The influence of patient readiness on implementation of evidence-based PTSD treatments in Veterans Affairs residential programs

OBJECTIVE

Mental health provider perceptions of patient readiness for trauma-focused evidence-based treatments (EBTs) for posttraumatic stress disorder (PTSD) have been found to impact outpatient care in the Department of Veterans Affairs (VA).

METHOD

One hundred and 72 mental health directors and providers from 36 VA residential PTSD treatment programs completed qualitative interviews regarding implementation of two EBTs, Prolonged Exposure (PE), and Cognitive Processing Therapy (CPT). Perceptions of patients' "readiness" for PE and CPT, including how to define and assess this construct and how it influences implementation of these EBTs, were discussed.

RESULTS

Patient readiness was identified as having three components: psychological and psychiatric stability, general readiness to change, and specific skills to manage trauma-focused EBTs (e.g., distress tolerance, affect regulation skills). Providers indicated that some patients who are deemed not ready are either screened out prior to entry or helped to get ready prior to or during their residential stay. Providers expressed difficulties predicting who is actually ready and described what they saw as differences between readiness for PE as compared with CPT.

CONCLUSIONS

The concept of readiness for trauma-focused EBTs impacted admission and access to services in the programs. Future research directions, such as empirically measuring readiness and formally assessing veterans' perceptions of and willingness to participate in these EBTs, are considered. (PsycINFO Database Record

Randomized controlled trial of acceptance and commitment therapy for distress and impairment in OEF/OIF/OND veterans

OBJECTIVE

Acceptance and commitment therapy (ACT) is a widely utilized psychotherapeutic approach, but randomized, controlled studies are lacking in veterans. This study evaluated the efficacy of ACT for emotional distress among veterans of the conflicts in Iraq and Afghanistan.

METHOD

One hundred sixty veterans (80% male, Mage = 34 years) with anxiety or depressive disorder according to the Diagnostic and Statistical Manual of Mental Disorders (4th ed.) were randomized to ACT or present-centered therapy (PCT) and assessed before, during, and after treatment and during 3- to 12-month follow-up. The primary outcome was general distress as measured by the Brief Symptom Inventory-18 Global Severity Index. Additional outcomes included symptomatology, disability, quality of life, acceptability, and satisfaction.

RESULTS

There was improvement following treatment in the whole sample across a variety of measures, including general distress (d = 0.74, 95% confidence interval [CI: 0.52, 0.96]) and functioning (d = 0.71, 95% CI [0.50, 0.93]) and moderate to high levels of satisfaction with treatment. Response to the 2 interventions did not differ on the primary outcome or most secondary outcomes, although ACT led to greater improvement in insomnia than did PCT (ds = 0.63 and 0.08, respectively). Treatment dropout did not differ by condition but was high (41.9%).

CONCLUSIONS

ACT's efficacy in this group was modest and generally did not differ from that for PCT. Additional work is needed to understand the reasons that ACT did not perform as well as predicted in this veteran sample. (PsycINFO Database Record

Validity of posttraumatic stress disorder service connection status in Veterans Affairs electronic records of Iraq and Afghanistan Veterans

OBJECTIVE

This study examined the extent to which veterans' posttraumatic stress disorder (PTSD) service connection (SC) status corresponded to their PTSD diagnostic status, as determined by a semistructured diagnostic interview.

METHOD

Participants were 834 veterans in the Veterans After-Discharge Longitudinal Registry (Project VALOR), an observational registry of veterans with and without PTSD who are enrolled in the Veterans Affairs (VA) health care system. PTSD diagnostic status was confirmed using the Structured Clinical Interview for DSM-IV (SCID).

RESULTS

Concordance between PTSD SC status and current and lifetime PTSD diagnosis was 70.2% and 77.2%, respectively. Individuals with PTSD SC were twice as likely as those without PTSD SC to have a current SCID PTSD diagnosis (OR = 2.11 [95% CI, 1.47-3.04]; P < .001) and almost 3 times as likely to have a lifetime SCID PTSD diagnosis (OR = 2.72 [95% CI, 1.67-4.41]; P < .001). For current PTSD, results showed a slightly higher proportion of false positives-individuals who did not meet SCID criteria but who did have SC for PTSD-than false negatives-individuals who met SCID criteria but did not have SC for PTSD. For lifetime PTSD, the proportion of false negatives was approximately twice the proportion of false positives.

CONCLUSIONS

PTSD diagnostic and SC status are discordant for a significant minority of veterans. Findings revealed that both the number of veterans who are service connected without meeting criteria for PTSD and the number of veterans who meet PTSD criteria but have not been granted SC status are concerning.

