Worse baseline executive functioning is associated with dropout and poorer response to trauma-focused treatment for veterans with PTSD and comorbid traumatic brain injury
Abstract: Although trauma-focused treatment, including Cognitive Processing Therapy (CPT), effectively reduces PTSD symptoms, treatment dropout, nonresponse, and relapse are substantial. Executive functioning (EF) is essential to engage the cognitive skills involved in CPT (e.g., inhibiting/evaluating distorted thoughts, flexibly generating alternative thoughts). It was hypothesized that worse baseline EF would be associated with reduced CPT completion and responsivity. Seventy-four Iraq/Afghanistan-era Veterans with PTSD and history of mild-to-moderate traumatic brain injury were randomized to either standard CPT or modified CPT that included cognitive rehabilitation strategies (SMART-CPT). Those who dropped out of treatment prematurely performed more poorly on EF tests at baseline than treatment completers. Worse baseline performances on EF tests of working memory, inhibition, and inhibition/switching were associated with poorer response to CPT (less reduction in PTSD symptoms). In addition, a three-way interaction indicated that individuals with worse baseline cognitive flexibility did not benefit as much from standard CPT but demonstrated significant PTSD symptom improvement in the SMART-CPT condition, comparable to those with better baseline cognitive flexibility. Modifying CPT to accommodate executive dysfunction may boost treatment effectiveness and allow Veterans to fully engage in and benefit more from components of CPT (e.g., cognitive restructuring).
Abstract: Introduction: Persistent inequities exist in obstetric and neonatal outcomes in military families despite universal health care coverage. Though the exact underlying cause has not been identified, social determinants of health may uniquely impact military families. The purpose of this study was to qualitatively investigate the potential impact of social determinants of health and the lived experiences of military individuals seeking maternity care in the Military Health System. Materials and methods: This was an Institutional Review Board-approved protocol. Nine providers conducted 31 semi-structured interviews with individuals who delivered within the last 5 years in the direct or purchased care market. Participants were recruited through social media blasts and clinic flyers with both maximum variation and homogenous sampling to ensure participation of diverse individuals. Data were coded and themes were identified using inductive qualitative research methods. Results: Three main themes were identified: Requirements of Military Life (with subthemes of pregnancy notification and privacy during care, role of pregnancy instructions and policies, and role of command support), Sociocultural Aspects of the Military Experience (with subthemes of pregnancy as a burden on colleagues and a career detractor, postpartum adjustment, balancing personal and professional requirements, pregnancy timing and parenting challenges, and importance of friendship and camaraderie in pregnancy), and Navigating the Healthcare Experience (including subthemes of transfer between military and civilian care and TRICARE challenges, perception of military care as inferior to civilian, and remote duty stations and international care). Conclusions: The unique stressors of military life act synergistically with the existing health care challenges, presenting opportunities for improvements in care. Such opportunities may include increased consistency of policies across services and commands. Increased access to group prenatal care and support groups, and increased assistance with navigating the health care system to improve care transitions were frequently requested changes by participants.