Facilitators and Barriers to Seeking Mental Health Care Among Primary Care Veterans With Posttraumatic Stress Disorder

Lifetime trauma, mental well-being, alcohol and help-seeking; the phenomenological experience of veterans residing in Northern Ireland

BACKGROUND

Veteran residents in Northern Ireland (NI) are an under-researched population. Little is known about their experiences of trauma and mental health management. The overall mental well-being of veterans living in NI may be poorer than other veteran populations, due to the challenges presented by the unique landscape. Understanding their experiences is crucial for providing appropriate, targeted support.

METHOD

Six male veterans, who had received a mental health diagnosis, living in NI and all aged > 40 years participated. Semi-structured interviews, using open-ended questions, were conducted over the telephone. Interpretative phenomenological analysis was used to explore their experiences.

RESULTS

Two experiential themes were identified each containing three experiential statements. Statements for 'an extreme lack of' included: lack of mental health literacy/awareness; lack of expectations of official support; lack of a sense of perceived appreciation. Statements for 'an extreme abundance of' included: exacerbated exposure to a range of extreme environments; high levels of ruled-based living; high levels of engaging with informal/local level support.

CONCLUSIONS

Several experiential statements aligned with existing literature, including having poor mental health literacy and problem recognition, and heavily utilising social support versus formal help-seeking. Some novel findings included bouncing between extreme positive and negative environments which could be as detrimental to mental health as experiencing conflict trauma. Heavy alcohol use was just another rule soldiers followed. Positive help-seeking experiences failed to improve poor opinions of support organisations. Finally, poor self-perceptions connected to military status are pertinent in NI, which seems to fuel self-marginalisation and distrust. A combination of factors likely contributes to many veterans living in NI having poorer mental well-being. Novel findings would benefit from further exploration as understanding how NI veterans interpret their experiences is key to providing adequate healthcare.

Cyr K, Liu JJW, Baker C, Nazarov A, Richardson JD. A rapid review of the barriers and facilitators of mental health service access among Veterans and their families

Introduction

Transitioning to civilian life after military service can be challenging for both Veterans and their families. Accessible mental health services are crucial during this period to provide support. The objective of this review was to conduct a rapid review to capture the barriers and identify facilitators that influence access to mental health services for Veterans and their families during the post-service transition period.

Methods

This review was conducted using the Cochrane Handbook for Systematic Reviews of Interventions as a methodological framework and followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses - Rapid Review (PRISMA-RR).

Results

A total of 60 articles and 67 independent samples were included in the final data analyses. Across the included articles, this review identified 23 barriers and 14 facilitator themes. Issues navigating the mental health care system was identified as the main challenge among Veterans and their families, and those who received support navigating the system identified this as a significant facilitator. Applying the Theoretical Domains Framework, most of the identified barriers and facilitators were categorized into environmental context and resources domain.

Discussion

The heterogeneity in Veterans' and Veteran families' experiences with mental health care-seeking may suggest that access to mental health care for Veterans and Veteran families cannot be solved by addressing one type of barrier alone. Instead, coordinated efforts to address prioritized systemic, logistical, social, and inter-/intrapersonal obstacles are essential for improving access and optimizing mental health care outcomes. These insights underscore the complexity of considerations for Veterans and families accessing mental health care.

A Systematic Review of the Department of Veterans Affairs Mental Health-Care Access Interventions for Veterans With PTSD

INTRODUCTION

Access to mental health care has been a priority area for the U.S. Department of Veterans Affairs (DVA) for decades. Access for veterans with PTSD is essential because untreated PTSD is associated with numerous adverse outcomes. Although interventions have been developed to improve access to DVA mental health care, the impact of these interventions on access for veterans with untreated PTSD has not been examined comprehensively, limiting guidance on appropriate implementation.

