnia symptoms. The present study examined longitudinal bidirectional relationships between insomnia and PTSD symptoms in treatment-seeking veterans. Participants were 693 ex-serving members of the Australian Defence Force who participated in an accredited, hospital-based outpatient PTSD program. Participants completed self-reported assessments of PTSD and insomnia symptoms at four time points: intake, discharge, 3-month, and 9-months posttreatment follow-up. Cross-lagged pathway analyses indicated significant bi-directional pathways between insomnia symptoms and PTSD symptoms at most time points. A final cross-lagged model between insomnia symptoms and the PTSD symptom clusters indicated that the PTSD symptom paths on insomnia symptoms, between intake and discharge, were attributable to reexperiencing PTSD symptoms. In contrast, across posttreatment follow-up time points there were significant paths of insomnia symptoms on all PTSD symptom clusters except from insomnia at 3-months to avoidance symptom at 9-months. PTSD symptoms and insomnia symptoms have bidirectional associations over time that may lead to the mutual maintenance or exacerbation of each condition following PTSD treatment. Where residual insomnia symptoms are present post-treatment, a sleep-focussed intervention is indicated and a sequenced approach to treatment recommended.
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http://dx.doi.org/10.1016/j.beth.2020.12.006DOI Listing
July 2021

Potential impacts of general practitioners working in or alongside emergency departments in England: initial qualitative findings from a national mixed-methods evaluation.

BMJ Open 2021 05 24;11(5):e045453. Epub 2021 May 24.

York Trials Unit, Department of Health Sciences, University of York, York, North Yorkshire, UK.

Objectives: To explore the potential impacts of introducing General Practitioners into Emergency Departments (GPED) from the perspectives of service leaders, health professionals and patients. These 'expectations of impact' can be used to generate hypotheses that will inform future implementations and evaluations of GPED.

Design: Qualitative study consisting of 228 semistructured interviews.

Setting: 10 acute National Health Service (NHS) hospitals and the wider healthcare system in England. Interviews were undertaken face to face or via telephone. Data were analysed thematically.

Participants: 124 health professionals and 94 patients and carers. 10 service leaders representing a range of national organisations and government departments across England (eg, NHS England and Department of Health) were also interviewed.

Results: A range of GPED models are being implemented across the NHS due to different interpretations of national policy and variation in local context. This has resulted in stakeholders and organisations interpreting the aims of GPED differently and anticipating a range of potential impacts. Participants expected GPED to affect the following areas: ED performance indicators; patient outcome and experience; service access; staffing and workforce experience; and resources. Across these 'domains of influence', arguments for positive, negative and no effect of GPED were proposed.

Conclusions: Evaluating whether GPED has been successful will be challenging. However, despite uncertainty surrounding the direction of effect, there was agreement across all stakeholder groups on the areas that GPED would influence. As a result, we propose eight domains of influence that will inform our subsequent mixed-methods evaluation of GPED.

Trial Registration Number: ISRCTN51780222.
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http://dx.doi.org/10.1136/bmjopen-2020-045453DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8149439PMC
May 2021

Prevalence and treatment implications of ICD-11 complex PTSD in Australian treatment-seeking current and ex-serving military members.

Eur J Psychotraumatol 2021 Feb 12;12(1):1844441. Epub 2021 Feb 12.

Phoenix Australia Centre for Posttraumatic Mental Health, Department of Psychiatry, The University of Melbourne, Australia.

: Despite growing support for the distinction between posttraumatic stress disorder (PTSD) and complex PTSD (CPTSD) as separate diagnoses within the ICD-11 psychiatric taxonomy, the prevalence and treatment implications of CPTSD among current and ex-serving military members have not been established. : The study aims were to a) establish the prevalence of provisional ICD-11 CPTSD diagnosis relative to PTSD in an Australian sample of treatment-seeking current and ex-serving military members, and b) examine the implications of CPTSD diagnosis for intake profile and treatment response. : The study analysed data collected routinely from Australian-accredited treatment programmes for military-related PTSD. Participants were 480 current and ex-serving military members in this programmes who received a provisional ICD-11 diagnosis of PTSD or CPTSD at intake using proxy measures. Measures of PTSD symptoms, disturbances in self-organisation, psychological distress, mental health and social relationships were considered at treatment intake, discharge, and 3-month follow-up. : Among participants with a provisional ICD-11 diagnosis, 78.2% were classified as having CPTSD, while 21.8% were classified as having PTSD. When compared to ICD-11 PTSD, participants with CPTSD reported greater symptom severity and psychological distress at intake, and lower scores on relationship and mental health dimensions of the quality of life measure. These relative differences persisted at each post-treatment assessment. Decreases in PTSD symptoms between intake and discharge were similar across PTSD (d  = -0.81) and CPTSD (d  = -0.76) groups, and there were no significant post-treatment differences between groups when controlling for initial scores. : CPTSD is common among treatment-seeking current and ex-serving military members, and is associated with initially higher levels of psychiatric severity, which persist over time. Participants with CPTSD were equally responsive to PTSD treatment; however, the tendency for those with CPTSD to remain highly symptomatic post-treatment suggests additional treatment components should be considered.
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http://dx.doi.org/10.1080/20008198.2020.1844441DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8128128PMC
February 2021

"I always walked out with an empty purse." Older adults' engagement with electronic gambling machines in Victoria, Australia.

Health Promot J Austr 2021 May 13. Epub 2021 May 13.

Institute for Health Transformation, Faculty of Health, Deakin University, Geelong, Australia.

Issue Addressed: Older adults are at an increased risk of experiencing gambling harm, which may be due to their use of high-intensity gambling products such as electronic gambling machines (EGMs). However, little research has explored the motivations behind older adults' engagement with EGMs, their understanding of the structural characteristics of EGMs, or their perceptions of risk associated with EGM gambling. This paper aims to address this gap in the literature.

Methods: Focus groups were conducted in Melbourne, Australia with n = 126 adults aged 55+, who had attended a club or pub in the last 12 months. Topics included EGM attitudes and behaviours, structural characteristics of EGMs, and the potential risks associated with EGM gambling. Thematic analysis was used to interpret the data.

Results: For most participants, EGM gambling was secondary to their participation in other activities available within venues. Participants identified structural characteristics of EGMs; however, there were some misconceptions about how EGMs operated, including how or why machines paid out. Most participants perceived that they were not at risk of gambling harm because they engaged in "responsible" gambling practices such as setting limits.

