May 24, 2024

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Computer-Based CBT for PTSD; Immune Aging and Life Stressors


TTHealthWatch is a weekly podcast from Texas Tech. In it, Elizabeth Tracey, director of electronic media for Johns Hopkins Medicine in Baltimore, and Rick Lange, MD, president of the Texas Tech University Health Sciences Center in El Paso, look at the top medical stories of the week.

This week’s topics include computer-based therapy for PTSD, maternal mortality during COVID, life stress and immune response, and smoking cessation basis.

Program notes:

0:40 Maternal mortality during COVID

1:40 Based on codes related to death

2:40 Immunization helpful

3:25 Computer-based cognitive behavioral therapy for PTSD

4:25 12 individual sessions or online

5:25 Requires less therapist time

6:30 Smoking cessation for those who’ve been hospitalized

7:31 Community-based quit line

8:30 Motivated individuals

9:27 Immune aging and life stressors

10:31 Lower naive T cells

11:32 Other significant associations dropped out

12:43 End


Elizabeth Tracey: Can computer-delivered therapy work as well as in-person therapy for post-traumatic stress disorder [PTSD]?

Rick Lange, MD: Did maternal mortality change at all during the COVID pandemic?

Elizabeth: How do social stressors associate with a fading immune response?

Rick: Is hospital- or community-based smoking cessation best for people that have been in the hospital?

Elizabeth: That’s what we’re talking about this week on TTHealthWatch, your weekly look at the medical headlines from Texas Tech University Health Sciences Center in El Paso. I’m Elizabeth Tracey, a Baltimore-based medical journalist.

Rick: I’m Rick Lange, president of Texas Tech University Health Sciences Center in El Paso, where I’m also the dean of the Paul L. Foster School of Medicine.

Elizabeth: In keeping with our long-standing now habit, let’s start first with the COVID material that’s in JAMA Network Open.

Rick: This is a study that looks at all-cause maternal mortality in the U.S., both before and during the COVID-19 pandemic, to ask a very simple question: was there a change at all in maternal mortality during the COVID pandemic, and was it related to the pandemic itself?

This is a study from the National Center for Health Statistics. They looked at maternal mortality from 2018 to 2020. During that time period here is what they found. There was a 33% relative increase in maternal mortality, from about 18.8 deaths in women per [100,000] live births to 25.1. Late mortality — and that is within the first 42 days after delivery — increased by 41%.

Unfortunately, there was a huge racial disparity. Relative changes were highest for Hispanics, 74%; for blacks, 40%; and for whites, 17%. They tried to drill down and they did this based upon codes that people enter into why someone died. There wasn’t a specific code for COVID-19, but they looked at things like was there a viral disease, or was there a respiratory illness, or a circulatory system issue. There were both direct and indirect causes.

Elizabeth: Is there data in here that also looks at was it that these were pre-existing conditions and that women who were pregnant avoided the healthcare system, and just like we saw with so many people with cancer, this is the causative factor behind this increase in maternal mortality?

Rick: That’s a great question. Unfortunately, the authors mentioned the fact that whether they were conditions related directly to COVID-19 or whether they were other conditions that were exacerbated by COVID-19 couldn’t be discerned from the data. It’s unknown.

Elizabeth: Clearly we know that women who are pregnant experience adverse outcomes relative to COVID infection. This, of course, is the huge argument for getting immunized.

Rick: Absolutely. For any of our listeners that are unconvinced about whether vaccines can be helpful, this particular group has been shown they are extremely helpful not only to the mothers, but the passive antibodies to the baby as well in the first 6 months of life. I wasn’t aware that the increase was really so substantial — a 33% increase.

Elizabeth: We already have this, of course, really not very laudatory record relative to maternal mortality in this country, especially when we look at other high-income countries. This is even more sobering.

Rick: It is. As I mentioned, there is a huge race disparity as well. It’s not to alarm our listeners, but to make them aware that these are the data and there are things that we can do to mitigate this. Vaccines end up playing an important role.

