Mental Health Service Utilization before and after Receipt of a Service-Connected Disability Award for PTSD: Findings from a National Sample

OBJECTIVE

To determine patterns of mental health service use before and after VA disability compensation awards for posttraumatic stress disorder (PTSD).

DATA SOURCES

A 10 percent random sample of VHA-enrolled Veterans with new or increased PTSD service connection between 2012 and 2014 (n = 22,249).

STUDY DESIGN

We used latent trajectory analysis to identify utilization patterns and multinomial logistic regression to assess associations between Veteran characteristics and trajectory membership.

DATA EXTRACTION METHODS

We assessed receipt of VHA mental health encounters in each of the 52 weeks prior to and following PTSD disability rating or rating increase.

PRINCIPAL FINDINGS

The best fitting model had five groups: No Use (36.6 percent), Low Use (37.7 percent), Increasing Use (9.4 percent), Decreasing Use (11.2 percent), and High Use (5.1 percent). Adjusting for demographic characteristics and compared with the No Use group, Veterans in the other groups were more likely to reside closer to a VHA facility, receive a higher PTSD disability rating, and screen positive for military sexual trauma.

CONCLUSIONS

Service use remained stable (80 percent) or increased (9 percent) for the vast majority of Veterans. Service utilization declined for only 11 percent. Data did not indicate substantial service discontinuation following rating. Low VHA service utilization suggests opportunities to enhance outreach for Veterans with PTSD-related disability benefits.

The Clinician-Administered PTSD Scale for DSM-5 (CAPS-5): Development and initial psychometric evaluation in military veterans

The Clinician-Administered PTSD Scale (CAPS) is an extensively validated and widely used structured diagnostic interview for posttraumatic stress disorder (PTSD). The CAPS was recently revised to correspond with PTSD criteria in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association, 2013). This article describes the development of the CAPS for DSM-5 (CAPS-5) and presents the results of an initial psychometric evaluation of CAPS-5 scores in 2 samples of military veterans (Ns = 165 and 207). CAPS-5 diagnosis demonstrated strong interrater reliability (к = .78 to 1.00, depending on the scoring rule) and test-retest reliability (к = .83), as well as strong correspondence with a diagnosis based on the CAPS for DSM-IV (CAPS-IV; к = .84 when optimally calibrated). CAPS-5 total severity score demonstrated high internal consistency (α = .88) and interrater reliability (ICC = .91) and good test-retest reliability (ICC = .78). It also demonstrated good convergent validity with total severity score on the CAPS-IV (r = .83) and PTSD Checklist for DSM-5 (r = .66) and good discriminant validity with measures of anxiety, depression, somatization, functional impairment, psychopathy, and alcohol abuse (rs = .02 to .54). Overall, these results indicate that the CAPS-5 is a psychometrically sound measure of DSM-5 PTSD diagnosis and symptom severity. Importantly, the CAPS-5 strongly corresponds with the CAPS-IV, which suggests that backward compatibility with the CAPS-IV was maintained and that the CAPS-5 provides continuity in evidence-based assessment of PTSD in the transition from DSM-IV to DSM-5 criteria. (PsycINFO Database Record

VA residential treatment providers' use of two evidence-based psychotherapies for PTSD: Global endorsement versus specific components

OBJECTIVE

Despite a growing body of knowledge about the dissemination of evidence-based psychotherapies (EBPs), their actual use in clinical settings is not well understood. The purpose of the current study was to compare self-reported component use with global use for 2 EBPs for posttraumatic stress disorder (PTSD), prolonged exposure (PE), and cognitive processing therapy (CPT).

METHOD

Around 174 providers from 38 VA PTSD residential treatment programs were asked about both global use and component use of PE and CPT.

RESULTS

Among frequent users of these EBPs, component use was generally high, especially for low-intensity and nonspecific components. For each form of treatment, there were a small number of providers who reported using the treatment frequently but did not use most of the key components of the treatment.

CONCLUSIONS

These findings highlight the importance of understanding the modifications that providers make to EBPs and suggest the importance of flexibility within fidelity to these treatments. (PsycINFO Database Record

What I have changed my mind about and why: public health and technology perspectives in the field of trauma studies

Background: This paper is based on a panel discussion at the 32nd annual meeting of the International Society for Traumatic Stress Studies in Dallas, Texas, in November 2016. Objective: Paula Schnurr convened a panel of experts in the fields of public health and technology to address the topic: 'What I have changed my mind about and why.' Method: The panel included Richard Bryant, Lucy Berliner, Dean Kilpatrick, Albert ('Skip') Rizzo, and Josef Ruzek. Results: Panellists discussed innovative strategies for the dissemination of scientific knowledge and evidence-based treatment. Conclusions: Although there are effective treatments, there is a need to enhance the effectiveness of these treatments. There also is a need to develop simpler, low-cost strategies to disseminate effective treatments. However, technology approaches also offer pathways to increased dissemination. Researchers must communicate scientific findings more effectively to impact public opinion and public policy.