MATERIALS AND METHODS

We conducted a systematic review of PubMed and PTSDpubs between May 2019 and January 2022 to identify DVA access interventions for veterans with PTSD not engaged in DVA mental health care. We identified 17 interventions and 29 manuscripts reporting quantitative access outcomes. We categorized interventions into four major categories: Primary care mental health integration, other national initiatives, telemental health, and direct outreach. We evaluated five outcome domains: Binary attendance, number of sessions attended, wait time, number of patients seen, and care initiation. We assessed the risk of bias using the Cochrane Collaboration criteria.

RESULTS

Across articles, binary attendance generally improved, whereas the impact on the number of sessions attended was equivocal. Overall, the number of patients seen increased compared to control participants and retrospective data. The few articles that examined care initiation had mixed results. Only one article examined the impact on wait time.

CONCLUSIONS

Access interventions for veterans with PTSD demonstrated varied success across interventions and outcomes. The national initiatives-particularly primary care mental health integration -were successful across several outcomes; telemental health demonstrated promise in improving access; and the success of direct outreach varied across interventions. Confidence in these findings is tempered by potential bias among studies. Limited literature on how these interventions impact relevant preattendance barriers, along with incomplete data on how many perform nationally, suggests that additional work is needed to ensure that these interventions increase access for veterans with PTSD nationwide.

A Randomized Controlled Pilot Trial of Primary Care Treatment Integrating Motivation and Exposure Treatment (PC-TIME) in Veterans With PTSD and Harmful Alcohol Use

Individuals with posttraumatic stress disorder (PTSD) often engage in harmful alcohol use. These co-occurring conditions are associated with negative health consequences and disability. PTSD and harmful drinking are typically experienced as closely related-thus treatments that target both simultaneously are preferred by patients. Many individuals with PTSD and harmful alcohol use receive primary care services but encounter treatment barriers in engaging in specialty mental health and substance use services. A pilot randomized controlled trial of a brief integrated treatment for PTSD and harmful drinking versus primary care treatment as usual (PC-TAU) took place in three U.S. Department of Veterans Affairs (VA) primary care clinics. The intervention (primary care treatment integrating motivation and exposure [PC-TIME]) combines motivational interviewing to reduce alcohol use and brief prolonged exposure for PTSD delivered over five brief sessions. Participants (N = 63) were veterans with PTSD and harmful drinking. Multilevel growth curve modeling examined changes in drinking (average number of drinks per drinking day and percentage of heavy drinking days) and self-reported PTSD severity at baseline, 8, 14, and 20 weeks. Participants reported high satisfaction with PC-TIME and 70% (n = 23) completed treatment. As hypothesized, a significantly steeper decrease in self-reported PTSD severity and heavy drinking was evident for participants randomized to PC-TIME compared with PC-TAU. Contrary to expectations, no significant posttreatment differences in PTSD diagnoses were observed. PC-TIME participants were less likely to exceed National Institute for Alcoholism and Alcohol Abuse (NIAAA) guidelines for harmful alcohol use posttreatment compared with PC-TAU participants. PC-TIME is a promising brief, primary care-based treatment for individuals with co-occurring PTSD and harmful alcohol use. A full-scale randomized clinical trial is needed to fully test its effectiveness.

Factors Associated with Delayed Care Among Women Veterans Actively Engaged in Primary Care

Background: Delaying needed medical care contributes to greater health risks and higher long-term medical costs. Women Veterans with complex medical and mental health needs face increased barriers to timely care access. Objectives: In a sample of women Veterans with recent engagement in Veterans Administration (VA) primary care, we aimed to compare characteristics of women Veterans who delayed care in the past 6 months with those who did not and examine factors associated with self-reported delayed care. Our study aims to inform interventions focused on eliminating health care access disparities among women Veterans. Materials and Methods: An innovation to improve women Veterans' engagement and retention in evidence-based health care for cardiovascular (CV) risk reduction (CV Toolkit) was implemented across five primary care sites within the VA. Women Veterans who were exposed to at least one CV Toolkit component participated in a mailed survey (n = 253). We used multivariate logistic regression to model factors associated with delaying care, including trust in VA providers, positive mental health screening (i.e., positive screen for either depression or anxiety), traumatic experience, self-rated health, and age. Results: Women with any mental health symptoms (odds ratio [OR] 2.42, 95% confidence interval [CI]: 1.23-4.74) and women who had experienced a traumatic event (OR 2.61, 95%CI: 1.11-6.14) were significantly more likely to report delaying care. Conclusions: Our study identified high rates of delayed care-over one-third of respondents-among women Veterans with recent primary care engagement. Mental health symptoms were the most common reported reason for delay among those who delayed care. Clinical Trial registration: NCT02991534.

