Journal of Psychosocial Nursing and Mental Health Services

Original Article 

Does Psychosocial Functioning Improve With Prolonged Exposure in Veterans With PTSD?: Exploring Traditional and Home-Based Telehealth Delivery Methods

Kristina Reich, PhD, PMHNP-BC; Lynne S. Nemeth, PhD, RN, FAAN; Martina Mueller, PhD; Lisa Marie Sternke, PhD, RN; Ron Acierno, PhD

Abstract

The current study explored whether prolonged exposure (PE), delivered in person or via home-based telehealth, had a therapeutic effect on psychosocial functioning in combat Veterans with posttraumatic stress disorder (PTSD). The effects of home-based telehealth on these metrics were also evaluated. In addition, we examined whether race, type of war conflict, and service-connected disability rating moderated the effect of PE on psychosocial functioning and whether PTSD, anxiety, and/or depression mediated the effect of PE on psychosocial functioning. We did not find moderating or mediating effects in our study. Improvements in PTSD, depression, and anxiety were associated with improvements in psychosocial functioning. We did not identify statistically significant differences in scores representing change in overall and each domain of psychosocial functioning between groups. Within-group analysis indicated psychosocial functioning improved in both groups but was mostly not statistically significant. However, some clinically relevant improvement may have occurred. [Journal of Psychosocial Nursing and Mental Health Services, 59(2), 31–40.]

Abstract

The current study explored whether prolonged exposure (PE), delivered in person or via home-based telehealth, had a therapeutic effect on psychosocial functioning in combat Veterans with posttraumatic stress disorder (PTSD). The effects of home-based telehealth on these metrics were also evaluated. In addition, we examined whether race, type of war conflict, and service-connected disability rating moderated the effect of PE on psychosocial functioning and whether PTSD, anxiety, and/or depression mediated the effect of PE on psychosocial functioning. We did not find moderating or mediating effects in our study. Improvements in PTSD, depression, and anxiety were associated with improvements in psychosocial functioning. We did not identify statistically significant differences in scores representing change in overall and each domain of psychosocial functioning between groups. Within-group analysis indicated psychosocial functioning improved in both groups but was mostly not statistically significant. However, some clinically relevant improvement may have occurred. [Journal of Psychosocial Nursing and Mental Health Services, 59(2), 31–40.]

Veterans are at high risk for developing posttraumatic stress disorder (PTSD) (Arenson et al., 2019) and PTSD symptomology, such as hyperarousal, hypervigilance, and avoidance, which can directly impact occupational, academic, marital, family, and parental functioning (Fang et al., 2015; Lyons et al., 2020; Rodriguez et al., 2012; Ross et al., 2018). A major contributing factor for developing PTSD is combat-related trauma that includes threats to life, violent and sudden loss of friends, personal injury, and witnessed death (Hoge et al., 2004; Yeterian et al., 2017). Veterans with combat-related trauma are at greater risk of interpersonal conflicts and overall impairment in the psychosocial functioning areas of employment, marriage, and partner violence (Renaud, 2008).

Evidence-based psychotherapies for PTSD, such as prolonged exposure (PE), reduce and improve PTSD–specific symptomology (Foa et al., 2005; Hernandez-Tejada et al., 2020; Nacasch et al., 2011; Zhou et al., 2020). PE is often the first treatment initiated to treat PTSD symptoms due to its efficacy and empirical support (Hernandez-Tejada et al., 2020; McLean & Foa, 2014). An important component of PE is trauma reprocessing via imagined and in vivo exposure to trauma-related memories, various triggers, and beliefs (Eftekhari et al., 2006). Each PE session is approximately 60 to 90 minutes long and usually eight to 15 sessions are necessary to produce improvements (Foa, 2011).

Although PE is an effective treatment, less is known regarding PE's impact on general psychosocial functioning (Monson et al., 2012; Rauch et al., 2009). Available evidence indicates reduction in PTSD symptoms may improve psychosocial functioning (Galovski et al., 2005; Monson et al., 2012; Reich et al., 2019), which can further lead to the additional benefit of improved quality of life (QOL) for this population (Schnurr et al., 2006; Schnurr & Lunney, 2012). However, despite significant PTSD treatment outcome research, PTSD symptom-specific outcomes are the focus of PTSD research studies, with less attention directed toward how PTSD symptom reduction affects psychosocial functioning (McKnight & Kashdan, 2009; Monson et al., 2012; Schnurr & Lunney, 2012, 2016; Yeterian et al., 2017).