Effect of Patient-Therapist Gender Match on Psychotherapy Retention Among United States Veterans with Posttraumatic Stress Disorder

Extant literature suggests that patient-therapist gender matching may be associated with psychotherapy retention. We examined this relationship in a national cohort of Veterans (n = 506,471) initiating psychotherapy for posttraumatic stress disorder (PTSD) using multivariate logistic regression models. Overall, women were retained in psychotherapy at higher rates than men. When patient and therapist factors as well as practice patterns are considered, gender match between female patients with PTSD and female therapists was not a positive predictor of psychotherapy retention. Contrary to our expectations, gender match between male patients with PTSD and male therapist was a negative predictor of psychotherapy retention.

Examining the diagnostic utility of the DSM-5 PTSD symptoms among male and female returning veterans

BACKGROUND

Posttraumatic stress disorder (PTSD) diagnostic criteria have been criticized for including symptoms that overlap with commonly comorbid disorders, which critics argue undermines the validity of the diagnosis and inflates psychiatric comorbidity rates. In response, the upcoming 11th edition of the International Classification of Diseases (ICD-11) will offer PTSD diagnostic criteria that are intended to promote diagnostic accuracy. However, diagnostic utility analyses have not yet assessed whether these criteria minimize diagnostic errors. The present study examined the diagnostic utility of each PTSD symptom in the fifth edition of the Diagnostic and Statistical Manual for Mental Disorders (DSM-5) for males and females.

METHODS

Participants were 1,347 individuals enrolled in a longitudinal national registry of returning veterans receiving care at a Department of Veterans Affairs (VA) facility. Doctoral level clinicians assessed all participants using the PTSD module of the Structured Clinical Interview for DSM.

RESULTS

Of the 20 symptoms examined, the majority performed in the fair to poor range on test quality indices. Although a few items did perform in the good (or better) range, only half were ICD-11 symptoms. None of the 20 symptoms demonstrated good quality of efficiency. Results demonstrated few sex differences across indices. There were no differences in the proportion of comorbid psychiatric disorders or functional impairment between DSM-5 and ICD-11 criteria.

CONCLUSIONS

ICD-11 PTSD criteria demonstrate neither greater diagnostic specificity nor reduced rates of comorbidity relative to DSM-5 criteria and, as such, do not perform as intended. Modifications to existing symptoms or new symptoms may improve differential diagnosis.

Trends in Opioid Use Disorder Diagnoses and Medication Treatment Among Veterans With Posttraumatic Stress Disorder

OBJECTIVE

Despite long-standing interest in posttraumatic stress disorder (PTSD) and opioid use disorder comorbidity, there is a paucity of data on the prevalence of opioid use disorder in patients with PTSD. Therefore, there is limited understanding of the use of medications for opioid use disorder in this population. We determined the prevalence of diagnosed opioid use disorder and use of medications for opioid use disorder in a large cohort of patients with PTSD.

METHODS

We obtained administrative and pharmacy data for veterans who initiated PTSD treatment in the Department of Veterans Affairs (VA) between 2004 and 2013 (N = 731,520). We identified those with a comorbid opioid use disorder diagnosis (2.7%; n = 19,998) and determined whether they received a medication for opioid use disorder in the year following their initial clinical PTSD diagnosis (29.6%; n = 5,913). Using logistic regression, we determined the predictors of receipt of opioid use disorder medications.

RESULTS

Comorbid opioid use disorder diagnoses increased from 2.5% in 2004 to 3.4% in 2013. Patients with comorbid opioid use disorder used more health services and had more comorbidities than other patients with PTSD. Among patients with PTSD and comorbid opioid use disorder, use of medications for opioid use disorder increased from 22.6% to 35.1% during the same time period. Growth in the use of buprenorphine (2.0% to 22.7%) was accompanied by relative decline in use of methadone (19.3% to 12.7%). Patients who received buprenorphine were younger and more likely to be rural, White, and married. Patients who received methadone were older, urban, unmarried, from racial and ethnic minorities, and more likely to see substance abuse specialists. While use of naltrexone increased (2.8% to 8.6%), most (87%) patients who received naltrexone also had an alcohol use disorder. Controlling for patient factors, there was a substantial increase in the use of buprenorphine, a substantial decrease in the use of methadone, and no change in use of naltrexone across years.

