Current Treatment Options in Psychiatry

, Volume 3, Issue 1, pp 60–72 | Cite as

Yoga as an Intervention for PTSD: a Theoretical Rationale and Review of the Literature

  • Stephanie Y. Wells
  • Ariel J. Lang
  • Laura Schmalzl
  • Erik J. Groessl
  • Jennifer L. Strauss
Post-Traumatic Stress Disorders (K Chard and T Geracioti, Section Editors)
Part of the following topical collections:
  1. Topical Collection on Post-Traumatic Stress Disorders

Opinion statement

There is evidence to suggest that yoga may reduce PTSD symptoms. It is unclear at this point, however, whether or not yoga reduces PTSD symptoms any more than a non-specific intervention given inconsistent findings and methodological limitations. Nonetheless, additional research in this area is important because of the high level of interest in and acceptability of yoga. Ultimately, yoga may be most effective when taught using trauma-sensitive guidelines and within a framework that helps the practitioner to apply the experience to coping with symptoms.

Keywords

PTSD Yoga Trauma Complementary and alternative medicine 

References and Recommended Reading

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    Kessler RC, Sonnega A, Bromet E, Hughes M, Nelson CB. Posttraumatic stress disorder in the National Comorbidity Survey. Arch Gen Psychiatry. 1995;52(12):1048–60.CrossRefPubMedGoogle Scholar
  2. 2.
    Kessler RC, Berglund P, Delmer O, Jin R, Merikangas KR, Walters EE. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62(6):593–602.CrossRefPubMedGoogle Scholar
  3. 3.
    Kessler RC, Chiu WT, Demler O, Merikangas KR, Walters EE. Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62(6):617–27.PubMedCentralCrossRefPubMedGoogle Scholar
  4. 4.
    Kilpatrick DG, Resnick HS, Milanak ME, Miller MW, Keyes KM, Friedman MJ. National estimates of exposure to traumatic events and PTSD prevalence using DSM-IV and DSM-5 criteria. J Trauma Stress. 2013;26(5):537–47.PubMedCentralCrossRefPubMedGoogle Scholar
  5. 5.
    Kang HK, Natelson BH, Mahan CM, Lee KY, Murphy FM. Post-traumatic stress disorder and chronic fatigue syndrome-like illness among Gulf War veterans: a population-based survey of 30,000 veterans. Am J Epidemiol. 2003;157(2):141–8.CrossRefPubMedGoogle Scholar
  6. 6.
    Tanelian T, Jaycox LH. Invisible wounds of war: psychological and cognitive injuries, their consequences, and services to assist recovery. Santa Monica: RAND Corporation; 2008.Google Scholar
  7. 7.
    Kulka RA, Schlenger WE, Fairbank JA, Hough RL, Jordan BK, Marmar CR, et al. Trauma and the Vietnam war generation: report of findings from the National Vietnam Veterans Readjustment Study: Brunner/Mazel; 1990Google Scholar
  8. 8.
    Pacella ML, Hruska B, Delahanty DL. The physical health consequences of PTSD and PTSD symptoms: a meta-analytic review. J Anxiety Disord. 2013;27(1):33–46.CrossRefPubMedGoogle Scholar
  9. 9.
    Schnurr PP, Jankowski MK. Physical health and post-traumatic stress disorder: review and synthesis. Semin Clin Neuropsychiatry. 1999;4(4):295–304.PubMedGoogle Scholar
  10. 10.
    Shalev AY, Freedman S, Peri T, Brandes D, Sahar T, Orr SP, et al. Prospective study of posttraumatic stress disorder and depression following trauma. Am J Psychiatr. 2014;155(5):630–7.CrossRefGoogle Scholar
  11. 11.
    Jacobsen LK, Southwick SM, Kosten TR. Substance use disorders in patients with posttraumatic stress disorder: a review of the literature. Am J Psychiatr. 2001;158(8):1184–90.CrossRefPubMedGoogle Scholar
  12. 12.
    Krysinska K, Lester D. Post-traumatic stress disorder and suicide risk: a systematic review. Arch Suicide Res. 2010;14(1):1–23.CrossRefPubMedGoogle Scholar