There are multiple barriers to accessing psychotherapy treatment for PTSD, including social stigma associated with PTSD, living in a rural setting, travel cost, and taking time away from work (Acierno et al., 2017; Cully et al., 2010; Gros, Strachan, et al., 2011; Reger et al., 2020). As such, available treatments such as PE are underutilized and often not completed or even available to rural residents (Acierno et al., 2017). Tele-health technology, including home-based telehealth, is increasingly used to address barriers to care and improve access to mental health treatment (Gros, Yoder, et al., 2011; Morland et al., 2020; Tuerk et al., 2010). Current literature suggests PE can be successfully delivered via home-based tele-health to treat symptoms of PTSD (Acierno et al., 2017; Chakrabarti, 2015); however, as increasing proportions of Veterans with PTSD are treated via telehealth (Gros, Yoder, et al., 2011), concerns are emerging that the home-based telehealth modality itself may facilitate social withdrawal and promote avoidance, hence interfering with psychosocial functioning (McLean et al., 2011; Whealin et al., 2016). Telehealth offers the convenience of home-based treatment, but for Veterans with PTSD who are already isolated, it may further enable isolation. Veterans receiving face-to-face care have multiple interactions with people and are forced to function in various situations. However, Veterans in home-based treatment may miss the interpersonal interactions that are necessary for healthy psychosocial functioning.

The current study used data from a previously conducted non-inferiority randomized controlled trial comparing PE delivered in person versus PE delivered via telehealth (Acierno et al., 2017) to examine relationships between psychosocial functioning symptom reduction following PE, with additional analysis to determine if treatment delivery method affected this relationship. We also examined whether PTSD (as measured by the PTSD Checklist-Military version [PCL-M]), depression (as measured by the Beck Depression Inventory [BDIII]), and anxiety (as measured by the Beck Anxiety Inventory [BAI]), acted as potential mediators, and explored the potential moderating effect of race/ethnicity, war conflict, and service-connected disability percentage (SC%).

Theoretical Framework

The socio-interpersonal framework of PTSD shifts attention from the primarily individualistic perspective of PTSD to a more social-interpersonal perspective and conceptualizes the environment of traumatized individuals across three levels: individual, close relationship, and distant relationship (Maercker & Hecker, 2016; Maercker & Horn, 2013).

In the current study, the outcome variables measured by the Inventory of Psychosocial Functioning (IPF) (Rodriguez et al., 2012) correspond to two levels (Table 1), and the education and work domains were theorized to be part of the distant relationship level because of that level's emphasis on group inclusion. The framework was used to inform the initial research question and suggested important variables to assess and test.

Theoretical Framework Levels and Variable Representationa

Table 1:

Theoretical Framework Levels and Variable Representation

Method

Participants

The parent study used provider referrals to recruit eligible individuals from the Ralph H. Johnson Veterans Affairs (VA) Medical Center and Medical University of South Carolina (MUSC). The Clinician-Administered PTSD Scale (CAPS) was used to establish a PTSD diagnosis and participant eligibility. Veterans were eligible to participate if their traumatic event was determined to be combat related. Veterans from the Vietnam, Operation Iraqi Freedom (OIF), Operation Enduring Freedom (OEF), and Operation New Dawn conflicts were part of the study sample. Exclusion criteria included Veterans having active psychotic symptoms, suicidal ideations and intent, or a current substance dependence diagnosis (Acierno et al., 2017).

Procedures

The current study received an exemption status from the Institutional Review Board at MUSC and was approved by the VA Research and Development (R&D) Committee. The parent study was also approved by the two aforementioned agencies. In the current article, an overview is provided by the authors to illustrate the basic procedural plan.

Consent was obtained from all participants, who were then randomized into one of two groups: PE in-person and PE via home-based telehealth. In both groups, clinicians with Master's degrees in counseling were responsible for treatment and assessment and received the full training workshop on PE. In addition, clinicians participated in weekly supervision with a senior researcher. Dependent measures discussed in the next section were administered by blinded study personnel post treatment (Acierno et al., 2017). The same PE manual was used by clinicians in both treatment groups, with 20% of session recordings randomly assessed for treatment fidelity.