Conclusions: Older adults often engaged in EGM gambling because of its availability in community-based venues. Older adults' perception that they are implementing responsible gambling practices may be increasing their susceptibility to harm. SO WHAT?: There is a need to reduce the availability and accessibility of EGMs in community settings and develop public education programs that are tailored to the needs of older adults.
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http://dx.doi.org/10.1002/hpja.500DOI Listing
May 2021

Defining post-traumatic stress disorder recovery in veterans: Benchmarking symptom change against functioning indicators.

Stress Health 2021 Aug 28;37(3):547-556. Epub 2020 Dec 28.

Department of Psychiatry, Phoenix Australia- Centre for Posttraumatic Mental Health, University of Melbourne, Melbourne, Australia.

Improved metrics of Post-traumatic stress disorder (PTSD) treatment response that extend beyond a focus on symptom reduction to incorporate meaningful, patient-centred indicators of functioning are needed in veteran populations. The aim of this study was to extend previous research by investigating whether indicators of functioning can successfully distinguish against symptom response categories derived from the Post-Traumatic Stress Disorder Checklist (PCL-5) pre- and post- PTSD treatment. Participants were 472 veterans receiving hospital-based treatment for PTSD. In addition to the PCL-5, measures included quality of life, social relationships, physical health and psychological distress. Four mutually exclusive, progressive response categories were used to define treatment response including: No Response, Response, Response and Below Threshold, and Remission. PTSD symptom reductions were associated with corresponding improvements in broader indicators of functioning. However, it was only when the magnitude of symptom reduction placed the individual in the 'Response and Below Threshold' category that improvement on functioning measures achieved levels indicative of a good end state. Traditional metrics of treatment 'response' in PTSD treatment do not necessarily indicate recovery on important functioning indicators. Only when an individual both responds to treatment and drops below threshold for probable disorder are they likely to report having meaningful levels of functioning.
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http://dx.doi.org/10.1002/smi.3019DOI Listing
August 2021

Treatment interventions to maintain abstinence from alcohol in primary care: systematic review and network meta-analysis.

BMJ 2020 11 25;371:m3934. Epub 2020 Nov 25.

Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK

Objective: To determine the most effective interventions in recently detoxified, alcohol dependent patients for implementation in primary care.

Design: Systematic review and network meta-analysis.

Data Sources: Medline, Embase, PsycINFO, Cochrane CENTRAL, ClinicalTrials.gov, and the World Health Organization's International Clinical Trials Registry Platform.

Study Selection: Randomised controlled trials comparing two or more interventions that could be used in primary care. The population was patients with alcohol dependency diagnosed by standardised clinical tools and who became detoxified within four weeks.

Data Extraction: Outcomes of interest were continuous abstinence from alcohol (effectiveness) and all cause dropouts (as a proxy for acceptability) at least 12 weeks after start of intervention.

Results: 64 trials (43 interventions) were included. The median probability of abstinence across placebo arms was 25%. Compared with placebo, the only intervention associated with increased probability of abstinence and moderate certainty evidence was acamprosate (odds ratio 1.86, 95% confidence interval 1.49 to 2.33, corresponding to an absolute probability of 38%). Of the 62 included trials that reported all cause dropouts, interventions associated with a reduced number of dropouts compared with placebo (probability 50%) and moderate certainty of evidence were acamprosate (0.73, 0.62 to 0.86; 42%), naltrexone (0.70, 0.50 to 0.98; 41%), and acamprosate-naltrexone (0.30, 0.13 to 0.67; 17%). Acamprosate was the only intervention associated with moderate confidence in the evidence of effectiveness and acceptability up to 12 months. It is uncertain whether other interventions can help maintain abstinence and reduce dropouts because of low confidence in the evidence.

Conclusions: Evidence is lacking for benefit from interventions that could be implemented in primary care settings for alcohol abstinence, other than for acamprosate. More evidence from high quality randomised controlled trials is needed, as are strategies using combined interventions (combinations of drug interventions or drug and psychosocial interventions) to improve treatment of alcohol dependency in primary care.

Systematic Review Registration: PROSPERO CRD42016049779.
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http://dx.doi.org/10.1136/bmj.m3934DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7687021PMC
November 2020

Treatment interventions to maintain abstinence from alcohol in primary care: systematic review and network meta-analysis.

BMJ 2020 11 25;371:m3934. Epub 2020 Nov 25.

Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK

Objective: To determine the most effective interventions in recently detoxified, alcohol dependent patients for implementation in primary care.

Design: Systematic review and network meta-analysis.

Data Sources: Medline, Embase, PsycINFO, Cochrane CENTRAL, ClinicalTrials.gov, and the World Health Organization's International Clinical Trials Registry Platform.

Study Selection: Randomised controlled trials comparing two or more interventions that could be used in primary care. The population was patients with alcohol dependency diagnosed by standardised clinical tools and who became detoxified within four weeks.

Data Extraction: Outcomes of interest were continuous abstinence from alcohol (effectiveness) and all cause dropouts (as a proxy for acceptability) at least 12 weeks after start of intervention.

Results: 64 trials (43 interventions) were included. The median probability of abstinence across placebo arms was 25%. Compared with placebo, the only intervention associated with increased probability of abstinence and moderate certainty evidence was acamprosate (odds ratio 1.86, 95% confidence interval 1.49 to 2.33, corresponding to an absolute probability of 38%). Of the 62 included trials that reported all cause dropouts, interventions associated with a reduced number of dropouts compared with placebo (probability 50%) and moderate certainty of evidence were acamprosate (0.73, 0.62 to 0.86; 42%), naltrexone (0.70, 0.50 to 0.98; 41%), and acamprosate-naltrexone (0.30, 0.13 to 0.67; 17%). Acamprosate was the only intervention associated with moderate confidence in the evidence of effectiveness and acceptability up to 12 months. It is uncertain whether other interventions can help maintain abstinence and reduce dropouts because of low confidence in the evidence.

Conclusions: Evidence is lacking for benefit from interventions that could be implemented in primary care settings for alcohol abstinence, other than for acamprosate. More evidence from high quality randomised controlled trials is needed, as are strategies using combined interventions (combinations of drug interventions or drug and psychosocial interventions) to improve treatment of alcohol dependency in primary care.

Systematic Review Registration: PROSPERO CRD42016049779.
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http://dx.doi.org/10.1136/bmj.m3934DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7687021PMC
November 2020

Gambling problems among military personnel after deployment.