  13. 13.
    Byers AL, Covinsky KE, Neylan TC, Yaffe K. Chronicity of posttraumatic stress disorder and risk of disability in older persons. JAMA Psychiatry. 2014;71(5):540–6.PubMedCentralCrossRefPubMedGoogle Scholar
  14. 14.
    Mendlowicz MV, Stein MB. Quality of life in individuals with anxiety disorders. Am J Psychiatr. 2014;157(5):669–82.CrossRefGoogle Scholar
  15. 15.
    Smith MW, Schnurr PP, Rosenheck RA. Employment outcomes and PTSD symptom severity. Ment Health Serv Res. 2005;7(2):89–101.CrossRefPubMedGoogle Scholar
  16. 16.
    Zatzick DF, Marmar CR, Weiss DS, Browner WS, Metzler TJ, Golding JM, et al. Posttraumatic stress disorder and functioning and quality of life outcomes in a nationally representative sample of male Vietnam veterans. Am J Psychiatr. 1997;154(12):1690–5.CrossRefPubMedGoogle Scholar
  17. 17.
    Foa EB, Keane TM, Friedman MJ. Effective treatments for PTSD: practice guidelines from the International Society for Traumatic Stress Studies. New York: Guilford; 2009.Google Scholar
  18. 18.
    The Management of Post-Traumatic Stress Working Group. VA/DoD clinical practice guideline for management of post-traumatic stress. Washington: Veterans Health Administration/Department of Defense; 2010.Google Scholar
  19. 19.
    Bradley R, Greene J, Russ E, Dutra L, Westen D. A multidimensional meta-analysis of psychotherapy for PTSD. Am J Psychiatry. 2005;162(2):214–27.CrossRefPubMedGoogle Scholar
  20. 20.•
    Steenkamp MM, Litz BT, Hoge CW, Marmar CR. Psychotherapy for military-related PTSD: a review of randomized clinical trials. J Am Med Assoc. 2015;314(5):489–500. This article reviewed the current PTSD treatment outcome literature in active duty and veteran military populations. Results indicated that current PTSD treatments are efficacious at clinically reducing PTSD symptoms and achieving diagnostic remission in some individuals with PTSD, but many still have clinically significant symptoms and meet diagnostic criteria for PTSD after treatment.CrossRefGoogle Scholar
  21. 21.
    Schottenbauer MA, Glass CR, Arnkoff DB, Tendick V, Gray SH. Nonresponse and dropout rates in outcome studies on PTSD: review and methodological considerations. Psychiatry. 2008;71(2):134–68.CrossRefPubMedGoogle Scholar
  22. 22.
    Complementary, alternative, or integrative health: what’s in a name?: National Center for Complementary and Integrative Health; 2015. Available from: https://nccih.nih.gov/sites/nccam.nih.gov/files/Whats_In_A_Name_08-11-2015.pdf.
  23. 23.
    Kessler RC, Davis RB, Foster DF, Van Rompay MI, Walters EE, Wilkey SA, et al. Long-term trends in the use of complementary and alternative medical therapies in the United States. Ann Intern Med. 2001;135(4):262–8.CrossRefPubMedGoogle Scholar
  24. 24.
    Barnes PM, Bloom B, Nahin RL. Complementary alternative medicine use among adults and children, United States, 2007. Natl Health Stat Rep. 2008;10(12):1–23.Google Scholar
  25. 25.
    Kessler RC, Soukup J, Davis RB, Foster DF, Wilkey SA, Van Rompay MI, et al. The use of complementary and alternative therapies to treat anxiety and depression in the United States. Am J Psychiatr. 2001;158:289–94.CrossRefPubMedGoogle Scholar
  26. 26.
    Knaudt PR, Connor KM, Weisler RH, Churchill LE, Davidson JR. Alternative therapy use by psychiatric outpatients. J Nerv Ment Dis. 1999;187(11):692–5.CrossRefPubMedGoogle Scholar
  27. 27.
    Micek MA, Bradley KA, Braddock 3rd CH, Maynard C, McDonell M, Fihn SD. Complementary and alternative medicine use among Veterans Affairs outpatients. J Altern Complement Med. 2007;13(2):190–3.CrossRefPubMedGoogle Scholar