Treatment Gap in Mental Health Care for Victims of Road Traffic Accidents

Road traffic accidents (RTAs) are among the most frequent negative life-events. About one in five RTA survivors is susceptible to posttraumatic stress disorder (PTSD). Knowledge about needs for, and usage of, mental health services (MHSs) may improve options for care for RTA victims. The current study aimed to assess rates of victims using different MHSs, including psychotherapy, pharmacotherapy and support groups, and to explore correlates of needs for and use of these MHSs. Further, we aimed to estimate the treatment gap in post-RTA care, defined as including people with probable PTSD who did not use MHSs and people wanting but not getting help from MHSs. Dutch victims of nonlethal RTAs (N = 259) completed self-report measures on needs for and use of MHSs and PTSD. Results showed that 26% of participants had utilized care from psychotherapy, pharmacotherapy or support groups. Among people with probable PTSD, this was 56%. Increased posttraumatic stress was the strongest correlate of MHS use. Forty-eight participants (17.8%) had an unmet care need and represented the treatment gap. Commonly reported reasons and barriers preventing MHS use were perceptions that problems were limited or would disappear without care and financial worries. Regarding possible future care, participants reported a preference for face-to-face (over online) help from a psychologist (over other professionals). The treatment gap for Dutch RTA victims may be limited. However, a significant number of RTA victims need care but do not obtain this care. Care options may be improved by reducing practical barriers to MHSs and increasing mental health literacy and acceptability of different forms of care (besides face-to-face care).

Patient Satisfaction With a Coach-Guided, Technology-Based Mental Health Treatment: Qualitative Interview Study and Theme Analysis

BACKGROUND

Technology-based mental health interventions address barriers rural veterans face in accessing care, including provider scarcity and distance from the hospital or clinic. webSTAIR is a 10-module, web-based treatment based on Skills Training in Affective and Interpersonal Regulation, designed to treat posttraumatic stress disorder and depression in individuals exposed to trauma. Previous work has demonstrated that webSTAIR is acceptable to participants and effective at reducing symptoms of posttraumatic stress disorder and depression when delivered synchronously or asynchronously (over 5 or 10 sessions).

OBJECTIVE

This study explored factors that lead to greater patient satisfaction with webSTAIR, a web-based, coach-guided intervention.

METHODS

We analyzed qualitative interview data to identify themes related to patient satisfaction with webSTAIR delivered with synchronous video-based coaching.

RESULTS

Four themes emerged from the data: (1) coaching provides accountability and support, (2) self-pacing offers value that meets individual needs, (3) participants like the comfort and convenience of the web-based format, and (4) technical issues were common but not insurmountable.

CONCLUSIONS

We conclude that participants valued the accountability, flexibility, and convenience of tech-based interventions with video-delivered coaching.