SYMPTOM BENCHMARKS OF IMPROVED QUALITY OF LIFE IN PTSD

BACKGROUND

Although research has shown that PTSD symptom change relates to improved quality of life, the question of how much improvement in PTSD symptoms is necessary to result in meaningful improvements in quality of life remains unanswered. We used data from a randomized clinical trial of psychotherapy for PTSD in female military veterans and active duty personnel to examine the correspondence between benchmarks of improvement in PTSD symptoms and changes in quality of life.

METHODS

Participants were 235 female veterans and Army soldiers who were randomized to 10 weekly sessions of Prolonged Exposure or Present-Centered Therapy. We operationalized PTSD symptom change in terms of four progressively stringent mutually exclusive definitions-No Response, Response, Loss of Diagnosis, and Remission-successively comparing each category to the prior one: No Response versus Response, Response versus Loss of Diagnosis, and Loss of Diagnosis versus Remission. Outcomes were clinically meaningful improvements and good endpoints in domains of clinician-rated and self-reported quality of life.

RESULTS

Response was associated with improvement on almost all measures, but with only one good endpoint. Loss of Diagnosis was associated with improvement on all measures except self-rated social functioning and with achieving a good endpoint on all measures. Remission was associated with improvement in clinician-rated social impairment and a good endpoint in clinician-rated occupational impairment.

CONCLUSIONS

For most domains of quality of life, treating a patient until the patient no longer meets diagnostic criteria would be optimal. For some domains, further improvements may result by helping a patient achieve remission.

Understanding and meeting information needs for patients with posttraumatic stress disorder

BACKGROUND

Posttraumatic Stress Disorder (PTSD) is a commonly occurring mental illness. There are multiple treatments for PTSD that have similar effectiveness, but these treatments differ substantially in other ways. It is desirable to have well-informed patients involved in treatment choices. A patient decision aid (PtDA) is one method to achieve this goal. This manuscript describes the rationale and development of a patient decision aid (PtDA) designed for patients with PTSD.

METHODS

We conducted an informational needs assessment of veterans (n = 19) to obtain their baseline information needs prior to the development of the PtDA. We also conducted a literature review of effective PTSD treatments, and we calculated respective effective sizes. A PtDA prototype was developed according to the guidelines from the International Patient Decision Aid Standards. These standards guided our development of both content and format for the PtDA. In accordance with the standards, we gathered feedback from patients (n = 20) and providers (n = 7) to further refine the PtDA. The information obtained from patients and the literature review was used to develop a decision aid for patients with PTSD.

RESULTS

Patients with PTSD reported a strong preference to receive information about treatment options. They expressed interest in also learning about PTSD symptoms. The patients preferred information presented in a booklet format. From our literature review several treatments emerged as effective for PTSD: Cognitive Therapy, Exposure Therapy, Eye Movement Desensitization Therapy, Selective Serotonin Reuptake Inhibitors, venlafaxine, and risperidone.

CONCLUSION

It appears that the criteria set forth to develop decision aids can effectively be applied to PTSD. The resultant PTSD patient decision aid is a booklet that describes the causes, symptoms, and treatments for PTSD. Future work will examine the effects of use of the PTSD decision aid in clinical practice.

TRIAL REGISTRATION

Clinicaltrials.gov identifier NCT00908440. Registered May 20, 2009.

PTSD-Related Cardiovascular Disease and Accelerated Cellular Aging

We reviewed the literature from 2010 to 2016 on the relationship between posttraumatic stress disorder (PTSD) and cardiometabolic health conditions, including metabolic syndrome, coronary artery disease, stroke, and myocardial infarction, among others. Collectively, PTSD was associated with increased risk of cardiometabolic health problems, with pre-clinical and clinical studies offering evidence of behavioral (e.g., poor sleep, cigarette use, poor diet and insufficient exercise) and biological (e.g., autonomic reactivity, inflammation) mediators of these associations. We discuss the possibility that these behavioral and biological mechanisms lead to accelerated cellular aging, as regulated in the epigenome, which contributes to premature cardiometabolic health decline. This has implications for the assessment, prevention, and treatment of cardiometabolic conditions among those with PTSD. It also highlights the need to better understand the mechanisms linking PTSD to accelerated aging and to develop interventions to attenuate or reverse this phenomenon.