Elizabeth: Let’s turn to something else that’s important — and that has clearly been exacerbated by COVID-19 — in the BMJ. This is a study taking a look at cognitive behavioral therapy that is performed on the internet versus in-person therapy. We have talked so many times about how the incidence of all kinds of mental illness is increasing during COVID. PTSD, of course, is definitely something that it makes sense, doesn’t it, that we’re all being exposed to these really traumatic events?

This study was conducted in the United Kingdom. There were 196 adults with a primary diagnosis of mild to moderate PTSD. They were randomized 1:1 to either have this in-person intervention for their PTSD or this internet-based.

Their retention rates were really pretty impressive, although those folks who took the computer-based therapy were more likely to leave therapy than the ones who had the face-to-face intervention. The face-to-face, up to 12 individual sessions, or the one on the internet, which was an eight-step online program with up to 3 hours of contact with the therapist and telephone calls or email contacts in between sessions.

The upshot of the whole thing is that it was more or less the same. That it was definitely acceptable to patients to do the one that was on the internet and that there were other advantages. They could self-guide their therapy. The fact that it ended up being almost the same with regard to outcomes, I thought it was very powerful. Since we are experiencing this huge need for these kinds of services, I think this is a good-news kind of study.

Rick: I do want to stress that these were people that had mild to moderate PTSD and so it doesn’t address those with severe PTSD. Across both different interventions, about 20% to 30% of people dropped out. But for those that did, they seemed to have similar outcomes, being able to deliver it online helps people that don’t want to get out of their house or can’t make it to a therapist or in remote areas. In addition, it requires less therapist’s time and as you said, it can be self-directed.

As you’re aware, as you read this, this is a very robust online therapy, so it wasn’t something just picked off the shelf. These individuals had spent an extensive amount of time developing these modules and then testing over a long period of time before they compare to these.

Elizabeth: Right, and so this one is called Spring. That’s right. It was developed over a long period of time, and it seems to me that this intervention is also extremely scalable.

Rick: And it is. If you had the choice between the two, Elizabeth, which would you prefer?

Elizabeth: Oh, I definitely would do the internet-based one just because I don’t have to go anywhere and be someplace at a specific time. I mean, it would be just great to say, “All right, I’m ready to do this. Now let’s turn on the computer.” How about you?

Rick: I think I would be in the same way and I’m a little stressed that about 30% of people didn’t complete it as opposed to 20% of the face-to-face. But for those that are self-motivated and have mild to moderate PTSD, the online-guided cognitive behavioral therapy seems to be quite appropriate.

Elizabeth: Okay. Now, let’s turn to if you’re in the hospital — and clearly while you’re in there, you’re not smoking — what can we do to keep that going when you get out of there?

Rick: Elizabeth, you nailed it. We still have about 14% of the U.S. adults that smoke cigarettes, and more than 3.2 million adults who smoke are hospitalized annually. We know that if you’re going to do smoking-cessation therapy it’s best to start it in the hospital. But obviously, it requires some continued therapy.

How is that best administered? Can it be best administered in a hospital-based system or in what’s called a quitline that’s community-based and oftentimes sponsored by the state? One would think that the hospital-based would be more effective because you’ve been in the hospital, you gain their trust, and they design a program.

What this study attempted to do was to compare the two. It was conducted at three hospitals in Massachusetts, Pennsylvania, and Tennessee from 2018 to 2020 with a total of 1,400 participants, either randomized to hospital-based, transitional-tobacco cure management or an electronic referral to a community-based quitline.

At the end of 6 months, which individuals were most likely to be abstinent? By the way, they could test that to make sure there was no nicotine in the system. Although at 3 months, it looked like the hospital-based management system was a little bit better in terms of abstinence, at 6 months there was no difference at all between the two.