J Psychiatr Res 2020 12 4;131:47-53. Epub 2020 Aug 4.

Phoenix Australia Centre for Posttraumatic Mental Health, Department of Psychiatry, The University of Melbourne, Australia; University of Adelaide, Adelaide, Australia.

Military and veteran populations may exhibit heightened vulnerability to gambling problems; however, there is scant relevant evidence outside the US, and few studies of transition periods, including return from operational deployment. The aim of this study was thus to highlight the extent, risk-factors, and implications of gambling problems among current members of the Australian Defence Force (ADF) following deployment to the Middle East Area of Operations (MEAO). It involved analyses of data from n = 1324 ADF personnel who deployed between 2010 and 2012, and completed surveys within four months of returning to Australia. The Problem Gambling Severity Index (PGSI) identified Problem Gambling (PG: PGSI ≥5) and At-Risk Gambling (ARG: PGSI 1-4), alongside measures of Depression (PHQ-9), Posttraumatic Stress Disorder (PCL-C), alcohol use problems (AUDIT), distress (K10), and post-deployment stressors. Analyses indicated that 7.7% of personnel reported at least some gambling problems post-deployment, including 2.0% that were distinguished by PG, and 5.7% indicating ARG. These figures were comparable to conditions including probable depression and alcohol dependence, while levels of any gambling problems were high relative to harmful drinking. Higher levels were observed among personnel who were aged 18-24, reported 0-4 years of military service, served in the Army, and comprised Non-Commissioned Officers/Other Ranks. There were strong associations with gambling problems and various indicators of mental health and wellbeing, and self-reported post-deployment difficulties. The findings indicate that gambling problems are salient concerns for some Australian military personnel post-deployment, and highlight the need for increased recognition and responses to these problems.
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http://dx.doi.org/10.1016/j.jpsychires.2020.07.035DOI Listing
December 2020

An Open Label Pilot Study of a Brief Psychosocial Intervention for Disaster and Trauma Survivors.

Front Psychiatry 2020 26;11:483. Epub 2020 Jun 26.

Phoenix Australia Centre for Posttraumatic Mental Health, The University of Melbourne, Carlton, VIC, Australia.

Background: In the aftermath of disaster, a large proportion of people will develop psychosocial difficulties that impair recovery, but for which presentations do not meet threshold criteria for disorder. Although these adjustment problems can cause high distress and impairment, and often have a trajectory towards mental health disorder, few evidence-based interventions are available to facilitate recovery.

Objective: This paper describes the development and pilot testing of an internationally developed, brief, and scalable psychosocial intervention that targets distress and poor adjustment following disaster and trauma.

Method: The Skills fOr Life Adjustment and Resilience (SOLAR) program was developed by an international collaboration of trauma and disaster mental health experts through an iterative expert consensus process. The resulting five session, skills-based intervention, deliverable by community-based or frontline health or disaster workers with little or no formal mental health training (known as coaches), was piloted with 15 Australian bushfire survivors using a pre-post with follow up, mixed-methods design study.

Results: Findings from this pilot demonstrated that the SOLAR program was safe and feasible for non-mental health frontline workers (coaches) to deliver locally after two days of training. Participants' attendance rates and feedback about the program indicated that the program was acceptable. Pre-post quantitative analysis demonstrated reductions in psychological distress, posttraumatic stress symptoms, and impairment.

Conclusions: This study provides preliminary evidence that the delivery of the SOLAR program after disaster by trained, frontline workers with little or no mental health experience is feasible, acceptable, safe, and beneficial in reducing psychological symptoms and impairment among disaster survivors. Randomized controlled trials of the SOLAR program are required to advance evidence of its efficacy.
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http://dx.doi.org/10.3389/fpsyt.2020.00483DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7332836PMC
June 2020

Exploring Theta Burst Stimulation for Post-traumatic Stress Disorder in Australian Veterans-A Pilot Study.

Mil Med 2020 09;185(9-10):e1770-e1778

Epworth Centre for Innovation in Mental Health (ECIMH), 888 Toorak Rd, Camberwell, Victoria 3124, Australia.

Introduction: Post-traumatic stress disorder (PTSD) is a severe and debilitating condition affecting a significant proportion of the veteran community. A substantial number of veterans with PTSD fail to benefit from trauma-focused psychological therapies or pharmacotherapy or are left with residual symptoms, and therefore, investigation of new and innovative treatment is required. Theta Burst Stimulation (TBS) is a novel form of Repetitive Transcranial Magnetic Stimulation, which has been shown to improve depression symptoms and associated cognitive deficits. The current pilot study aimed to explore the acceptability, safety, and tolerability of intermittent TBS (iTBS) as a treatment for PTSD in Australian veterans.

Materials And Methods: This study employed a case series, repeated-measures design. Eight Australian Defence Force veterans with PTSD received 20 bilateral iTBS treatments (1 session per day, 5 days per week over a 4-week period) and were assessed on a range of mental health and neuropsychological measures, including the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) and Hamilton Depression Rating Scale (HAM-D), at pretreatment, post-treatment, and a 3-month follow-up.

Results: Treatment was generally welltolerated, with reported side-effects including mild to moderate site-specific cranial pain and headaches during stimulation, which were relieved with the use of low dose analgesics. No serious side effects or adverse events were reported. Participants exhibited reductions in both PTSD and depression symptom severity (the repeated-measures effect size [dRM] for the CAPS-5 was -1.78, and the HAM-D was -1.16 post-treatment), as well as improvements in working memory and processing speed. Although significance cannot be inferred, these preliminary estimates of effect size indicate change over time.

Conclusions: Bilateral iTBS appears to be welltolerated by Australian veterans. Within this repeated-measures case series, iTBS treatment shows promise in reducing both PTSD and mood symptoms, as well as improving cognitive difficulties associated with these disorders. Large-scale randomized controlled trials of this promising treatment are warranted.
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http://dx.doi.org/10.1093/milmed/usaa149DOI Listing
September 2020

Posttraumatic Stress Disorder in Primary Care: A Study of General Practices in England.

J Clin Psychol Med Settings 2021 09;28(3):427-435

Centre for Academic Primary Care, Population Health Sciences, University of Bristol, Bristol, UK.