Psychometric properties of the PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition (PCL-5) in veterans

This study examined the psychometric properties of the posttraumatic stress disorder (PTSD) Checklist for Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition (PCL-5; Weathers, Litz, et al., 2013b) in 2 independent samples of veterans receiving care at a Veterans Affairs Medical Center (N = 468). A subsample of these participants (n = 140) was used to define a valid diagnostic cutoff score for the instrument using the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5; Weathers, Blake, et al., 2013) as the reference standard. The PCL-5 test scores demonstrated good internal consistency (α = .96), test-retest reliability (r = .84), and convergent and discriminant validity. Consistent with previous studies (Armour et al., 2015; Liu et al., 2014), confirmatory factor analysis revealed that the data were best explained by a 6-factor anhedonia model and a 7-factor hybrid model. Signal detection analyses using the CAPS-5 revealed that PCL-5 scores of 31 to 33 were optimally efficient for diagnosing PTSD (κ(.5) = .58). Overall, the findings suggest that the PCL-5 is a psychometrically sound instrument that can be used effectively with veterans. Further, by determining a valid cutoff score using the CAPS-5, the PCL-5 can now be used to identify veterans with probable PTSD. However, findings also suggest the need for research to evaluate cluster structure of DSM-5. (PsycINFO Database Record

Using the WHODAS 2.0 to Assess Functioning Among Veterans Seeking Compensation for Posttraumatic Stress Disorder

OBJECTIVE

One of the major changes in DSM-5 was removal of the Global Assessment of Functioning (GAF). To determine whether the World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0) is a suitable replacement for the GAF, this study compared how well the WHODAS 2.0 and the GAF measured functional impairment and other phenomena related to posttraumatic stress disorder (PTSD) among veterans applying for financial compensation (service connection) for PTSD.

METHODS

Clinicians evaluating veteran claimants administered the Clinician Administered PTSD Scale (CAPS) and the WHODAS 2.0 to 177 veterans during their evaluations. Veterans also completed the Inventory of Psychosocial Functioning (IPF), a self-report measure of functional impairment, and received a GAF rating from the examiner. Actual benefit determinations and ratings were obtained.

RESULTS

Confirmatory factor analyses demonstrated that the WHODAS 2.0 and the IPF were stronger indicators of a latent variable reflecting functioning compared with the GAF. In receiver operating characteristic curve analyses, the WHODAS 2.0, IPF, and GAF all displayed similar ability to identify veterans with PTSD-related impairment assessed by the CAPS. Compared with the GAF, the WHODAS 2.0 and IPF were less strongly related to PTSD symptom severity and disability ratings by the U.S. Department of Veterans Affairs, but these variables are typically influenced by GAF scores.

CONCLUSIONS

The WHODAS 2.0 and IPF are acceptable replacements for the GAF and can be used to assess functional impairment among veterans seeking compensation for PTSD.

Predictors of Initiation and Engagement of Cognitive Processing Therapy Among Veterans With PTSD Enrolled in Collaborative Care

Collaborative care (CC) increases access to evidence-based pharmacotherapy and psychotherapy. The study aim was to identify the characteristics of rural veterans receiving a telemedicine-based CC intervention for posttraumatic stress disorder (PTSD) who initiated and engaged in cognitive processing therapy (CPT) delivered via interactive video. Veterans diagnosed with PTSD were recruited from 11 community-based outpatient clinics (N = 133). Chart abstraction identified all mental health encounters received during the 12-month study. General linear mixed models were used to identify characteristics that predicted CPT initiation and engagement (attendance at 8 or more sessions). For initiation, higher PTSD severity according to the Clinician Administered PTSD Scale (d = -0.39, p = .038) and opt-out recruitment (vs. self-referral; d = -0.49, p = .010) were negative predictors. For engagement, major depression (d = -1.32, p = .006) was a negative predictor whereas a pending claim for military service connected disability (d = 2.02, p = .008) was a positive predictor. In general, veterans enrolled in CC initiated and engaged in CPT at higher rates than usual care. Those with more severe symptoms and comorbidity, however, were at risk of not starting or completing CPT.