  28. 28.
    Eisenberg DM, Davis RB, Ettner SL, et al. Trends in alternative medicine use in the United States, 1990-1997: results of a follow-up national survey. J Am Med Assoc. 1998;280(18):1569–75.CrossRefGoogle Scholar
  29. 29.
    Wang PS, Lane M, Olfson M, Pincus HA, Wells KB, Kessler RC. Twelve-month use of mental health services in the United States: results from the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62(6):629–40.CrossRefPubMedGoogle Scholar
  30. 30.
    Libby DJ, Pilver CE, Desai R. Complementary and alternative medicine use among individuals with posttraumatic stress disorder. Psychol Trauma. 2013;5(3):277–85.CrossRefGoogle Scholar
  31. 31.
    Libby D, Reddy F, Pilver C, Desai R. The use of yoga in specialized VA PTSD treatment programs. Int J Yoga Ther. 2012;22(1):79–88.Google Scholar
  32. 32.
    Jeter PE, Slutsky J, Singh N, Khalsa SBS. Yoga as a therapeutic intervention: a bibliometric analysis of published research studies from 1967 to 2013. J Alternat Complement Med. 2015;21(10):586–92.CrossRefGoogle Scholar
  33. 33.
    Yoga Warriors International. Available from: http://www.yogawarriors.com.
  34. 34.
    Move: yoga: good for the mind & body San Diego, CA 2014. Available from: http://www.med.navy.mil/sites/nmcsd/Pages/Care/HealthWellnessMoveArticlesYoga.aspx.
  35. 35.
    Trauma-sensitive yoga. Available from: http://www.traumacenter.org/clients/yoga_svcs.php.
  36. 36.
    Clarke TC, Black LI, Stussman BJ, Barnes PM, Nahin RL. Trends in the use of complementary health approaches among adults: United States. 2002–2012. Natl Health Stat Rep. 2015;79(79):1–16.Google Scholar
  37. 37.
    Gard T, Taquet M, Dixit R, Hölzel BK, de Montjoye YA, Brach N, et al. Fluid intelligence and brain functional organization in aging yoga and meditation practitioners. Front Aging Neurosci. 2014;6:1–2.CrossRefGoogle Scholar
  38. 38.
    Payne P, Crane-Godreau MA. Meditative movement for depression and anxiety. Front Psychiatry. 2013;4:1–15.CrossRefGoogle Scholar
  39. 39.
    Boiten FA, Frijda NH, Wientjes CJ. Emotions and respiratory patterns: review and critical analysis. Int J Psychophysiol. 1994;17(2):103–28.CrossRefPubMedGoogle Scholar
  40. 40.
    Brown RP, Gerbarg PL. Sudarshan Kriya yogic breathing in the treatment of stress, anxiety and depression: part I—neurophysiologic model. J Alternat Complement Med. 2005;11(1):189–201.CrossRefGoogle Scholar
  41. 41.
    Henje Blom E, Serlachius E, Chesney MA, Olsson EM. Adolescent girls with emotional disorders have a lower end-tidal CO2 and increased respiratory rate compared with healthy controls. Psychophysiology. 2014;51(5):412–8.PubMedCentralCrossRefPubMedGoogle Scholar
  42. 42.
    Spicuzza L, Gabutti A, Porta C, Montano N, Bernardi L. Yoga and chemoreflex response to hypoxia and hypercapnia. Lancet. 2000;356(9240):1495–6.CrossRefPubMedGoogle Scholar
  43. 43.
    Sharma H, Sen S, Singh A, Bhardwaj NK, Kochupillai V, Singh N. Sudarshan Kriya practitioners exhibit better antioxidant status and lower blood lactate levels. Biol Psychol. 2003;63(3):281–91.CrossRefPubMedGoogle Scholar
  44. 44.
    Esposito P, Mereu R, De Barbieri G, Rampino T, Di Toro A, Groop PH, et al. Trained breathing-induced oxygenation acutely reverses cardiovascular autonomic dysfunction in patients with type 2 diabetes and renal disease. Acta Diabetologica. 2015Google Scholar
  45. 45.
    Torner L, Toschi N, Nava G, Clapp C, Neumann ID. Increased hypothalamic expression of prolactin in lactation: involvement in behavioural and neuroendocrine stress responses. Eur J Neurosci. 2002;15(8):1381–9.CrossRefPubMedGoogle Scholar