Acceptance and commitment therapy for co-occurring gambling disorder and posttraumatic stress disorder in veterans: a narrative review

Background: PTSD and gambling disorder (GD) are frequently comorbid. Gambling may provide escape-based coping for the emotions experienced by PTSD sufferers. Military personnel may be at increased risk of PTSD and/or GD. Acceptance and Commitment Therapy (ACT) has been found to improve both PTSD and GD outcomes, yet research into the potential effectiveness of ACT for PTSD and/GD in veterans is scarce.Objective: This review aimed to systematically assess and describe the evidence relating to the use of ACT and acceptance-based therapy for military populations with PTSD and/or GD.Method: Six databases were searched. Selection criteria included studies that featured the armed forces/military, delivered ACT/acceptance-based therapy, and aimed to improve PTSD and/or GD outcomes. A narrative synthesis approach was adopted.Results: From 1,117 results, 39 studies were fully screened and 14 met inclusion criteria. All studies originated from the USA and 9 were associated with United States Department of Veterans Affairs. Therapy use within each study produced an improvement in PTSD and/or GD, yet only one study examined GD and no studies considered comorbid PTSD/GD. The broad range of study designs made it difficult to compare the findings or make generalisations from the collective results. It is unclear which method of ACT delivery is superior (app-based, telehealth, face-to-face, groups, one-to-one, manualised, or unstructured), or what the true effect size is of ACT for PTSD and/or GD.Conclusions: These preliminary findings are promising, yet more research is needed on the delivery format and content of ACT sessions, and whether findings generalise beyond USA-recruited military samples. The cost-effectiveness of remote-based ACT also warrants investigation.HIGHLIGHTS Among veterans, psychological interventions such as Acceptance and Commitment Therapy (ACT) may be effective for Post-Traumatic Stress Disorder (PTSD) and/or Gambling Disorder (GD).There is a paucity of evidence on ACT approaches for treating PTSD and GD in veterans.Further work is needed on context-specific delivery (in-person vs. group), method of ACT intervention (manualised vs unstructured, digital therapeutics) with non-US samples.

Integrating stakeholder feedback into the design of a peer-delivered primary care wellness program: A rapid qualitative study

BACKGROUND

Individuals seen in Primary Care with behavioral health concerns who decline behavioral health treatment may benefit from the support of peers (consumers in recovery from behavioral health concerns employed to support other consumers). Whole Health STEPS is a new intervention for Veterans in Primary Care with behavioral health concerns which combines essential elements of peers' role and the Whole Health model using a stepped-care design. We incorporated stakeholder feedback in the Whole Health STEPS design to improve fit with Veterans, peers, and primary care settings.

METHODS

We conducted semi-structured qualitative interviews with VA staff using questions derived from the Consolidated Framework for Implementation Research (CFIR). Participants were recruited via a maximum variation strategy across a national sample and interviewed between January 2021-April 2021. The analytic design was a rapid qualitative analysis. Interviews addressed design decisions and potential barriers and facilitators to future implementation. Then, we made adaptations to Whole Health STEPS and catalogued changes using the Framework for Adaptations and Modifications-Enhanced (FRAME). A VA peer conducted the interviews, participated in analyses, assisted with design modifications, and co-wrote this paper.

RESULTS

Sixteen staff members from 9 VA primary care peer programs participated (8 peers and 8 supervisors/administrators). Feedback themes included: capitalizing on peer skills (e.g., navigation), ensuring patient-centered and flexible design, and making it easy and efficient (e.g., reducing session length). Understanding the structure of primary care peers' roles and their interactions with other programs helped us identify role conflicts (e.g., overlap with Whole Health Coaches and Health Behavior Coordinators), which led to design modifications to carve out a unique role for Whole Health STEPS. Staff also made recommendations about marketing materials and training tools to support Whole Health STEPS roll out.

CONCLUSIONS

Feedback from frontline staff, including peers, in the design process was crucial to identifying essential modifications that would not have been possible after initial trials without re-evaluating efficacy due to the extent of the changes. Whole Health STEPS was adapted to fit within a range of program structures, emphasize peers' unique contributions, and streamline delivery. Lessons learned can be applied to other interventions.