CONCLUSIONS

Opioid use disorder is an uncommon but increasing comorbidity among patients with PTSD. Patients entering VA treatment for PTSD have their opioid use disorder treated with opioid agonist treatments in large and increasing numbers. There is a need for research both on the epidemiology of opioid use disorder among patients with PTSD and on screening for opioid use disorder.

The Role of PTSD, Depression, and Alcohol Misuse Symptom Severity in Linking Deployment Stressor Exposure and Post-Military Work and Family Outcomes in Male and Female Veterans

Exposure to stressors during military deployment puts veterans at risk for reduced post-military quality of life. Stress-related mental health problems may lead to decreased well-being within work and family domains, yet few studies have explored associations in the context of gender. We examined relationships between deployment stressors and post-military functioning and satisfaction in the domains of work and family, with a focus on PTSD, depression, and alcohol misuse symptomatology as potential mediators. Participants included 522 male and female Iraq and Afghanistan War veterans assessed longitudinally. Structural equation models supported several direct and indirect pathways linking deployment stressors to work and family outcomes for both men and women. PTSD had an important role in these associations. Depression also played a significant role, particularly for women. These findings build on prior research by elucidating potential gender-specific risk, which may be applied to better tailor services to veterans' unique needs.

Anticonvulsant Medication Use in Veterans With Posttraumatic Stress Disorder

OBJECTIVE

Anticonvulsants have been studied for many indications, including posttraumatic stress disorder (PTSD). The limited efficacy research on anticonvulsants for PTSD is mixed. However, anticonvulsants are prescribed widely to veterans with PTSD. Our objective was to measure trends and factors associated with anticonvulsant prescriptions among veterans with PTSD.

METHODS

We obtained administrative and pharmacy data for veterans who initiated PTSD treatment in the US Department of Veterans Affairs (VA) between 2004 and 2013 (N = 731,520). We identified those who received anticonvulsants during the year following their initial clinical PTSD diagnosis and examined common indications for anticonvulsant use, patient characteristics, and service use characteristics. Using logistic regression, we determined the predictors of anticonvulsant initiation among those without an indication.

RESULTS

Although 24.9% of patients in the cohort received an anticonvulsant during their initial year of PTSD treatment, 94.6% had an indication unrelated to PTSD and 51.2% initiated anticonvulsant use before their PTSD diagnosis. While there was growth in anticonvulsant initiation over the 10-year period, this was explained both by growth in indications unrelated to PTSD and by increased use of anticonvulsants for these indications. The rate of anticonvulsant initiation without an indication was stable at approximately 5% throughout the period, with patient and service use characteristics driving the selection of individual agents.

CONCLUSIONS

A large and increasing proportion of veterans with PTSD receives anticonvulsant prescriptions. However, this may be appropriate use driven by increased prevalence of comorbid conditions that may be an indication for anticonvulsant use, including pain and headache disorders.

Editorial overview: Advances in science and practice in traumatic stress

This issue provides an expansive overview of the field of posttraumatic stress disorder (PTSD). The featured articles highlight novel, creative, and innovative topics and methodologies, consolidate recent scientific advances, and delineate future directions. The content spans various topics in the field of traumatic stress, including assessment, biopsychosocial correlates, clinical considerations, including comorbidity, anger, self-directed violence, and dissociative manifestations, evidence-based interventions, and innovative delivery formats that maximize dissemination and implementation. The issue's overarching goal is to stimulate creative, multidisciplinary, methodologically rigorous, and theoretically grounded research to advance knowledge and practice in PTSD and related conditions.

An RCT of Effects of Telephone Care Management on Treatment Adherence and Clinical Outcomes Among Veterans With PTSD

OBJECTIVE

This study assessed whether adding telephone care management to usual outpatient mental health care improved treatment attendance, medication compliance, and clinical outcomes of veterans with posttraumatic stress disorder (PTSD).

METHODS

In a multisite randomized controlled trial, 358 veterans were assigned to either usual outpatient mental health treatment (N=165) or usual care plus twice-a-month telephone care management (TCM) and support in the first three months of treatment (N=193). Treatment utilization and medication refills were determined from U.S. Department of Veterans Affairs administrative data. PTSD, depression, quality of life, aggressive behavior, and substance use were assessed with self-report questionnaires at intake, four months, and 12 months.