Elizabeth: This is so disappointing, isn’t it? Let me just mention this is in JAMA Internal Medicine. I say to patients all the time when I see them in the hospital, patients who smoke, that they are already nonsmokers because they can’t smoke in the hospital. I’m wondering about what makes somebody go back to it when we know that the physiologic things that are in place when somebody smokes are really largely eliminated often by the time they are discharged.

Rick: Well, you’re right, Elizabeth. That’s a fairly short period of time. Now, what we didn’t ask is how successful are these programs? Well, between 17% to 20% of individuals were abstinent at the end of 6 months. Oh, by the way, these were individuals that were motivated. Yes, during the hospital, I really do want to try and throw your best therapy at me. That therapy involves both counseling from either hospital-based or the quitline, but also the use of nicotine replacement therapies or other medications as well.

The disappointing thing as you noted is the fact that only about one in five of these therapies are successful. I’m actually surprised because I would have thought a hospital-based system would be a little bit better. Again, it was at 3 months, but not at 6.

Now, in fairness, the therapies all stop at 3 months. The authors hypothesized since the hospital-based was better at 3 months, had we continued both therapies for 6 months, maybe it would have continued to be better.

Elizabeth: We still have work to do with this smoking cessation and I respectfully suggest what we need to do is just abolish cigarettes and then we don’t have to worry about it anymore.

Rick: As you know, we are doing that with some of the flavored cigarettes now, thanks to the work of the FDA.

Elizabeth: Absolutely. JUUL looks like it’s going to be off the market at least hopefully.

Let’s turn to PNAS, Proceedings of the National Academy of Sciences, and this looks at social stressors, age-related T lymphocyte percentages in U.S. older adults from the U.S. Health and Retirement Study, and clearly an association. It’s interesting though they defined immune aging as including a decline in both naive — so never before exposed to anything — T cell increases in the terminally differentiated T cells, which of course indicates that those T cells aren’t going to be able to respond to anything else that comes across the transom.

They took a look at 5,700-plus U.S. adults over age 50. They also looked at their psychosocial stressors: how many of these stressors did you have, how many terminally differentiated T cells did you have, and how many naive T cells did you have. They also looked at CMV, cytomegalovirus-seropositivity, to see how that might impact this whole thing.

To make a long story short, they do find that there is a lower percentage of CD8+, one subset of T cells, naive cells in people who have experienced a lot of stressful life events, high lifetime discrimination and chronic stress, and increased terminally differentiated CD4 cells, which is their standing, of course, for your immune function is declining and stress is contributing. It’s not just age.

Rick: What they are trying to do is correlate stress with aging T cells that help fight infection.

A couple of things that you said is it’s just an association. They did look at different types of stress: stressful life events, chronic stress, everyday discrimination, lifetime discrimination, and life trauma. What they did was just a single measurement of T cells. In other words, what you’d like to know is maybe some of those T cells are normal at baseline and then when someone is exposed to stress you can see a change in those T cells. But that’s not what this did. You’re right it’s just an association.

It’s interesting because when they looked at other significant associations — things like if you control for socioeconomic status and lifestyle changes, education, smoking, BMI [body mass index], alcohol use, and CMV-seropositivity — some of these things fell out. They were no longer significant.

That suggests that other things besides stressors themselves may be accountable — for example, CMV infection as well. It’s kind of an interesting study. I’m not quite sure what to do with it. We do know that stress does increase inflammation and it appears to suppress the immune system — whether it’s by this mechanism or something else, in my mind still remains undetermined.

Elizabeth: Exactly. I don’t know what you do to stimulate anybody’s T cells as they age, because we certainly recognize that regardless of what we try to hitch it to.

Rick: Right, I mean, you want a bunch of young T cells that are ready to attack any infection, not a bunch of old ones who say, “Oh, I’m just going to recognize one infection and the rest of them I don’t care about.”

Elizabeth: Thank you for that Texasism. On that note, that’s a look at this week’s medical headlines from Texas Tech. I’m Elizabeth Tracey.

Rick: I’m Rick Lange. Y’all listen up and make healthy choices.


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