Improving suicide prevention for women veterans: Recommendations from VHA suicide prevention coordinators

OBJECTIVE

Women are a minority veteran subpopulation experiencing particular risk for suicide and facing distinct challenges in accessing Veterans Health Administration (VHA) care. As part of efforts to enhance suicide prevention, the VHA established Suicide Prevention Coordinators (SPC) as clinicians who work exclusively to connect high-risk veterans to the scope of VHA's services. To understand the experiences of women veterans with suicide risk who access care, this study presents findings from qualitative interviews with SPCs regarding the care needs, preferences, and concerns of women veterans who utilize VHA for enhanced suicide-related care.

METHODS

We conducted qualitative interviews with 20 SPCs from 13 VAMCs around the United States. We specifically asked SPCs to share perspectives on women veterans' barriers to accessing care and their recommendations to improve suicide prevention for this subpopulation. We conducted a thematic content analysis to extract key themes.

RESULTS

SPCs revealed that women veterans opt to avoid VHA due to prior negative experiences, often related to provider sensitivity to women's issues. Safety was another key concern, specifically related to feeling unwelcome or intimidated in the male dominated veteran community. Key provider recommendations include increasing the availability of gender-sensitive providers and making changes to the physical spaces of the VHA to better facilitate women veterans' access to care.

CONCLUSIONS

SPCs underscored the importance of comfort and relatability between women patients and providers, especially in relation to enhanced care for suicide risk. This study presents important evidence in support of enhancing suicide prevention by better engaging women veterans in care that is more inclusive and more sensitive to their experiences and identity, in and outside VHA.

Intentional Self-Harm Among US Veterans With Traumatic Brain Injury or Posttraumatic Stress Disorder: Retrospective Cohort Study From 2008 to 2017

BACKGROUND

Veterans with a history of traumatic brain injury (TBI) and/or posttraumatic stress disorder (PTSD) may be at increased risk of suicide attempts and other forms of intentional self-harm as compared to veterans without TBI or PTSD.

OBJECTIVE

Using administrative data from the US Veterans Health Administration (VHA), we studied associations between TBI and PTSD diagnoses, and subsequent diagnoses of intentional self-harm among US veterans who used VHA health care between 2008 and 2017.

METHODS

All veterans with encounters or hospitalizations for intentional self-harm were assigned "index dates" corresponding to the date of the first related visit; among those without intentional self-harm, we randomly selected a date from among the veteran's health care encounters to match the distribution of case index dates over the 10-year period. We then examined the prevalence of TBI and PTSD diagnoses within the 5-year period prior to veterans' index dates. TBI, PTSD, and intentional self-harm were identified using International Classification of Diseases diagnosis and external cause of injury codes from inpatient and outpatient VHA encounters. We stratified analyses by veterans' average yearly VHA utilization in the 5-year period before their index date (low, medium, or high). Variations in prevalence and odds of intentional self-harm diagnoses were compared by veterans' prior TBI and PTSD diagnosis status (TBI only, PTSD only, and comorbid TBI/PTSD) for each VHA utilization stratum. Multivariable models adjusted for age, sex, race, ethnicity, marital status, Department of Veterans Affairs service-connection status, and Charlson Comorbidity Index scores.

RESULTS

About 6.7 million veterans with at least two VHA visits in the 5-year period before their index dates were included in the analyses; 86,644 had at least one intentional self-harm diagnosis during the study period. During the periods prior to veterans' index dates, 93,866 were diagnosed with TBI only; 892,420 with PTSD only; and 102,549 with comorbid TBI/PTSD. Across all three VHA utilization strata, the prevalence of intentional self-harm diagnoses was higher among veterans diagnosed with TBI, PTSD, or TBI/PTSD than among veterans with neither diagnosis. The observed difference was most pronounced among veterans in the high VHA utilization stratum. The prevalence of intentional self-harm was six times higher among those with comorbid TBI/PTSD (6778/58,295, 11.63%) than among veterans with neither TBI nor PTSD (21,979/1,144,991, 1.92%). Adjusted odds ratios suggested that, after accounting for potential confounders, veterans with TBI, PTSD, or comorbid TBI/PTSD had higher odds of self-harm compared to veterans without these diagnoses. Among veterans with high VHA utilization, those with comorbid TBI/PTSD were 4.26 (95% CI 4.15-4.38) times more likely to receive diagnoses for intentional self-harm than veterans with neither diagnosis. This pattern was similar for veterans with low and medium VHA utilization.