Enrolled Veterans participated in 10 to 12 therapy sessions that were approximately 90 minutes long. Home-based telehealth treatment was delivered via encrypted VA software adhering to HIPAA guidelines. Participants could use their own devices, such as smartphones or tablets. Veterans who did not have telehealth capabilities (e.g., no access to a smart-phone) were issued devices for use during treatment. The research team was available to resolve technology-related issues regardless of the device that was used. In-person PE treatment followed standard VA office visit procedures. See Acierno et al. (2017) for details of study procedures.

Measures

Psychosocial Functioning. Level of psychosocial functioning was assessed using the IPF self-report measure (Bovin et al., 2018) This scale measures level of functioning across romantic relationships with spouse or partner, family, work, friendships and socializing, parenting, education, and general self-care domains within the past 30 days. Answer options are scaled from 0 to 6, where 0 corresponds to never and 6 corresponds to always (Rodriguez et al., 2012). Scores are calculated for each domain and for overall functioning level; higher scores indicate a higher level of functional impairment, with overall scores ranging from 0 to 100. This scale has excellent psychometric properties, including internal consistency (Cronbach's alpha of 0.93) (Rodriguez et al., 2012), and the total score correlates with other measures with similar constructs (Bovin et al., 2018). The IPF scale outcome measures have been shown to accurately represent the level of functioning in the psychosocial domains of interest. In the current study, we used the total IPF score and total scores for each domain.

PTSD. PTSD severity was measured by the PCL-M, which is a self-report measure that evaluates symptoms over the past 1 month (Wilkins et al., 2011). The checklist has 17 Likert-type questions, where 1 correlates to not at all and 5 correlates to extremely. The instrument exhibits good psychometric properties, including test–retest reliability, internal consistency, and convergent and discriminant validity (Wilkins et al., 2011). In the current study, we used the total PCL-M score, which can range from 17 to 85, and is obtained by adding all the response scores.

Depression. Data on depression severity were collected via the BDI-II, which measures symptoms over the past 2 weeks (Beck et al., 1961). This measure has 21 questions with excellent test–retest reliability and internal consistency (Strachan et al., 2012). The responses are rated on a 4-point Likert scale and measure the level of depression. Total BDI-II score, which can range from 0 to 65, is obtained by adding the 21 response scores.

Anxiety. Anxiety severity was measured by the BAI, which measures symptoms over the past 1 week (Beck et al., 1988). This scale has 21 items with good psychometric properties. For example, it showed high internal consistency (<0.92) and showed a moderate correlation with the Hamilton Anxiety Rating Scale (Beck et al., 1988; Stulz & Crits-Christoph, 2010). The responses are rated on a 4-point Likert scale, ranging from 0 (not at all) to 3 (severely) (Stulz & Crits-Christoph, 2010). We used the total BAI score, which is obtained by adding all the response scores, and ranges from 0 to 65 (Julian, 2011).

Statistical Analysis

Data analysis was conducted using SPSS version 25, and results were deemed statistically significant at p < 0.05. Multiple imputation (MI) was used to handle missing values. Based on recommendations in the literature, we used 10 imputations in our MI procedure (Stephens et al., 2018). Assumptions of normality and linearity were examined before beginning data analysis. To represent change in scores after treatment, baseline scores were subtracted from post treatment scores. We did not report findings for the educational domain due to the small sample size for that specific domain across both groups (n = 17).

First, the effects of depression, anxiety, and PTSD on psychosocial functioning were explored using simple linear regression. This analysis provided information on psychopathology variables and their effect on IPF scores individually (Table 2).

Simple Linear Regression Analysis: Evaluating the Total Inventory of Psychosocial Functioning Change Scores

Table 2:

Simple Linear Regression Analysis: Evaluating the Total Inventory of Psychosocial Functioning Change Scores

Second, we compared baseline characteristics between the two groups by conducting independent groups t test and chi-square tests. Next, to examine whether the effect of PE differed between the two groups, we conducted independent groups t tests. To examine whether there was a change from baseline within PE groups, we conducted paired t tests. To test whether race, war conflict, and/or SC% moderated the effect of PE (home-based telehealth vs. in-person) on psychosocial functioning (as measured by the IPF), we conducted moderation analysis by including the interaction term of the potential moderator with PE in the linear regression models. Moderation is identified if the interaction term is statistically significant.