Randomized Controlled Trial of Online Expressive Writing to Address Readjustment Difficulties Among U.S. Afghanistan and Iraq War Veterans

We examined the efficacy of a brief, accessible, nonstigmatizing online intervention-writing expressively about transitioning to civilian life. U.S. Afghanistan and Iraq war veterans with self-reported reintegration difficulty (N = 1,292, 39.3% female, M = 36.87, SD = 9.78 years) were randomly assigned to expressive writing (n = 508), factual control writing (n = 507), or no writing (n = 277). Using intention to treat, generalized linear mixed models demonstrated that 6-months postintervention, veterans who wrote expressively experienced greater reductions in physical complaints, anger, and distress compared with veterans who wrote factually (ds = 0.13 to 0.20; ps < .05) and greater reductions in PTSD symptoms, distress, anger, physical complaints, and reintegration difficulty compared with veterans who did not write at all (ds = 0.22 to 0.35; ps ≤ .001). Veterans who wrote expressively also experienced greater improvement in social support compared to those who did not write (d = 0.17). Relative to both control conditions, expressive writing did not lead to improved life satisfaction. Secondary analyses also found beneficial effects of expressive writing on clinically significant distress, PTSD screening, and employment status. Online expressive writing holds promise for improving health and functioning among veterans experiencing reintegration difficulty, albeit with small effect sizes.

The influence of the dissociative subtype of posttraumatic stress disorder on treatment efficacy in female veterans and active duty service members

OBJECTIVE

A dissociative subtype of posttraumatic stress disorder (PTSD) was recently added to the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; American Psychiatric Association, 2013) and is thought to be associated with poor PTSD treatment response.

METHOD

We used latent growth curve modeling to examine data from a randomized controlled trial of prolonged exposure and present-centered therapy for PTSD in a sample of 284 female veterans and active duty service members with PTSD to test the association between the dissociative subtype and treatment response.

RESULTS

Individuals with the dissociative subtype (defined using latent profile analysis) had a flatter slope (p = .008) compared with those with high PTSD symptoms and no dissociation, such that the former group showed, on average, a 9.75 (95% confidence interval [-16.94, -2.57]) lesser decrease in PTSD severity scores on the Clinician Administered PTSD Scale (Blake et al., 1995) over the course of the trial. However, this effect was small in magnitude. Dissociative symptoms decreased markedly among those with the subtype, though neither treatment explicitly addressed such symptoms. There were no differences as a function of treatment type.

CONCLUSIONS

Results raise doubt about the common clinical perception that exposure therapy is not effective or appropriate for individuals who have PTSD and dissociation, and provide empirical support for the use of exposure treatment for individuals with the dissociative subtype of PTSD.

A Quantitative Test of an Implementation Framework in 38 VA Residential PTSD Programs

This study examines the implementation of two evidence-based psychotherapies, Prolonged Exposure (PE) and Cognitive Processing Therapy (CPT), in the Department of Veterans Affairs residential Posttraumatic Stress Disorder treatment programs. Two hundred and one providers from 38 programs completed an online survey concerning implementation of PE delivered on an individual basis and CPT delivered in individual and group formats. For PE, a supportive organizational context (dedicated time and resources, and incentives and mandates) and overall positive view of the treatment were related to its implementation. For both group and individual CPT, only the supportive organizational context was significantly associated with outcome. Implications for implementation efforts are discussed.

Evaluation of an implementation model: a national investigation of VA residential programs

This national investigation utilizes qualitative data to evaluate an implementation model regarding factors influencing provider use of two evidence-based treatments for posttraumatic stress disorder (PTSD). Semi-structured qualitative interviews with 198 mental health providers from 38 Department of Veterans Affairs' (VA) residential treatment programs were used to explore these issues regarding prolonged exposure (PE) and cognitive processing therapy (CPT) in VA residential PTSD programs. Several unique and some overlapping predictors emerged. Leadership was viewed as an influence on implementation for both CPT and PE, while a lack of dedicated time and resources was viewed as a deterrent for both. Compatibility of CPT with providers' existing practices and beliefs, the ability to observe noticeable patient improvement, a perceived relative advantage of CPT over alternative treatments, and the presence of a supportive peer network emerged as influential on CPT implementation. Leadership was associated with PE implementation. Implications for the design and improvement of training and implementation efforts are discussed.

A randomized controlled clinical trial of a patient decision aid for posttraumatic stress disorder

OBJECTIVE

Patient decision aids have been used in many clinical situations to improve the patient centeredness of care. A patient decision aid for patients with posttraumatic stress disorder (PTSD) has not been developed or tested. The authors evaluated the effects of a patient decision aid on the patient centeredness of PTSD treatment.

METHODS

The study was a randomized trial of a patient decision aid for PTSD versus treatment as usual (control group). The participants were 132 male and female veterans who presented to a single U.S. Department of Veterans Affairs hospital with a new diagnosis of PTSD. Patient centeredness was assessed by knowledge of PTSD and its treatment, level of decisional uncertainty, and ability to state a preferred treatment option. Secondary outcomes included treatments received and PTSD symptoms in the six months after study entry.