CONCLUSIONS

Veterans with TBI and/or PTSD diagnoses, compared to those with neither diagnosis, were substantially more likely to be subsequently diagnosed with intentional self-harm between 2008 and 2017. These associations were most pronounced among veterans who used VHA health care most frequently. These findings suggest a need for suicide prevention efforts targeted at veterans with these diagnoses.

A Randomized Clinical Trial of Clinician-Supported PTSD Coach in VA Primary Care Patients

BACKGROUND

Posttraumatic stress disorder (PTSD) is common in primary care patients; however, evidence-based treatments are typically only available in specialty mental healthcare settings and often not accessed.

OBJECTIVE

To test the effectiveness of a brief primary care-based treatment, Clinician-Supported PTSD Coach (CS PTSD Coach) was compared with Primary Care Mental Health Integration-Treatment as Usual (PCMHI-TAU) in (1) reducing PTSD severity, (2) engaging veterans in specialty mental health care, and (3) patient satisfaction with care.

DESIGN

Multi-site randomized pragmatic clinical trial.

PARTICIPANTS

A total of 234 veterans with PTSD symptoms who were not currently accessing PTSD treatment.

INTERVENTION

CS PTSD Coach was designed to be implemented in Veterans Affairs PCMHI and combines mental health clinician support with the "PTSD Coach" mobile app. Four 30-min sessions encourage daily use of symptom management strategies.

MAIN MEASURES

PTSD severity was measured by clinician-rated interviews pre- and post-treatment (8 weeks). Self-report measures assessed PTSD, depression, and quality of life at pretreatment, posttreatment, and 16- and 24-week follow-ups, and patient satisfaction at post-treatment. Mental healthcare utilization was extracted from medical records.

KEY RESULTS

Clinician-rated PTSD severity did not differ by condition at post-treatment. CS PTSD Coach participants improved more on patient-reported PTSD severity at post-treatment than TAU participants (D = .28, p = .021). Coach participants who continued to have problematic PTSD symptoms at post-treatment were not more likely to engage in 2 sessions of specialty mental health treatment than TAU participants. Coach participants engaged in 74% more sessions in the intervention and reported higher treatment satisfaction than TAU participants (p < .001).

CONCLUSIONS

A structured 4-session intervention designed to align with patient preferences for care resulted in more patient-reported PTSD symptom relief, greater utilization of mental health treatment, and overall treatment satisfaction than TAU, but not more clinician-rated PTSD symptom relief or engagement in specialty mental health.

Understanding veteran barriers to specialty outpatient PTSD clinical care

OBJECTIVE

Veterans seeking treatment for posttraumatic stress disorder (PTSD) commonly report general and veteran-specific barriers to treatment such as stigma and challenges with navigating the Veterans Health Affairs (VHA) system. This study aimed to characterize barriers endorsed by a national sample of veterans seeking care in VHA PTSD specialty outpatient clinics, as well as to examine the impact of demographics on endorsed barriers.

METHODS

This study included 17,069 veterans referred to PTSD specialty outpatient clinics in the VHA during Fiscal Year 2019. Barriers to care, demographics, clinical concerns, and PTSD symptom severity (PCL-5) were assessed at intake.

RESULTS

Veterans (mean age=47.6 years, 83.3% male) endorsed an average of 2.39 barriers. The most commonly endorsed barriers included difficulty interacting with others (37.9%), difficulty being in public (33.8%), work (30.3%), concern for finances (20%), and difficulty getting out of bed (19.5%). A significant minority of veterans (22%) endorsed no barriers. Male sex (23.1%) and White race (23.6%) were associated with a greater likelihood of reporting no barriers.