Posttraumatic Stress Disorder (PTSD) may be a common issue in primary care in the UK, but there have been no studies of all-cause PTSD in general samples of attenders in this country. The current paper thus explores the extent and distribution of probable PTSD among patients attending general practices in England. Cross-sectional survey data from adult patients (n = 1058) attending 11 general practices in southwest England were analysed. Patients were recruited from waiting rooms and completed anonymous questionnaires, including measures of depression, anxiety and risky alcohol use. Current probable PTSD was measured using the 4-item Primary Care PTSD Scale (PC-PTSD). Results indicated 15.1% of patients that exhibited probable PTSD (PC-PTSD ≥ 3), with higher levels observed in practices from deprived areas. There were 53.8% of patients with probable PTSD that expressed the desire for help with these issues. The analyses suggested that rates were lowest among older adults, and highest among patients who were not in cohabitating relationships or were unemployed. Measures of anxiety and depression were associated with 10-fold and 16-fold increases in risk of probable PTSD, respectively, although there were no discernible associations with risky drinking. Such preliminary findings highlight the need for vigilance for PTSD in routine general practice in the UK, and signal a strong need for additional research and attention in this context.
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http://dx.doi.org/10.1007/s10880-020-09732-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7318731PMC
September 2021

The impact of received social support on posttraumatic growth after disaster: The importance of both support quantity and quality.

Psychol Trauma 2020 Jan 2. Epub 2020 Jan 2.

Phoenix Australia - Centre for Posttraumatic Mental Health.

Objective: Few studies have investigated the relationship between received social support (actual help received) and posttraumatic growth (PTG), and these studies focused only on the quantity of support received. This study examined the joint implications of both the quantity and quality of postdisaster received social support for PTG.

Method: Data were collected from Lushan earthquake (China, in 2013) survivors at 7 ( = 199) and 31 ( = 161) months after the earthquake. The main effects of quantity and quality of received support, and the interaction between support quantity and support quality, were examined using hierarchical multiple regression analyses controlling for the extent of disaster exposure, postdisaster negative life events, and sociodemographic factors.

Results: Neither quantity nor quality of received social support exerted significant main effects on PTG. However, the influence of the amount of received social support on PTG was moderated by the quality of received social support. Among survivors who appraised the postdisaster social support they received as higher in quality, greater amounts of received support were associated with more subsequent PTG. Among those survivors who appraised the postdisaster social support they received as lower in quality, greater quantity of received support was associated with lower levels of reported PTG.

Conclusion: This study calls attention to the importance of enhancing the quality of help provided to disaster survivors because simply "more" support is not necessarily better. (PsycINFO Database Record (c) 2020 APA, all rights reserved).
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http://dx.doi.org/10.1037/tra0000541DOI Listing
January 2020

Couple and family therapies for post-traumatic stress disorder (PTSD).

Cochrane Database Syst Rev 2019 12 4;12:CD011257. Epub 2019 Dec 4.

The University of Melbourne, Phoenix Australia Centre for Posttraumatic Mental Health, Department of Psychiatry, Melbourne, Australia.

Background: Post-traumatic stress disorder (PTSD) refers to an anxiety or trauma- and stressor-related disorder that is linked to personal or vicarious exposure to traumatic events. PTSD is associated with a range of adverse individual outcomes (e.g. poor health, suicidality) and significant interpersonal problems which include difficulties in intimate and family relationships. A range of couple- and family-based treatments have been suggested as appropriate interventions for families impacted by PTSD.

Objectives: The objectives of this review were to: (1) assess the effects of couple and family therapies for adult PTSD, relative to 'no treatment' conditions, 'standard care', and structured or non-specific individual or group psychological therapies; (2) examine the clinical characteristics of studies that influence the relative effects of these therapies; and (3) critically evaluate methodological characteristics of studies that may bias the research findings.

Search Methods: We searched MEDLINE (1950- ), Embase (1980- ) and PsycINFO (1967- ) via the Cochrane Common Mental Disorders Controlled Trials Register (CCMDCTR) to 2014, then directly via Ovid after this date. We also searched the Cochrane Central Register of Controlled Trials (CENTRAL) via the Cochrane Library. We conducted supplementary searches of PTSDPubs (all available years) (this database is formerly known as PILOTS (Published International Literature on Traumatic Stress)). We manually searched the early editions of key journals and screened the reference lists and bibliographies of included studies to identify other relevant research. We also contacted the authors of included trials for unpublished information. Studies have been incorporated from searches to 3 March 2018.

Selection Criteria: Eligible studies were randomised controlled trials (RCTs) of couple or family therapies for PTSD in adult samples. The review considered any type of therapy that was intended to treat intact couples or families where at least one adult family member met criteria for PTSD. It was required that participants were diagnosed with PTSD according to recognised classification systems.

Data Collection And Analysis: We used the standard methodological procedures prescribed by Cochrane. Three review authors screened all titles and abstracts and two authors independently extracted data from each study deemed eligible and assessed the risk of bias for each study. We used odds ratios (OR) to summarise the effects of interventions for dichotomous outcomes, and standardised mean differences (SMD) to summarise post-treatment between-group differences on continuous measures.

Main Results: We included four trials in the review. Two studies examined the effects of cognitive behavioural conjoint/couple's therapy (CBCT) relative to a wait list control condition, although one of these studies only reported outcomes in relation to relationship satisfaction. One study examined the effects of structural approach therapy (SAT) relative to a PTSD family education (PFE) programme; and one examined the effects of adjunct behavioural family therapy (BFT) but failed to report any outcome variables in sufficient detail - we did not include it in the meta-analysis. One trial with 40 couples (80 participants) showed that CBCT was more effective than wait list control in reducing PTSD severity (SMD -1.12, 95% CI -1.79 to -0.45; low-quality evidence), anxiety (SMD -0.93, 95% CI -1.58 to -0.27; very low-quality evidence) and depression (SMD -0.66, 95% CI -1.30 to -0.02; very low-quality evidence) at post-treatment for the primary patient with PTSD. Data from two studies indicated that treatment and control groups did not differ significantly according to relationship satisfaction (SMD 1.07, 95% CI -0.17 to 2.31; very low-quality evidence); and one study showed no significant differences regarding depression (SMD 0.28, 95% CI -0.35 to 0.90; very low-quality evidence) or anxiety symptoms (SMD 0.15, 95% CI -0.47 to 0.77; very low-quality evidence) for the partner of the patient with PTSD. One trial with 57 couples (114 participants) showed that SAT was more effective than PFE in reducing PTSD severity for the primary patient (SMD -1.32, 95% CI -1.90 to -0.74; low-quality evidence) at post-treatment. There was no evidence of differences on the other outcomes, including relationship satisfaction (SMD 0.01, 95% CI -0.51 to 0.53; very low-quality evidence), depression (SMD 0.21, 95% CI -0.31 to 0.73; very low-quality evidence) and anxiety (SMD -0.16, 95% CI -0.68 to 0.36; very low-quality evidence) for intimate partners; and depression (SMD -0.28, 95% CI -0.81 to 0.24; very low-quality evidence) or anxiety (SMD -0.34, 95% CI -0.87 to 0.18; very low-quality evidence) for the primary patient. Two studies reported on adverse events and dropout rates, and no significant differences between groups were observed. Two studies were classified as having a 'low' or 'unclear' risk of bias in most domains, except for performance bias that was rated 'high'. Two studies had significant amounts of missing information resulting in 'unclear' risk of bias. There were too few studies available to conduct subgroup analyses.

