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Publications from the Columbia Roybal Center

Bergman M, Markowitz JC, Kronish IM, Agarwal S, Fisch C, Eder-Moreau E, Neria Y. Acceptance and mindfulness-based exposure therapy (AMBET) for PTSD after cardiac arrest: an open feasibility trial. Journal of clinical psychiatry.

Background: Posttraumatic stress disorder (PTSD) is prevalent after surviving sudden cardiac arrest (SCA). SCA-induced PTSD is associated with increased mortality and cardiovascular risk, yet no psychotherapeutic treatment has been developed and tested for this population. Exposure therapy is standard treatment for PTSD, but its safety and efficacy remain unconfirmed for SCA survivors: current protocols do not address their specific disease course and have high attrition. Mindfulness-based interventions are typically well-tolerated and have shown promise in reducing PTSD symptoms from other traumas.

Objective: This study sought to determine feasibility, safety, and preliminary efficacy of acceptance and mindfulness-based exposure therapy (AMBET), a novel SCA-specific psychotherapy protocol combining mindfulness and exposure-based interventions with cardiac focused psychoeducation to reduce symptoms and improve health behaviors in patients with post-SCA PTSD.

Methods: We conducted an open feasibility pilot study from January 2021 to April 2022 with a small sample (N = 11) of SCA survivors meeting DSM-5 PTSD criteria. AMBET comprised eight 90-minute remotely delivered individual sessions. Clinical evaluators assessed PTSD symptoms using the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) at baseline, midpoint, posttreatment, and 3-month follow-up.

Results: Ten (91%) of 11 enrolled patients completed treatment. Satisfaction was high and patients reported no adverse events. PTSD symptoms significantly improved statistically (P < .001) and clinically with large effect sizes (g = 1.34–2.21) and treatment gains sustained at 3-month follow-up. Posttreatment, 80% of completers (n=8) showed significant treatment response, 70% (n=7) with PTSD diagnostic remission. No patient reported symptom increases.

Conclusions: This initial trial found AMBET feasible, safe, and potentially efficacious in reducing PTSD following SCA. These encouraging pilot results warrant further research.

Birk J, Cumella R, Lopez-Veneros D, Agarwal S, Kronish IM. Feasibility of a remote heart rate variability biofeedback intervention for reducing anxiety in cardiac arrest survivors: a pilot trial. Contemporary clinical trials communications.

Background: Heart rate variability biofeedback (HRVB) is a promising non-pharmacologic approach for reducing anxiety. This intervention's feasibility needs testing in psychologically distressed cardiac patients for whom heart-related anxiety is a core concern. To enhance scalability and convenience, remote delivery of HRVB also needs to be assessed. Accordingly, we evaluated the feasibility of remote HRVB in survivors of cardiac arrest (CA) with elevated CA-related psychological distress.


The intervention was comprised of daily sessions of diaphragmatic paced breathing and real-time monitoring of cardiac activity guided by a smartphone app and heart rate monitor. This single-arm feasibility trial assessed the percentage of eligible contacted patients who consented and engaged in the study and the self-reported acceptability, feasibility, appropriateness, and usability of the intervention. Exploratory analyses assessed pre-to-post changes in trait anxiety, negative affect, cardiac-related interoceptive fear, and resting-state HRV.


Of 12 eligible CA survivors contacted, 10 enrolled. All 10 patients completed the virtual study visits and the majority (>50 %) of prescribed training sessions. Ninety percent reported good scores for intervention acceptability and feasibility, and 80 % reported good scores for its appropriateness and usability for reducing fear. Trait anxiety decreased significantly pre-to-post intervention. There were no changes in negative affect, interoceptive fear, or resting state HRV.


A remotely delivered HRVB intervention was acceptable, feasible, and useable for cardiac patients with CA-related psychological distress. A phase 2 randomized controlled trial evaluating the efficacy of HRVB on cardiac patients’ psychological distress, health behaviors, and autonomic dysfunction may be warranted.


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