CONCLUSIONS

These findings indicate the need for a comprehensive approach to addressing multi-faceted barriers for veterans seeking treatment in PTSD specialty clinics. Findings also highlight the potential importance of tailoring strategies to reduce barriers based on demographic and clinical characteristics such as race, sex, and degree of avoidance. Future research should seek to longitudinally examine the impact of barriers on treatment engagement.

Development and cross-validation of a veterans mental health risk factor screen

BACKGROUND

VA primary care patients are routinely screened for current symptoms of PTSD, depression, and alcohol disorders, but many who screen positive do not engage in care. In addition to stigma about mental disorders and a high value on autonomy, some veterans may not seek care because of uncertainty about whether they need treatment to recover. A screen for mental health risk could provide an alternative motivation for patients to engage in care.

METHOD

Data from samples of veterans and traumatic injury survivors were analyzed to identify mental health risk factors that are characteristics of individuals or stressors or of post-trauma, post-deployment, or post-military service resources, experiences, or responses. Twelve risk factors were strongly related to PTSD (r > .50): current PTSD, depression, dissociation, negative thinking, and emotional lability symptoms, life stress, relationship stress, social constraints, and deployment experiences of a difficult environment, concerns about life and family, perceived threat, and moral injury. Items assessing each of these risk factors were selected and their validity to prospectively predict PTSD and/or depression 6 months later was assessed in a new sample of 232 VA primary care patients.

RESULTS

Twelve items assessing dissociation, emotional lability, life stress, and moral injury correctly classified 86% of those who later had elevated PTSD and/or depression symptoms (sensitivity) and 75% of those whose later symptoms were not elevated (specificity). Performance was also very good for 110 veterans who identified as members of ethnic/racial minorities.

CONCLUSIONS

Mental health status was prospectively predicted in VA primary care patients with high accuracy using a screen that is brief, easy to administer, score, and interpret, and fits well into VA's integrated primary care. When care is readily accessible, appealing to veterans, and not perceived as stigmatizing, information about mental health risk may result in higher rates of engagement than information about current mental disorder status.

Improving function through primary care treatment of PTSD: The IMPACT study protocol

Despite the availability of effective psychological interventions for PTSD, access to and retention in these interventions remains problematic. Of note, the Veterans Health Administration (VHA) developed and implemented post-deployment health surveys that screen for PTSD in primary care (PC), but effective PC-based, psychological intervention treatment options have yet to be established. To address the literal physical gap between where the patients first present for care (i.e., primary care) and where they must go to receive first-line treatment for PTSD (i.e., specialty mental health), study investigators developed a 4-6 visit Prolonged Exposure for Primary Care (PE-PC) treatment that has shown efficacy in reduction of PTSD. To extend previous work to recovery-based mental health care, the Improving Function Through Primary Care Treatment of PTSD (IMPACT) study examined function as assessed by the World Health Organization Disability Assessment Schedule [WHODAS 2.0; (Axelsson, Lindsäter, Ljótsson, Andersson, & Hedman-Lagerlöf, 2017)]. Veterans presenting in VHA primary care mental health integration (PCMHI) clinics with PTSD or significant subsyndromal PTSD who met minimal inclusion and exclusion criteria were randomly assigned to PE-PC or treatment as usual (TAU). If proven effective in improving function, PE-PC would provide a new access point for high quality PTSD care and allow greater numbers of veterans to access effective PTSD treatment. Trial Registration: http://ClinicalTrials.gov: NCT03581981.