Authors' Conclusions: There are few trials of couple-based therapies for PTSD and evidence is insufficient to determine whether these offer substantive benefits when delivered alone or in addition to psychological interventions. Preliminary RCTs suggest, however, that couple-based therapies for PTSD may be potentially beneficial for reducing PTSD symptoms, and there is a need for additional trials of both adjunctive and stand-alone interventions with couples or families which target reduced PTSD symptoms, mental health problems of family members and dyadic measures of relationship quality.
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http://dx.doi.org/10.1002/14651858.CD011257.pub2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6890534PMC
December 2019

Learning How to Ask - Does a one-day training increase trauma inquiry in routine substance use disorder practice? Results of a cluster-randomized controlled trial.

J Subst Abuse Treat 2019 12 7;107:8-16. Epub 2019 Aug 7.

Department of Psychiatry and Psychotherapy, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany; Center for Interdisciplinary Addiction Research, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany.

Aims: To examine the effectiveness of a one-day skills training program for increasing trauma inquiry in routine substance use disorder treatment.

Design: Cluster-randomized two-armed controlled trial, with 12 substance use disorder (SUD) organizations operating 25 counseling centers, randomly assigned to training in trauma inquiry (13 counseling centers of 8 SUD organizations) or no training (12 counseling centers of 4 SUD organizations).

Setting: SUD counseling centers in Northern Germany.

Cases: N = 5204 SUD counseling services.

Intervention: The professionals assigned to the intervention group received a one-day training in trauma inquiry plus a 1.5-hour refresher session 3 months later. Professionals in the control group received no training.

Measures: Over a 12-month period, professionals documented for each counseling service whether they asked the client about four traumatic events: physical abuse, emotional abuse, sexual abuse and neglect.

Analysis: Primary outcomes were rates of asking about physical abuse, sexual abuse, emotional abuse and neglect in the 6 months after training. These were compared across conditions, while adjusting for baseline probabilities in the 6 months before training, using mixed-effects logistic regression.

Findings: In the 6 months after training, the rate of asking about physical abuse was 18% higher in the SUD counseling services of trained professionals, relative to services of untrained professionals (OR = 1.18, 95% CI = [1.01-1.37, p = .035]). No effect was found for asking about sexual abuse, emotional abuse and neglect.

Conclusion: A one-day training program in trauma inquiry, combined with a brief refresher session, was effective in increasing inquiries about physical abuse in routine counseling practice. The training was ineffective in increasing inquiries about sexual abuse, emotional abuse and neglect. The effectiveness of a one-day training of trauma inquiry might be increased by a longer training, or by combining it with additional elements, such as ongoing supervision.
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http://dx.doi.org/10.1016/j.jsat.2019.08.005DOI Listing
December 2019

Psychiatric comorbidity for veterans with posttraumatic stress disorder (PTSD): A latent profile analysis and implications for treatment.

Psychol Trauma 2019 Oct 28. Epub 2019 Oct 28.

The University of Melbourne.

Background And Objective: Psychiatric comorbidity is common among veterans with posttraumatic stress disorder (PTSD), but there is little known about the patterns of co-occurring mental health problems and implications for treatment. The aim of this study was to identify comorbidity profiles among veterans at treatment intake and assess associations with PTSD and quality of life (QOL) outcomes.

Method: The study included 2,522 veterans accessing outpatient treatment for PTSD in Australia who self-completed measures of comorbid issues including depression, anger, alcohol use problems, guilt, and dissociation. Latent Profile Analysis (LPA) was used to identify subgroups based on comorbidity profiles, and their association with outcomes.

Results: LPA suggested 5 comorbidity profiles: (a) low comorbidity severity, (b) moderate comorbidity severity with low alcohol, (c) moderate comorbidity severity with high alcohol, (d) high comorbidity severity with low alcohol, and (e) high comorbidity severity with high alcohol. The absence of alcohol problems was associated with improved treatment outcomes when overall comorbidity severity was high but not moderate. While all profiles evidenced symptom improvement from intake to discharge and follow-up, this did not correspond to quality of life improvements equally across classes. The highest severity comorbidity class experienced no improvement on psychological quality of life.

Conclusions: The comorbidity profiles of veterans in treatment for PTSD can be distinguished by levels of severity and the specific presence or absence of alcohol use problems. Alcohol use problems have discernible implications for treatment in the context of comorbidity. Group treatments for PTSD should consider tailoring interventions to comorbidity profiles. (PsycINFO Database Record (c) 2019 APA, all rights reserved).
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http://dx.doi.org/10.1037/tra0000520DOI Listing
October 2019

Social support following a natural disaster: A longitudinal study of survivors of the 2013 Lushan earthquake in China.

Psychiatry Res 2019 03 28;273:641-646. Epub 2019 Jan 28.

Phoenix Australia - Centre for Posttraumatic Mental Health, Department of Psychiatry, The University of Melbourne, Melbourne, VIC, Australia.

The idea that social support post-disaster is beneficial to survivors' mental health is widely accepted by both researchers and practitioners. However previous social support studies are mainly focused on perceived social support, and the limited received social support studies have produced mixed results. In this study we modelled the influence of both quantity and quality of received social support on long-term mental health outcomes in a longitudinal study of 2013 Lushan earthquake survivors in China. Survivors were invited to complete a questionnaire interview 7 months after the earthquake and were followed up 31 months later (n = 161). Hierarchical regression analyses that controlled for disaster exposure variables showed that greater quality of social support received 7 months after disaster predicted lower levels of posttraumatic stress symptoms and psychological distress two years later, however quantity of received social support was not significant in predicting these two outcomes. These results remained robust when controlled for gender, negative life events and family financial status. The findings of this study suggest that what appears to be critical in the process of supporting disaster survivors is the quality, not necessarily the quantity, of support provided.
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http://dx.doi.org/10.1016/j.psychres.2019.01.085DOI Listing
March 2019

Young people's awareness of the timing and placement of gambling advertising on traditional and social media platforms: a study of 11-16-year-olds in Australia.