In addition, we conducted mediation analysis to investigate whether PTSD, anxiety, and/or depression mediated the effect of PE (home-based telehealth vs. in-person) on psychosocial functioning (as measured by the IPF). Our plan for mediation analysis was guided by the model proposed by Baron and Kenny (1986).

Variables of interest in the current study include the following: (a) baseline demographic characteristics, including race, war conflict (Vietnam, OIF/OEF, and Operation New Dawn), and SC%; (b) psychopathology-related factors, including depression total scores measured by the BDI, anxiety total scores measured by the BAI, and PTSD symptoms as measured by the PCL-M; (c) psychosocial functioning across several areas, including romantic relationships with spouse or partner, family, work, friendships and socializing, and parenting, as measured by the IPF; and (d) PE treatment delivery modality (in-person vs. home-based telehealth). The VA R&D Committee classified age as an identifying variable; therefore, it could not be included in the analysis.

Results

Outliers were within acceptable ranges and were retained in the dataset. No violations of normality or linearity assumptions were found. The sample (N = 150) included mostly male Veterans (n = 144), and Veterans of the OEF/OIF conflicts (n = 95), with a mean age of 42 (Acierno et al., 2017). Most Veterans were White (n = 89) and married (n = 80), and some were employed (n = 61).

Change in PTSD scores was positively correlated with change in the overall psychosocial functioning scores (r = 0.456, p < 0.001) and explained 20% of the variance in the overall psychosocial functioning. When PTSD symptoms decreased, impairment of psychosocial functioning decreased. Similarly, change in depression scores was positively correlated with change in overall psychosocial functioning scores (r = 0.426, p = 0.001) and explained 18% of its variance. Although change in anxiety scores was also positively correlated with change in overall psychosocial functioning scores (r = 0.29, p = 0.023), the correlation was moderate and anxiety change scores explained only 9% of variance in the overall psychological functioning. We can also report that PTSD change scores (β = 0.389, p = 0.001), depression change scores (β = 0.555, p = 0.001), and anxiety change scores (β = 0.325, p = 0.033) were all statistically significant predictors of IPF change scores. The IPF changes scores increased by 0.389 for every 1 point increase in PTSD change scores, by 0.555 for every 1 point increase in depression change scores, and by 0.033 for every 1 point increase in anxiety change scores.

Demographic variables, baseline PTSD, anxiety, depression, and overall psychosocial functioning scores were not significantly different for the two treatment groups. Detailed information on sample characteristics and baseline scores are presented in Table 3 and Table 4.

Baseline Sample Characteristics

Table 3:

Baseline Sample Characteristics

Baseline Posttraumatic Stress Disorder, Depression, Anxiety, And Total Inventory Of Psychosocial Functioning (IPF) Scores

Table 4:

Baseline Posttraumatic Stress Disorder, Depression, Anxiety, And Total Inventory Of Psychosocial Functioning (IPF) Scores

When we compared psychosocial functioning between PE treatment modalities, there were no significant differences on IPF pre treatment, post treatment, and change scores between groups. When we compared change from baseline to post treatment psychosocial functioning within treatment modalities, the overall and individual domain scores improved with in-person and home-based tele-health delivery of PE; however, the improvement was mostly not statistically significant (Table 5). There were three exceptions: for the home-based treatment group, only the family domain showed statistically significant improvement; for the in-person group, overall psychosocial functioning and the relationship domain showed statistically significant improvements. Although we noted some statistically significant improvement, most Veterans remained in the same functional impairment category post treatment. However, in the family domain, across groups, mean scores moved from the severe impairment to the moderate impairment category post treatment. In the home-based telehealth group, mean scores in the parenting domain moved from the moderate to the mild impairment category. An interesting finding was noted for the home-based telehealth group; the improvement in family domain mean scores was considered statistically significant and clinically relevant.