RESULTS

Telephone care managers reached 95% of TCM participants (N=182), completing an average 5.1 of 6.0 planned telephone calls. During the three-month intervention period, TCM participants completed 43% more mental health visits (M±SD=5.9±6.8) than did those in usual care (4.1±4.2) (incident rate ratio=1.36, χ²=6.56, df=1, p<.01). Treatment visits in the nine-month follow-up period and medication refills did not differ by condition. Only 9% of participants were scheduled to receive evidence-based psychotherapy. Slopes of improvement in PTSD, depression, alcohol misuse, drug problems, aggressive behavior, and quality of life did not differ by condition or treatment attendance.

CONCLUSIONS

TCM improved PTSD patients' treatment attendance but not their outcomes. TCM can enhance treatment engagement, but outcomes depend on the effectiveness of the treatments that patients receive.

Usual Care for Rural Veterans With Posttraumatic Stress Disorder

PURPOSE

Community-Based Outpatient Clinics (CBOCs) provide primary-care-based mental health services to rural veterans who live long distances from Veterans Affairs (VA) hospitals. Characterizing the composition of usual care will highlight the need and potential strategies to improve access to and engagement in evidence-based psychotherapy for posttraumatic stress disorder (PTSD).

METHOD

Veterans (N = 132) with PTSD recruited from 5 large- (5,000-10,000 patients) and 6 medium-sized (1,500-4,999) CBOCs were enrolled in the usual care arm of a randomized control trial for a PTSD collaborative care study. Chart review procedures classified all mental health encounters during the 1-year study period into 10 mutually exclusive categories (7 psychotherapy and 3 medication management).

FINDINGS

Seventy-two percent of participants received at least 1 medication management encounter with 30% of encounters being delivered via interactive video. More than half of veterans (58.3%) received at least 1 session of psychotherapy. Only 12.1% received a session of therapy classified as an evidence-based psychotherapy for PTSD. The vast majority of psychotherapy encounters were delivered in group format and only a small proportion were delivered via interactive video.

CONCLUSIONS

Findings suggest that veterans diagnosed with PTSD who receive their mental health treatment in large and medium CBOCs are likely to receive medication management, and very few veterans received evidence-based psychotherapy. There may be ways to increase access to evidence-based psychotherapy by expanding the use of interactive video to connect specialty mental health providers with patients, hosted either in CBOCs or in home-based care, and to offer more group-based therapies.

Iraq and Afghanistan War Veterans with Reintegration Problems: Differences by Veterans Affairs Healthcare User Status

We studied 1,292 Iraq and Afghanistan War veterans who participated in a clinical trial of expressive writing to estimate the prevalence of perceived reintegration difficulty and compare Veterans Affairs (VA) healthcare users to nonusers in terms of demographic and clinical characteristics. About half of participants perceived reintegration difficulty. VA users and nonusers differed in age and military background. Levels of mental and physical problems were higher in VA users. In multivariate analysis, military service variables and probable traumatic brain injury independently predicted VA use. Findings demonstrate the importance of research comparing VA users to nonusers to understand veteran healthcare needs.

Longitudinal Examination of Posttraumatic Stress Disorder as a Long-Term Outcome of Iraq War Deployment

The mental health toll of the Iraq and Afghanistan Wars on military veterans has been considerable, yet little is known about the persistence of these adverse outcomes, especially relative to predeployment status. We prospectively examined posttraumatic stress disorder (PTSD) as a long-term consequence of warzone deployment, integrating data collected from 2003-2014. In the Neurocognition Deployment Health Study, we measured PTSD symptoms in US Army soldiers before and shortly after Iraq War deployment. We used the PTSD Checklist-Civilian Version and a structured clinical interview (i.e., Clinician-Administered PTSD Scale) to reassess PTSD in 598 service members and military veterans a median of 7.9 years (interquartile range, 7.2-8.5 years) after an index Iraq deployment. At long-term follow-up, 24.7% (95% confidence interval (CI): 21.5, 28.4) of participants met the case definition for PTSD, which was an absolute increase of 14.2% from the percentage assessed postdeployment (10.5%; 95% CI: 7.8, 13.7) and of 17.3% from the percentage assessed predeployment (7.4%; 95% CI: 5.5, 9.8). These findings highlight that PTSD is an enduring consequence of warzone participation among contemporary military personnel and veterans. The largest increase in PTSD cases occurred between the postdeployment and long-term follow-up assessments, which suggests that adverse stress reactions cannot necessarily be expected to dissipate over time and actually may increase.