Harm Reduct J 2018 10 19;15(1):51. Epub 2018 Oct 19.

Faculty of Health Sciences, Curtin University, Bentley, Australia.

Background: Research has demonstrated that the promotion of gambling, particularly within sport, may have a significant impact on positively shaping young people's attitudes towards gambling. While some governments have implemented restrictions to limit young people's exposure to gambling advertising, few studies have investigated where young people recall seeing gambling advertising, and whether they perceive that advertising restrictions have gone far enough in reducing exposure to these promotions.

Method: Mixed methods, interviewer-assisted surveys were conducted with n = 111 young people aged 11-16 years, who were self-reported fans of basketball in Victoria, Australia. Interviews were conducted at basketball stadiums between May and July 2018. The study assessed media viewing patterns; recall and awareness of the timing, placement, and content of gambling advertising; the impact of gambling advertising restrictions; and attitudes towards sporting organisations' roles in the promotion of gambling.

Results: The majority of young people recalled seeing gambling advertising on television (n = 101, 91.0%), with most recalling advertising within sporting matches or games (n = 79, 71.2%). Most young people recalled seeing gambling advertising in the early evening before 8:30 pm (n = 75, 67.6%). Just over half of young people described seeing gambling advertisements on social media (n = 61, 55.0%), and over a third (n = 40, 36.0%) recalled gambling advertising on YouTube, predominantly before watching sporting or gaming videos. The majority stated that they continued to watch sport after 8:30 pm (n = 93, 83.7%), which is when restrictions on advertising in live sport in Australia end. The majority (n = 88, 79.3%) stated that there were too many gambling advertisements in sport. Three quarters believed that sporting codes should do more to prevent young people from being exposed to advertising for gambling in sport (n = 84, 75.7%).

Conclusions: There is now a clear body evidence that current regulatory systems for gambling advertising are ineffective, with further restrictions urgently needed across a range of media channels to prevent exposure to promotions that may encourage young people's interest and involvement in gambling.
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http://dx.doi.org/10.1186/s12954-018-0254-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6194705PMC
October 2018

General practitioners and emergency departments (GPED)-efficient models of care: a mixed-methods study protocol.

BMJ Open 2018 10 3;8(10):e024012. Epub 2018 Oct 3.

Faculty of Health and Life Sciences, University of the West of England, Bristol, UK.

Introduction: Pressure continues to grow on emergency departments in the UK and throughout the world, with declining performance and adverse effects on patient outcome, safety and experience. One proposed solution is to locate general practitioners to work in or alongside the emergency department (GPED). Several GPED models have been introduced, however, evidence of effectiveness is weak. This study aims to evaluate the impact of GPED on patient care, the primary care and acute hospital team and the wider urgent care system.

Methods And Analysis: The study will be divided into three work packages (WPs). WP-A; Mapping and Taxonomy: mapping, description and classification of current models of GPED in all emergency departments in England and interviews with key informants to examine the hypotheses that underpin GPED. WP-B; Quantitative Analysis of National Data: measurement of the effectiveness, costs and consequences of the GPED models identified in WP-A, compared with a no-GPED model, using retrospective analysis of Hospital Episode Statistics Data. WP-C; Case Studies: detailed case studies of different GPED models using a mixture of qualitative and quantitative methods including: non-participant observation of clinical care, semistructured interviews with staff, patients and carers; workforce surveys with emergency department staff and analysis of available local routinely collected hospital data. Prospective case study sites will be identified by completing telephone interviews with sites awarded capital funding by the UK government to implement GPED initiatives. The study has a strong patient and public involvement group that has contributed to study design and materials, and which will be closely involved in data interpretation and dissemination.

Ethics And Dissemination: The study has been approved by the National Health Service East Midlands-Leicester South Research Ethics Committee: 17/EM/0312. The results of the study will be disseminated through peer-reviewed journals, conferences and a planned programme of knowledge mobilisation.

Trial Registration Number: ISRCTN51780222.
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http://dx.doi.org/10.1136/bmjopen-2018-024012DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6194458PMC
October 2018

Associations among Elder Abuse, Depression and PTSD in South Korean Older Adults.

Int J Environ Res Public Health 2018 09 6;15(9). Epub 2018 Sep 6.

Phoenix Australia Centre for Posttraumatic Mental Health, Department of Psychiatry, University of Melbourne, Melbourne, VIC 3053, Australia.

Increasing attention is being placed on the prevalence of elder abuse and its impact on mental health. This study conducted a survey of 172 elderly people in South Korea to determine the prevalence of elder abuse and the relationships involving elder abuse, depression and posttraumatic stress disorder (PTSD). Participants completed a battery of self-report questionnaires, which included the Korean Geriatric Depression Screening Scale (KGDS) and Impact of Event Scale-Revised Korean version (IES-R-K). Descriptive analyses were conducted to examine the frequency of specific forms of abuse. Logistic regression models were estimated to identify the factors that contributed to risk of abuse exposure and the relationship between exposure and PTSD or depression. The results indicated around 22% of the participants reported abuse exposure, which most commonly included being refused physical contact, verbal threats, and/or being excluded from decision-making about personal issues. Low education and being unmarried, separated or divorced was associated with an increased risk of abuse exposure. There were strong associations between elder abuse and PTSD symptoms, while comparable relationships with depression were weaker and were not robust to the inclusion of control variables. The findings provided empirical support for the relationship between abuse experiences of the elderly and poor mental health and raise important issues for the mental health care of the elderly.
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http://dx.doi.org/10.3390/ijerph15091948DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6165533PMC
September 2018

Adjustment of refugee children and adolescents in Australia: outcomes from wave three of the Building a New Life in Australia study.

BMC Med 2018 09 4;16(1):157. Epub 2018 Sep 4.

Phoenix Australia, Melbourne, Victoria, Australia.

Background: High-income countries like Australia play a vital role in resettling refugees from around the world, half of whom are children and adolescents. Informed by an ecological framework, this study examined the post-migration adjustment of refugee children and adolescents 2-3 years after arrival to Australia. We aimed to estimate the overall rate of adjustment among young refugees and explore associations with adjustment and factors across individual, family, school, and community domains, using a large and broadly representative sample.