Comparison of Treatment Effect on Psychosocial Functioning Between and Within Prolonged Exposure-In Person (PE-IP) and Prolonged Exposure-Home-Based Telehealth (PE-HBT) GroupsComparison of Treatment Effect on Psychosocial Functioning Between and Within Prolonged Exposure-In Person (PE-IP) and Prolonged Exposure-Home-Based Telehealth (PE-HBT) Groups

Table 5:

Comparison of Treatment Effect on Psychosocial Functioning Between and Within Prolonged Exposure-In Person (PE-IP) and Prolonged Exposure-Home-Based Telehealth (PE-HBT) Groups

No significant results were found when examining race, type of war conflict, and SC%, indicating that no moderation effects were present. The final step in the analytical plan was to examine the mediation effect of PTSD, anxiety, and depression; however, there were no grounds for full mediation analysis because the first condition of a direct effect of the treatment modality on psychosocial functioning scores was not met.

Discussion

The current study incorporated the principles of the socio-interpersonal framework of PTSD (Maercker & Horn, 2013) and sought to investigate whether PE as PTSD treatment had a therapeutic effect on psychosocial functioning. Moreover, home-based telehealth was evaluated as a potential treatment delivery method. We used the framework's key attributes regarding the importance of the interpersonal processes occurring after trauma to guide our research question and in the selection of psychosocial functioning domains that would be meaningful to our study population.

The comparison between in-person and home-based telehealth groups among a sample of 150 combat Veterans with PTSD did not result in statistically significant changes in IPF scores. Our exploration of PE expands the use of this treatment to psychosocial functioning and exposes the current gap in literature related to telehealth delivery methods and the possible association with conditioning avoidance that may obstruct psychosocial functioning (McLean et al., 2011; Whealin et al., 2016). Our findings indicate both modalities might be possible options; however, this should be confirmed in studies specifically designed to examine the effects of these modalities on psychosocial functioning. Studies comparing the same treatment modalities in terms of PTSD outcomes illustrate both are acceptable and effective. Notably, the parent study did not find home-based telehealth inferior to the in-person delivery method when used to treat PTSD (Acierno et al., 2017).

Race, type of war conflict, and SC% rating did not moderate the effects of PE on psychosocial functioning, suggesting these demographic characteristics were not factors in the direction of our intervention response. One study reported no difference in the effects of PE, delivered via telehealth, on PTSD outcomes between groups of Veterans with various demographic characteristics (e.g., age, race, type of war conflict, disability status) (Gros, Yoder, et al., 2011). In the future, it would be of value to investigate whether there are psychosocial functioning outcome differences between demographic groups and further examine if both (in-person and telehealth) modalities may be used to deliver PE to various groups of combat Veterans.

Veterans in both groups experienced a decrease in overall and individual domains post treatment scores, suggesting that Veterans' psychosocial functioning improved after participating in PE. However, this finding should be judged with caution, as the functional improvement findings largely lacked statistical significance. When evaluating these findings, we considered the clinical relevance of our results. In the literature, the discussion is currently moving toward determining clinically relevant improvement in addition to, or regardless of, statistically significant improvement (El-Masri, 2016; Page, 2014). We did not find guidelines for evaluating clinically important improvement for the IPF scale; however, we argue that movement between impairment categories signifies clinical relevance and speaks to the effect size of our intervention. Therefore, detected movement from a higher impairment to a lower impairment category is an important finding on its own and supports further examination of this topic.

Although no mediation was found, PTSD improvement contributed to improvement in psychosocial functioning. This finding supports the rationale for the current study and the main hypothesis of using evidence-based treatment, such as PE, to influence psychosocial functioning impairment. Similarly, improvement in depression contributed to improvement in psychosocial functioning. This finding is in line with other studies identifying depression as a contributing factor to poor psychosocial functioning (Kozel et al., 2016); therefore, treating depression as well as PTSD should be considered during the treatment planning phase for Veterans with psychosocial functioning impairment.

Anxiety, on the other hand, accounted for the smallest percentage of the variance explained in psychosocial functioning improvement. This finding suggests improvement in anxiety does not influence psychosocial functioning improvement to the same extent as improvements in depression or PTSD, but all of the tested psychopathology variables had correlations in the moderate range, which provides additional evidence of their importance and association with psychosocial functioning improvement. Overall, the goals for treatment should include assessment and treatment of all associated conditions, not just PTSD alone.