RESULTS

Compared with the control group (N=65), participants who reviewed the patient decision aid (N=63) had higher scores for PTSD knowledge (p=.002) and less conflict about their choice of treatment (p=.003). In addition, participants who reviewed the patient decision aid were more likely to select and receive an evidence-based treatment for PTSD (p=.04) and had superior PTSD outcomes (p=.004) compared with the control group.

CONCLUSIONS

Use of a patient decision aid was associated with improvements in patient-centered PTSD treatment. The patient decision aid was also associated with greater use of evidence-based treatments and improvement of PTSD symptoms. This study suggests that clinics should consider using a patient decision aid for patients with PTSD.

Telemedicine-based collaborative care for posttraumatic stress disorder: a randomized clinical trial

IMPORTANCE

Posttraumatic stress disorder (PTSD) is prevalent, persistent, and disabling. Although psychotherapy and pharmacotherapy have proven efficacious in randomized clinical trials, geographic barriers impede rural veterans from engaging in these evidence-based treatments.

OBJECTIVE

To test a telemedicine-based collaborative care model designed to improve engagement in evidence-based treatment of PTSD.

DESIGN, SETTING, AND PARTICIPANTS

The Telemedicine Outreach for PTSD (TOP) study used a pragmatic randomized effectiveness trial design with intention-to-treat analyses. Outpatients were recruited from 11 Department of Veterans Affairs (VA) community-based outpatient clinics serving predominantly rural veterans. Inclusion required meeting diagnostic criteria for current PTSD according to the Clinician-Administered PTSD Scale. Exclusion criteria included receiving PTSD treatment at a VA medical center or a current diagnosis of schizophrenia, bipolar disorder, or substance dependence. Two hundred sixty-five veterans were enrolled from November 23, 2009, through September 28, 2011, randomized to usual care (UC) or the TOP intervention, and followed up for 12 months.

INTERVENTIONS

Off-site PTSD care teams located at VA medical centers supported on-site community-based outpatient clinic providers. Off-site PTSD care teams included telephone nurse care managers, telephone pharmacists, telepsychologists, and telepsychiatrists. Nurses conducted care management activities. Pharmacists reviewed medication histories. Psychologists delivered cognitive processing therapy via interactive video. Psychiatrists supervised the team and conducted interactive video psychiatric consultations.

MAIN OUTCOMES AND MEASURES

The primary outcome was PTSD severity as measured by the Posttraumatic Diagnostic Scale. Process-of-care outcomes included medication prescribing and regimen adherence and initiation of and adherence to cognitive processing therapy.

RESULTS

During the 12-month follow-up period, 73 of the 133 patients randomized to TOP (54.9%) received cognitive processing therapy compared with 16 of 132 randomized to UC (12.1%) (odds ratio, 18.08 [95% CI, 7.96-41.06]; P < .001). Patients in the TOP arm had significantly larger decreases in Posttraumatic Diagnostic Scale scores (from 35.0 to 29.1) compared with those in the UC arm (from 33.5 to 32.1) at 6 months (β = -3.81; P = .002). Patients in the TOP arm also had significantly larger decreases in Posttraumatic Diagnostic Scale scores (from 35.0 to 30.1) compared with those in the UC arm (from 33.5 to 31.7) at 12 months (β = -2.49; P=.04). There were no significant group differences in the number of PTSD medications prescribed and adherence to medication regimens were not significant. Attendance at 8 or more sessions of cognitive processing therapy significantly predicted improvement in Posttraumatic Diagnostic Scale scores (β = -3.86 [95% CI, -7.19 to -0.54]; P = .02) and fully mediated the intervention effect at 12 months.

CONCLUSIONS AND RELEVANCE

Telemedicine-based collaborative care can successfully engage rural veterans in evidence-based psychotherapy to improve PTSD outcomes.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00821678.

Perceived Characteristics of Intervention Scale

The Perceived Characteristics of Intervention Scale (PCIS), a 20-item assessment measure, was developed to assess health care providers’ views of interventions. Two hundred and fifteen Department of Veterans Affairs’ residential treatment providers from 38 programs across the United States completed an online survey that included the PCIS as well as self-reported use of two evidence-based treatments. The PCIS was anchored to ask about two evidence-based psychotherapies for posttraumatic stress disorder, prolonged exposure, and cognitive processing therapy. The PCIS is a reliable measure of perceived characteristics of interventions, with some preliminary support for its validity. Consideration of providers’ perceptions of particular evidence-based treatments may serve as an aid to improve their dissemination, implementation, and sustained use.