  46. 46.
    Lutz A, Slagter HA, Dunne JD, Davidson RJ. Attention regulation and monitoring in meditation. Trends Cogn Sci. 2008;12(4):163–9.PubMedCentralCrossRefPubMedGoogle Scholar
  47. 47.
    Farb N, Daubenmier J, Price CJ, Gard T, Kerr C, Dunn BD, et al. Interoception, contemplative practice, and health. Front Psychol. 2015;6:1–26.CrossRefGoogle Scholar
  48. 48.
    Baas LS, Beery TA, Allen G, Wizer M, Wagoner LE. An exploratory study of body awareness in persons with heart failure treated medically or with transplantation. J Cardiovasc Nurs. 2004;19(1):32–40.CrossRefPubMedGoogle Scholar
  49. 49.
    Hasenkamp W, Wilson-Mendenhall CD, Duncan E, Barsalou LW. Mind wandering and attention during focused meditation: a fine-grained temporal analysis of fluctuating cognitive states. NeuroImage. 2012;59(1):750–60.CrossRefPubMedGoogle Scholar
  50. 50.
    Wolkin JR. Cultivating multiple aspects of attention through mindfulness meditation accounts for psychological well-being through decreased rumination. Psychol Res Behav Manag. 2015;8:171–80.PubMedCentralCrossRefPubMedGoogle Scholar
  51. 51.
    Brewer JA, Worhunsky PD, Gray JR, Tang YY, Weber J, Kober H. Meditation experience is associated with differences in default mode network activity and connectivity. Proc Natl Acad Sci U S A. 2011;108(50):20254–9.PubMedCentralCrossRefPubMedGoogle Scholar
  52. 52.
    Porges SW. The polyvagal theory: phylogenetic substrates of a social nervous system. Int J Psychophysiol. 2001;42(2):123–46.CrossRefPubMedGoogle Scholar
  53. 53.
    Porges SW. Orienting in a defensive world: mammalian modification of our evolutionary heritage. A polyvagal theory. Psychophysiology. 1995;32(4):301–18.CrossRefPubMedGoogle Scholar
  54. 54.
    Berthoud HR, Neuhuber WL. Functional and chemical anatomy of the afferent vagal system. Auton Neurosci. 2000;85(1–3):1–17.CrossRefPubMedGoogle Scholar
  55. 55.
    Thayer JF, Sternberg E. Beyond heart rate variability: vagal regulation of allostatic systems. Ann N Y Acad Sci. 2006;1088(1):361–72.CrossRefPubMedGoogle Scholar
  56. 56.
    Porges SW. The polyvagal perspective. Biol Psychol. 2007;74(2):116–43.PubMedCentralCrossRefPubMedGoogle Scholar
  57. 57.
    Ritter S, Ritter RC, Barnes CD. Neuroanatomy and physiology of abdominal vagal afferents. Boca Raton: FL: CRC; 1992.Google Scholar
  58. 58.
    Rocha KK, Ribeiro AM, Rocha KC, Sousa MB, Albuquerque FS, Ribeiro S, et al. Improvement in physiological and psychological parameters after 6 months of yoga practice. Conscious Cogn. 2012;21(2):843–50.CrossRefPubMedGoogle Scholar
  59. 59.
    Streeter CC, Gerbarg PL, Saper RB, Ciraulo DA, Brown RP. Effects of yoga on the autonomic nervous system, gamma-aminobutyric-acid, and allostasis in epilepsy, depression, and post-traumatic stress disorder. Med Hypotheses. 2012;78(5):571–9.CrossRefPubMedGoogle Scholar
  60. 60.
    Papp ME, Lindfors P, Storck N, Wandell PE. Increased heart rate variability but no effect on blood pressure from 8 weeks of hatha yoga—a pilot study. BMC Res Notes. 2013;6:59.PubMedCentralCrossRefPubMedGoogle Scholar
  61. 61.
    Gard T, Brach N, Hölzel BK, Noggle JJ, Conboy LA, Lazar SW. Effects of a yoga-based intervention for young adults on quality of life and perceived stress: the potential mediating roles of mindfulness and self-compassion. J Posit Psychol. 2012;7(3):165–75.CrossRefGoogle Scholar
  62. 62.
    David N, Fiori F, Aglioti SM. Susceptibility to the rubber hand illusion does not tell the whole body-awareness story. Cogn Affec Behav Neurosci. 2014;14(1):297–306.CrossRefGoogle Scholar
  63. 63.