Limitations

One major limitation of the current study is lack of an established criterion for assessing clinical relevance using the IPF measure. Without that information, it is not possible to determine how much meaningful improvement occurred. Moving forward, it will be important to establish a minimum clinical improvement criterion to evaluate improvement according to clinical relevance.

With any research study, one goal is to generalize findings to the larger population; therefore, we must bring attention to the overwhelmingly White male study sample. This sample is not representative of the Veteran population, and we advise that future studies include more ethnically and gender diverse individuals. Another limitation is the use of secondary analysis, as the focus of the parent study was not on psychosocial functioning. Thus, we recommend conducting an adequately powered, randomized controlled trial with a control group to establish the ability of PE to improve psychosocial functioning. In the education domain, impairment is evident; however, we were not able to formulate conclusions or evaluate this domain due to limited data. Future research is recommended in this important domain for Veterans.

Conclusion

Although we did not observe statistically significant differences between groups, we cannot draw a definitive conclusion on whether there is truly no difference between the two modalities. Future research should include a design with psychosocial functioning as the primary focus and be sufficiently powered. Furthermore, based on the findings in our sample population, it would be premature to draw conclusions about the efficacy of PE in relation to psychosocial functioning improvement after PE delivery via home-based telehealth or in-person, but the results remain promising. We identified improvements indicating potential clinical relevance in two domains and in overall functioning. In addition, the family domain not only had statistically significant improvement but also clinically relevant improvement in the home-based telehealth group. However, although researchers have examined PTSD outcomes and concluded that home-based telehealth and in-person modalities of PE are effective (Acierno et al., 2016; Acierno et al., 2017), more research on psychosocial functioning outcomes is necessary.

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Theoretical Framework Levels and Variable Representationa

LevelDescription of LevelPsychosocial Functioning Domain
Close relationshipIntimate relationshipsParenting; family; romantic relationships; friendships
Distant relationshipSocietal and cultural groupsEducation; work

Simple Linear Regression Analysis: Evaluating the Total Inventory of Psychosocial Functioning Change Scores

Variableβtp ValueR2
PTSD0.3893.90.0010.20
Depression0.5553.70.0010.18
Anxiety0.3252.10.0330.09

Baseline Sample Characteristics

Characteristicn (%)χ2/tp Value
All Participants (N = 150)PE-IP (n = 76)PE-HBT (n = 74)
Race0.0910.763
  White89 (59.3)46 (60.5)43 (58.1)
  Non-white61 (40.7)30 (39.5)31 (41.9)
Gendera1.740.367
  Male144 (96)72 (94.7)72 (97.3)
  Female5 (3.3)4 (5.3)1 (1.4)
Marital statusb0.1450.735
  Married80 (54.4)40 (54.1)40 (54.8)
  Never married34 (23.1)18 (24.3)16 (21.9)
  Separated/divorced29 (19.7)14 (18.9)15 (20.5)
  Widowed4 (2.7)2 (2.7)2 (2.7)
Employment status0.0280.867
  Unemployed89 (59.3)45 (52.3)44 (51.6)
  Employed61 (40.7)31 (47.7)30 (48.4)
War conflict0.0160.992
  OEF/OIF95 (63.3)48 (63.2)47 (63.5)
  Vietnam31 (20.7)16 (21.1)15 (20.3)
  Persian Gulf24 (16)12 (15.8)12 (16.2)
Mean (SD)
Education (years)12.1 (4.7)12.2 (4.5)11.9 (5)0.2950.769
Service connection (%)54.2 (37.5)51.6 (39.2)56.9 (35.2)−0.7420.459

Baseline Posttraumatic Stress Disorder, Depression, Anxiety, And Total Inventory Of Psychosocial Functioning (IPF) Scores

Baseline TestMean (SD)tp Value
TotalPE-IPPE-HB
PCLa62.7 (12.3)62.1 (12.2)63.4 (12.3)0.6620.508
BDIb28.2 (12.5)28 (11.7)28.5 (13.3)−0.2330.816
BAIc26.5 (13.2)27 (13.3)26.5 (13)0.4100.508
IPFd45.6 (17.5)46.7 (17.2)44.4 (17.8)0.7640.445