Methods: Data were drawn from Wave 3 of the Building a New Life in Australia (BNLA) study, a nationally representative, longitudinal study of settlement among humanitarian migrants in Australia. Caregivers of refugee children aged 5-17 (N = 694 children and adolescents) were interviewed about their children's physical health and activity, school absenteeism and achievement, family structure and parenting style, and community and neighbourhood environment. Parent and child forms of the Strengths and Difficulties Questionnaire (SDQ) were completed by caregivers and older children to assess social and emotional adjustment.

Results: Sound adjustment according to the SDQ was observed regularly among young refugees, with 76-94% (across gender and age) falling within normative ranges. Comparison with community data for young people showed that young refugees had comparable or higher adjustment levels than generally seen in the community. However, young refugees as a group did report greater peer difficulties. Bivariate and multivariate linear regression analyses showed that better reported physical health and school achievement were associated with higher adjustment. Furthermore, higher school absenteeism and endorsement of a hostile parenting style were associated with lower adjustment.

Conclusions: This is the first study to report on child psychosocial outcomes from the large, representative longitudinal BNLA study. Our findings indicate sound adjustment for the majority of young refugees resettled in Australia. Further research should examine the nature of associations between variables identified in this study. Overall, treating mental health problems early remains a priority in resettlement. Initiatives to enhance parental capability, physical health, school achievement and participation could assist to improve settlement outcomes for young refugees.
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http://dx.doi.org/10.1186/s12916-018-1124-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6122776PMC
September 2018

Treatment Outcomes for Military Veterans With Posttraumatic Stress Disorder: Response Trajectories by Symptom Cluster.

J Trauma Stress 2018 06;31(3):401-409

Phoenix Australia Centre for Posttraumatic Mental Health, Department of Psychiatry, University of Melbourne, Melbourne, Australia.

Although effective posttraumatic stress disorder (PTSD) treatments are available, outcomes for veterans with PTSD are relatively modest. Previous researchers have identified subgroups of veterans with different response trajectories but have not investigated whether PTSD symptom clusters (based on a four-factor model) have different patterns of response to treatment. The importance of this lies in the potential to increase treatment focus on less responsive symptoms. We investigated treatment outcomes by symptom cluster for 2,685 Australian veterans with PTSD. We used Posttraumatic Stress Disorder Checklist scores obtained at treatment intake, posttreatment, and 3- and 9-month follow-ups to define change across symptom clusters. Repeated measures effect sizes indicated that arousal and numbing symptoms exhibited the largest changes between intake and posttreatment, d = -0.61 and d = -0.52, respectively, whereas avoidance and intrusion symptoms showed more modest reductions, d = -0.36 and d = -0.30, respectively. However, unlike the other symptom clusters, the intrusions cluster continued to show significant changes between posttreatment and 3-month follow-up, d = -0.21. Intrusion and arousal symptoms also showed continued changes between 3- and 9-month follow-ups although these effects were very small, d = -0.09. Growth curve model analyses produced consistent findings and indicated modest initial changes in intrusion symptoms that continued posttreatment. These findings may reflect the longer time required for emotional processing, relative to behavioral changes in avoidance, numbing, and arousal, during the program; they also reinforce the importance of prioritizing individual trauma-focused therapy directly targeting intrusions as the core component of programmatic treatment.
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http://dx.doi.org/10.1002/jts.22299DOI Listing
June 2018

Identification of Gambling Problems in Primary Care: Properties of the NODS-CLiP Screening Tool.

J Addict Med 2018 Nov/Dec;12(6):442-446

Phoenix Australia Centre for Posttraumatic Mental Health, Department of Psychiatry, The University of Melbourne, Australia (SC); Centre for Academic Primary Care, Bristol Medical School, University of Bristol, UK (SC, DK); Department of Health Sciences, University of York, UK (JM).

Introduction: There are several brief screening tools for gambling that possess promising psychometric properties, but have uncertain utility in generalist healthcare environments which prioritize prevention and brief interventions. This study describes an examination of the National Opinion Research Centre Diagnostic and Statistical Manual of Mental Disorders Screen for Gambling Problems (NODS-CLiP), in comparison with the Problem Gambling Severity Index (PGSI), when used to operationalize gambling problems across a spectrum of severity.

Methods: Data were obtained from 1058 primary care attendees recruited from 11 practices in England who completed various measures including the NODS-CLiP and PGSI. The performance of the former was defined by estimates of sensitivity, specificity, positive predictive values (PPVs), and negative predictive values (NPVs), when PGSI indicators of problem gambling (5+) and any gambling problems (1+), respectively, were reference standards.

Results: The NODS-CLiP demonstrated perfect sensitivity for problem gambling, along with high specificity and a NPV, but a low PPV. There was much lower sensitivity when the indicator of any gambling problems was the reference standard, with capture rates indicating only 20% of patients exhibiting low to moderate severity gambling problems (PGSI 1-4) were identified by the NODS-CLiP.

Conclusions: The NODS-CLiP performs well when identifying severe cases of problem gambling, but lacks sensitivity for less severe problems and may be unsuitable for settings which prioritize prevention and brief interventions. There is a need for screening measures which are sensitive across the full spectrum of risk and severity, and can support initiatives for improving identification and responses to gambling problems in healthcare settings such as primary care.
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http://dx.doi.org/10.1097/ADM.0000000000000429DOI Listing
November 2019

Therapist-delivered and self-help interventions for gambling problems: A review of contents.

J Behav Addict 2018 Jun 13;7(2):211-226. Epub 2018 Jun 13.

2 School of Psychology, Deakin University , Geelong, VIC, Australia.

Background and aims To date, no systematic approach to identifying the content and characteristics of psychological interventions used to reduce gambling or problem gambling has been developed. This study aimed to develop a reliable classification system capable of identifying intervention characteristics that could, potentially, account for greater or lesser effectiveness. Methods Intervention descriptions were content analyzed to identify common and differentiating characteristics. A coder manual was developed and applied by three independent coders to identify the presence or absence of defined characteristics in 46 psychological and self-help gambling interventions. Results The final classification taxonomy, entitled Gambling Intervention System of CharacTerization (GIST), included 35 categories of intervention characteristics. These were assigned to four groups: (a) types of change techniques (18 categories; e.g., cognitive restructuring and relapse prevention), (b) participant and study characteristics (6 categories; e.g., recruitment strategy and remuneration policy), and (c) characteristics of the delivery and conduct of interventions (11 categories; e.g., modality of delivery and therapist involvement), and (d) evaluation characteristics (e.g., type of control group). Interrater reliability of identification of defined characteristics was high (κ = 0.80-1.00). Discussion This research provides a tool that allows systematic identification of intervention characteristics, thereby enabling consideration, not only of whether interventions are effective or not, but also of which domain-relevant characteristics account for greater or lesser effectiveness. The taxonomy also facilitates standardized description of intervention content in a field in which many diverse interventions have been evaluated. Conclusion Application of this coding tool has the potential to accelerate the development of more efficient and effective therapist-delivered and self-directed interventions to reduce gambling problems.
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http://dx.doi.org/10.1556/2006.7.2018.44DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6174602PMC
June 2018

Women's gambling behaviour, product preferences, and perceptions of product harm: differences by age and gambling risk status.