    Villemure C, Ceko M, Cotton VA, Bushnell MC. Insular cortex mediates increased pain tolerance in yoga practitioners. Cereb Cortex. 2014;24(10):2732–40.PubMedCentralCrossRefPubMedGoogle Scholar
  64. 64.
    Narayana NVVS. The effect of yoga on visual reaction time. Indian J Soc Sci Res. 2009;6(2):63–70.Google Scholar
  65. 65.
    Manjunath NK, Telles S. Improved performance in the Tower of London test following yoga. Indian J Physiol Pharmacol. 2001;45(3):351–4.PubMedGoogle Scholar
  66. 66.
    Froeliger B, Garland EL, McClernon FJ. Yoga meditation practitioners exhibit greater gray matter volume and fewer reported cognitive failures: results of a preliminary voxel-based morphometric analysis. Evid Based Complement Alternat Med. 2012;2012:821307.PubMedCentralPubMedGoogle Scholar
  67. 67.
    Bomyea J, Lang AJ. The role of executive functioning in PTSD and its treatment. Curr Psychiatr Rev. 2015;11(3):160–71.CrossRefGoogle Scholar
  68. 68.
    Lang AJ, Strauss JL, Bomyea J, Bormann JE, Hickman SD, Good RC, et al. The theoretical and empirical basis for meditation as an intervention for PTSD. Behav Modif. 2012;36(6):759–86.CrossRefPubMedGoogle Scholar
  69. 69.
    Pence PG, Katz LS, Huffman C, Cojucar G. Delivering integrative restoration-yoga nidra meditation (iRest(R)) to women with sexual trauma at a veteran’s medical center: a pilot study. Int J Yoga Ther. 2014;24:53–62.Google Scholar
  70. 70.
    Descilo T, Vedamurtachar A, Gerbarg P, Nagaraja D, Gangadhar B, Damodaran B, et al. Effects of a yoga breath intervention alone and in combination with an exposure therapy for post‐traumatic stress disorder and depression in survivors of the 2004 South‐East Asia tsunami. Acta Psychiatr Scand. 2010;121(4):289–300.CrossRefPubMedGoogle Scholar
  71. 71.••
    Jindani F, Turner N, Khalsa SB. A yoga intervention for posttraumatic stress: a preliminary randomized control trial. Evid Based Complement Alternat Med. 2015;2015:351746. This is the largest randomized controlled study to examine the efficacy of yoga for PTSD. Individuals in the Kundalini yoga intervention group had greater decreases in PTSD symptoms than individuals in the wait list control group.PubMedCentralCrossRefPubMedGoogle Scholar
  72. 72.
    Emerson D, Sharma R, Chaudhry S, Turner J. Trauma-sensitive yoga: principles, practice, and research. Int J Yoga Ther. 2009;19(1):123–8.Google Scholar
  73. 73.••
    van der Kolk BA, Stone L, West J, Rhodes A, Emerson D, Suvak M, et al. Yoga as an adjunctive treatment for posttraumatic stress disorder: a randomized controlled trial. J Clin Psychiatry. 2014;75(6):e559–65. This randomized controlled trial compared the efficacy of a hatha yoga intervention to a women’s health education group for women with chronic, treatment-resistant PTSD. Both groups experienced significant decreases in clinician-assessed PTSD symptoms, but the yoga group had significantly greater decreases.CrossRefPubMedGoogle Scholar
  74. 74.
    Mitchell KS, Dick AM, DiMartino DM, Smith BN, Niles B, Koenen KC, et al. A pilot study of a randomized controlled trial of yoga as an intervention for PTSD symptoms in women. J Trauma Stress. 2014;27(2):121–8.CrossRefPubMedGoogle Scholar
  75. 75.
    Thordardottir K, Gudmundsdottir R, Zoega H, Valdimarsdottir UA, Gudmundsdottir B. Effects of yoga practice on stress-related symptoms in the aftermath of an earthquake: a community-based controlled trial. Complement Ther Med. 2014;22(2):226–34.CrossRefPubMedGoogle Scholar
  76. 76.
    Telles S, Singh N, Joshi M, Balkrishna A. Post traumatic stress symptoms and heart rate variability in Bihar flood survivors following yoga: a randomized controlled study. BMC Psychiatry. 2010;10:18.PubMedCentralCrossRefPubMedGoogle Scholar