Comparison of Treatment Effect on Psychosocial Functioning Between and Within Prolonged Exposure-In Person (PE-IP) and Prolonged Exposure-Home-Based Telehealth (PE-HBT) Groups

IPFMean (SD)95% CItp Value
PE-IPPE-HBTMean Difference
Total IPF
  Pre46.7 (17.2)44.4 (17.9)2.4 (3.06)[−3.7, 8.3]0.7640.445
  Post42.3 (15.7)40 (15.9)2.4 (2.83)[−3.2, 7.9]0.8270.41
  Change4.4 (15.1)−4.4 (14.5)0 (3)[−5.9, 5.9]01
   t21.8
   p value0.0490.088
Relationship
  Pre49 (3.19)40.9 (3.4)8.1 (4.68)[−1.1, 17.2]1.7250.084
  Post40 (3.01)37.9 (3.6)2.1 (4.72)[−7.1, 11.2]0.4480.654
  Change−9.4 (17.72)−1.9 (13.9)−7.4 (5.63)[−18.5, 3.6]−1.390.187
   t2.40.53
   p value0.0150.595
Family
  Pre53.7 (3.02)56.3 (3.5)−2.6 (4.59)[−11.6, 6.4]0.5610.575
  Post48.2 (3.11)41.1 (3.5)7.2 (4.81)[−2.2, 16.6]1.4930.135
  Change−4.2 (21.67)−10.2 (14.3)6 (6.05)[−5.8, 17.9]0.9980.318
   t12.9
   p value0.2930.004
Work
  Pre34.3 (3.13)28.9 (3.1)5.3 (4.61)[−3.7, 14.3]1.1470.251
  Post30.6 (3.51)21.7 (2.8)8.8 (4.87)[−0.6, 18.1]1.8420.066
  Change−4 (14.51)−1.4 (12.6)−2.6 (5.69)[−13.7, 8.6]0.4490.653
   t1.10.36
   p value0.2530.719
Friendship
  Pre50.6 (4.23)46.8 (3.2)3.7 (5.39)[−6.8, 14.3]0.6950.487
  Post46.5 (3.58)38.3 (3.6)8.2 (5.26)[−2.1, 18.5]1.550.121
  Change−7.2 (21.96)−2 (15.7)−5.1 (6.57)[−18, 7.7]0.7820.434
   t1.40.53
   p value1520.596
Parenting
  Pre34.8 (4.43)31.3 (3.8)3.4 (6.01)[−8.3, 15.2]−0.7640.445
  Post31.4 (3.36)23.3 (3.6)7.9 (4.94)[−1.7, 17.6]1.6090.108
  Change−2.6 (17.96)−4.8 (18.5)2.3 (7.97)[−13.3, 17.9]0.2830.777
   t0.460.87
   p value0.6480.384
Authors

Dr. Reich is Psychiatric Mental Health Nurse Practitioner, Mental Health Service Line, Dr. Sternke is Health Services Researcher, and Dr. Acierno is PTSD Clinical Team and Senior Research Psychologist, Department of Psychiatry and Behavioral Sciences, Ralph H. Johnson VA Medical Center, Charleston, South Carolina; and Dr. Nemeth is Professor, and Dr. Mueller is Professor, Medical University of South Carolina, College of Nursing, Charleston, South Carolina. Dr. Sternke is also Affiliate Instructor, Medical University of South Carolina, College of Nursing, Charleston, South Carolina; and Dr. Acierno is also Executive Director, University of Texas Health Science Center at Houston, Trauma and Resilience Center, Houston, Texas.

The authors have disclosed no potential conflicts of interest, financial or otherwise. This article is the result of work supported with resources and the use of facilities at the Ralph H. Johnson VA Medical Center. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government.

Address correspondence to Kristina Reich, PhD, PMHNP-BC, Psychiatric Mental Health Nurse Practitioner, Mental Health Service Line, 9229 University Boulevard, North Charleston, SC 29406; email: kristinaraykh@gmail.com.

Received: May 03, 2020
Accepted: July 28, 2020
Posted Online: October 23, 2020

10.3928/02793695-20201015-01

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