Identity adjustment among Afghanistan and Iraq war veterans with reintegration difficulty

OBJECTIVE

To examine perceptions of identity adjustment in a diverse, national sample of U.S. veterans of the wars in Afghanistan and Iraq.

METHOD

The authors conducted a planned thematic analysis of text written by Afghanistan and Iraq war veterans when they were asked to describe their reintegration difficulties as part of a randomized controlled trial (RCT) of online expressive writing (Sayer et al., 2015). Participants were 100 randomly selected veterans from the larger study (42 women and 58 men, 60 active duty and 38 reserves or National Guard).

RESULTS

Nearly 2/3s of participants wrote about their identity adjustment. The 5 interrelated areas of identity adjustment difficulty were (a) feeling like one does not belong in civilian society, (b) missing the military's culture and structured lifestyle, (c) holding negative views of civilian society, (d) feeling left behind compared to civilian counterparts due to military service, and (e) having difficulty finding meaning in the civilian world. The authors did not observe differences by gender. However, those deployed from active duty were particularly likely to feel as if they did not belong in civilian society and that they had not acquired needed skills, whereas those deployed from the reserves or National Guard experienced difficulty in reestablishing former civilian identities.

CONCLUSIONS

Identity adjustment is a critical yet understudied aspect of veteran reintegration into community life following combat deployment. (PsycINFO Database Record

The Primary Care PTSD Screen for DSM-5 (PC-PTSD-5): Development and Evaluation Within a Veteran Primary Care Sample

BACKGROUND

Posttraumatic Stress Disorder (PTSD) is associated with increased health care utilization, medical morbidity, and tobacco and alcohol use. Consequently, screening for PTSD has become increasingly common in primary care clinics, especially in Veteran healthcare settings where trauma exposure among patients is common.

OBJECTIVE

The objective of this study was to revise the Primary Care PTSD screen (PC-PTSD) to reflect the new Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria for PTSD (PC-PTSD-5) and to examine both the diagnostic accuracy and the patient acceptability of the revised measure.

DESIGN

We compared the PC-PTSD-5 results with those from a brief psychiatric interview for PTSD. Participants also rated screening preferences and acceptability of the PC-PTSD-5.

PARTICIPANTS

A convenience sample of 398 Veterans participated in the study (response rate = 41 %). Most of the participants were male, in their 60s, and the majority identified as non-Hispanic White.

MEASURES

The PC-PTSD-5 was used as the screening measure, a modified version of the PTSD module of the MINI-International Neuropsychiatric Interview was used to diagnose DSM-5 PTSD, and five brief survey items were used to assess acceptability and preferences.

KEY RESULTS

The PC-PTSD-5 demonstrated excellent diagnostic accuracy (AUC = 0.941; 95 % C.I.: 0.912- 0.969). Whereas a cut score of 3 maximized sensitivity (κ[1]) = 0.93; SE = .041; 95 % C.I.: 0.849-1.00), a cut score of 4 maximized efficiency (κ[0.5] = 0.63; SE = 0.052; 95 % C.I.: 0.527-0.731), and a cut score of 5 maximized specificity (κ[0] = 0.70; SE = 0.077; 95 % C.I.: 0.550-0.853). Patients found the screen acceptable and indicated a preference for administration by their primary care providers as opposed to by other providers or via self-report.

CONCLUSIONS

The PC-PTSD-5 demonstrated strong preliminary results for diagnostic accuracy, and was broadly acceptable to patients.

Emergence of Transdiagnostic Treatments for PTSD and Posttraumatic Distress

Both theoretical and empirical findings have demonstrated similarities across diagnoses, leading to a growing interest in transdiagnostic interventions. Most of the evidence supporting transdiagnostic treatment has accumulated for depression, anxiety, and eating disorders, with minimal attention given to posttraumatic stress disorder and other reactions to traumatic stressors. Although single-diagnosis protocols are effective for posttraumatic stress disorder (PTSD) and other trauma-related disorders, in principle, transdiagnostic approaches may have beneficial applications within a traumatized population. This paper defines different types of transdiagnostic treatments, reviews transdiagnostic approaches used in related disorders, and discusses their applicability to PTSD. Examples are drawn from existing transdiagnostic treatments in order to provide a framework for the application of such interventions to the field of traumatic stress. Implications for implementation and dissemination are also discussed.