Harm Reduct J 2018 04 24;15(1):22. Epub 2018 Apr 24.

Faculty of Health Sciences, Curtin University, Perth, Australia.

Background: Women's participation in, and harm from gambling, is steadily increasing. There has been very limited research to investigate how gambling behaviour, product preferences, and perceptions of gambling harm may vary across subgroups of women.

Methods: This study surveyed a convenience sample of 509 women from Victoria and New South Wales, Australia. Women were asked a range of questions about their socio-demographic characteristics and gambling behaviour. Focusing on four gambling products in Australia-casino gambling, electronic gambling machines (EGMs), horse betting, and sports betting-women were asked about their frequency of participation, their product preferences, and perceptions of product harms. The sample was segmented a priori according to age and gambling risk status, and differences between groups were identified using Chi-square tests and ANOVAs. Thematic analysis was used to interpret qualitative data.

Results: Almost two thirds (n = 324, 63.7%) of women had engaged with one of the four products in the previous 12 months. Compared to other age groups, younger women aged 16-34 years exhibited a higher proportion of problem gambling, gambled more frequently, and across more products. While EGMs were the product gambled on most frequently by women overall, younger women were significantly more likely to bet on sports and gamble at casinos relative to older women. Qualitative data indicated that younger women engaged with gambling products as part of a "night out", "with friends", due to their "ease of access" and perceived "chance of winning big". There were significant differences in the perceptions of the harms associated with horse and sports betting according to age and gambling risk status, with younger women and gamblers perceiving these products as less harmful.

Conclusions: This study highlights that there are clear differences in the gambling behaviour, product preferences, and perceptions of product harms between subgroups of women. A gendered approach will enable public health researchers and policymakers to ensure that the unique factors associated with women's gambling are taken into consideration in a comprehensive public health approach to reducing and preventing gambling harm.
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http://dx.doi.org/10.1186/s12954-018-0227-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5916584PMC
April 2018

Primary Care Outcomes Questionnaire: psychometric testing of a new instrument.

Br J Gen Pract 2018 06 26;68(671):e433-e440. Epub 2018 Mar 26.

Centre for Academic Primary Care (CAPC), Population Health Sciences, Bristol Medical School, University of Bristol, Bristol.

Background: Patients attend primary care for many reasons and to achieve a range of possible outcomes. There is currently no Patient Reported Outcome Measure (PROM) designed to capture these diverse outcomes, and trials of interventions in primary care may thus fail to detect beneficial effects.

Aim: This study describes the psychometric testing of the Primary Care Outcomes Questionnaire (PCOQ), which was designed to capture a broad range of outcomes relevant to primary care.

Design And Setting: Questionnaires were administered in primary care in South West England.

Method: Patients completed the PCOQ in GP waiting rooms before a consultation, and a second questionnaire, including the PCOQ and seven comparator PROMs, after 1 week. Psychometric testing included exploratory factor analysis on the PCOQ, internal consistency, correlation coefficients between domain scores and comparator measures, and repeated measures effect sizes indicating change across 1 week.

Results: In total, 602 patients completed the PCOQ at baseline, and 264 (44%) returned the follow-up questionnaire. Exploratory factor analysis suggested four dimensions underlying the PCOQ items: health and wellbeing, health knowledge and self-care, confidence in health provision, and confidence in health plan. Each dimension was internally consistent and correlated as expected with comparator PROMs, providing evidence of construct validity. Patients reporting an improvement in their main problem exhibited small to moderate improvements in relevant domain scores on the PCOQ.

Conclusion: The PCOQ was acceptable, feasible, showed strong psychometric properties, and was responsive to change. It is a promising new tool for assessment of outcomes of primary care interventions from a patient perspective.
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http://dx.doi.org/10.3399/bjgp18X695765DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6001981PMC
June 2018

Gambling and physical intimate partner violence: Results from the national epidemiologic survey on alcohol and related conditions (NESARC).

Am J Addict 2018 Jan 27;27(1):7-14. Epub 2017 Dec 27.

Phoenix Australia Centre for Posttraumatic Mental Health, Department of Psychiatry, The University of Melbourne, Australia.

Background And Objectives: Links between intimate partner violence (IPV) and gambling problems are under researched in general population samples. Understanding these relationships will allow for improved identification and intervention. We investigated these relationships and sought to determine whether links were attenuated by axis I and II disorders.

Methods: This study examined data from waves 1 and 2 (N = 25,631) of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC); a nationally representative survey of U.S. adults. Gambling symptoms and other psychiatric disorders were measured at wave 1 by the Alcohol Use Disorder and Associated Disability Interview Schedule-DSM-IV Version (AUDADIS-IV). Physical IPV victimization and perpetration in the last 12 months were assessed 3 years later at wave 2 using items from the Conflict Tactics Scale-R. Binary logistic regression models were used to examine associations separately for males and females.

Results: Problem gambling was associated with increased odds of both IPV perpetration for males (OR = 2.62, 95%CI = 1.22-5.60) and females (OR = 2.87, 95%CI = 1.29-6.42), and with IPV victimization for females only (OR = 2.97, 95%CI = 1.31-6.74). Results were attenuated with inclusion of axis I and axis II disorders; links between gambling and IPV were weaker than those involving other mental health conditions.

Conclusions And Scientific Significance: There are prospective associations with gambling problems and physical IPV which have implications for identification, spontaneous disclosure, and treatment seeking. The links between gambling problems and violence are complex and should not be considered independently of co-occurring mental health and substance use disorders. (Am J Addict 2018;27:7-14).
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http://dx.doi.org/10.1111/ajad.12656DOI Listing
January 2018
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