  77. 77.••
    Johnston JM, Minami T, Greenwald D, Li C, Reinhardt K, Khalsa SB. Yoga for military service personnel with PTSD: a single arm study. Psychol Trauma. 2015;7(6):555–62. This single-arm study used a benchmark comparison condition to examine the efficacy of Kripalu yoga for active duty personnel and veterans with PTSD. Individuals with PTSD had clinically and significant decreases in clinician-assessed PTSD symptoms from pretreatment to posttreatment, but the effect size did not meet the targeted benchmark effect size.CrossRefPubMedGoogle Scholar
  78. 78.
    Staples JK, Hamilton MF, Uddo M. A yoga program for the symptoms of post-traumatic stress disorder in veterans. Mil Med. 2013;178(8):854–60.CrossRefPubMedGoogle Scholar
  79. 79.
    Groessl EJ, Maiya M, Elwy AR, Riley KE, Sarkin AJ, Eisen SV, et al. The essential properties of yoga questionnaire: development and methods. Int J Yoga Ther. 2015;25(1):51–9.CrossRefGoogle Scholar
  80. 80.
    Dunlop BW, Kaye JL, Youngner C, Rothbaum B. Assessing treatment resistant posttraumatic stress disorder: The Emory Resistance Interview for PTSD (E-TRIP). Behav Sci. 2014;8(4):511–27.CrossRefGoogle Scholar
  81. 81.
    Schmalzl L, Powers C, Henje BE. Neurophysiological and neurocognitive mechanisms underlying the effects of yoga-based practices: towards a comprehensive theoretical framework. Front Hum Neurosci. 2015;9:235.PubMedCentralCrossRefPubMedGoogle Scholar
  82. 82.
    Frawley D. Yoga: the greater tradition. San Rafael: CA Mandala Publishing; 2008.Google Scholar
  83. 83.
    Laifer AL, Wirth KA, Lang AJ. Mindfulness and acceptance and commitment therapy in the treatment of trauma. In: Dallenberg C, editor. APA handbook of trauma psychology. Washington: American Psychological Association; 2016.Google Scholar
  84. 84.
    Minassian A, Maihofer AX, Baker DG, et al. Association of predeployment heart rate variability with risk of postdeployment posttraumatic stress disorder in active-duty marines. JAMA Psychiatry. 2015;72(10):979–86.CrossRefPubMedGoogle Scholar
  85. 85.
    Allan NP, Short NA, Albanese BJ, Keough ME, Schmidt NB. Direct and mediating effects of an anxiety sensitivity intervention on posttraumatic stress disorder symptoms in trauma-exposed individuals. Cogn Behav Ther. 2015:1–13.Google Scholar
  86. 86.
    Orcutt HK, Pickett SM, Pope B. Experiential avoidance and forgiveness as mediators in the relation between traumatic interpersonal events and posttraumatic disorder symptoms. J Soc Clin Psychol. 2005;24(7):1003–29.CrossRefGoogle Scholar
  87. 87.
    Janoff-Bulman R. Assumptive worlds and the stress of traumatic events: applications of the schema construct. Soc Cogn. 1989;7(2):113–36.CrossRefGoogle Scholar
  88. 88.
    Ehlers A, Clark DM. A cognitive model of posttraumatic stress disorder. Behav Res Ther. 2000;38(4):319–45.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing AG (outside the USA) 2016

Authors and Affiliations

  • Stephanie Y. Wells
    • 1
  • Ariel J. Lang
    • 2
  • Laura Schmalzl
    • 3
  • Erik J. Groessl
    • 3
  • Jennifer L. Strauss
    • 4
  1. 1.SDSU/UCSD Joint Doctoral Program in Clinical Psychology and VA San Diego Healthcare SystemSan DiegoUSA
  2. 2.VA Center of Excellence for Stress and Mental Health and UCSD Department of PsychiatryLa JollaUSA
  3. 3.UCSD Department of Family Medicine and Public HealthLa JollaUSA
  4. 4.Mental Health Services, Department of Veterans Affairs; Department of Psychiatry and Behavioral ScienceDuke University Medical CenterDurhamUSA

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