The “trauma pitch”: How stigma emerges for Iraq and Afghanistan veterans seeking disability compensation

Posttraumatic Stress Disorder continues to be a highly stigmatized disease for the veteran population and stigma, experienced as a mark of discredit or shame, continues to be identified as the main deterrent in treatment seeking. Little attention has been paid to how the process of obtaining service-connected disability status can amplify veterans’ perceptions of being stigmatized. The following ethnographic study identified how combat veterans experienced stigma in processing through Veterans Affairs care and the effects of linking a Posttraumatic Stress Disorder diagnosis with disability compensation. Stigma was identified in two inter-related areas: 1) the structural level in the Veterans Affairs disability claims process and 2) the individual level in interactions with Veterans Affairs service providers. Findings based on veterans’ narratives suggest that the disability claims process, requiring multiple repetitions of personal trauma, coupled with perceptions of institutional stigmas of malingering, created bureaugenic effects: a worsening of symptoms caused by bureaucratic protocols intended to help veterans. This process influenced first time treatment users of the Veterans Affairs by deterring treatment-seeking behavior but was not found to affect veterans who had already initiated treatment. Despite the experience of stigma and commodification of their suffering through disability and diagnostic screening, veterans still sought disability compensation. Veterans viewed this compensation as acknowledgment of their loss and validation of their sacrifice.

Psychologist veteran status as a predictor of veterans’ willingness to engage in psychotherapy

Many veterans experience difficulties with mental health and functioning, yet many do not seek treatment and dropout rates are high. A small body of literature suggests that veterans prefer to work with providers or peer support specialists who are also veterans. Research with trauma-exposed veterans suggests that some veterans prefer to work with female providers. In an experimental study with 414 veterans, we examined whether veterans' ratings of a psychologist (e.g., helpfulness, ability to understand the participant, likelihood of making an appointment) described in a vignette were impacted by the psychologist's veteran status and gender. Results indicated that veterans who read about a veteran psychologist rated the psychologist as more able to help and understand them, reported being more willing to see and more comfortable seeing the psychologist, and reported greater belief that they should see the psychologist, relative to those who read about a non-veteran psychologist. Contrary to hypotheses, there was no main effect of psychologist gender nor any interaction between psychologist gender and psychologist veteran status on ratings. Findings suggest that having access to mental health providers who are also veterans may reduce barriers to treatment-seeking among veteran patients.

Web-Based Problem-solving Training With and Without Peer Support in Veterans With Unmet Mental Health Needs: Pilot Study of Feasibility, User Acceptability, and Participant Engagement

BACKGROUND

eHealth tools have the potential to meet the mental health needs of individuals who experience barriers to accessing in-person treatment. However, most users have less than optimal engagement with eHealth tools. Coaching from peer specialists may increase their engagement with eHealth.

OBJECTIVE

This pilot study aims to test the feasibility and acceptability of a novel, completely automated web-based system to recruit, screen, enroll, assess, randomize, and then deliver an intervention to a national sample of military veterans with unmet mental health needs; investigate whether phone-based peer support increases the use of web-based problem-solving training compared with self-directed use; and generate hypotheses about potential mechanisms of action for problem-solving and peer support for future full-scale research.

METHODS

Veterans (N=81) with unmet mental health needs were recruited via social media advertising and enrolled and randomized to the self-directed use of a web-based problem-solving training called Moving Forward (28/81, 35%), peer-supported Moving Forward (27/81, 33%), or waitlist control (26/81, 32%). The objective use of Moving Forward was measured with the number of log-ins. Participants completed pre- and poststudy measures of mental health symptoms and problem-solving confidence. Satisfaction was also assessed post treatment.

RESULTS

Automated recruitment, enrollment, and initial assessment methods were feasible and resulted in a diverse sample of veterans with unmet mental health needs from 38 states. Automated follow-up methods resulted in 46% (37/81) of participants completing follow-up assessments. Peer support was delivered with high fidelity and was associated with favorable participant satisfaction. Participants randomized to receive peer support had significantly more Moving Forward log-ins than those of self-directed Moving Forward participants, and those who received peer support had a greater decrease in depression. Problem-solving confidence was associated with greater Moving Forward use and improvements in mental health symptoms among participants both with and without peer support.

CONCLUSIONS

Enrolling and assessing individuals in eHealth studies without human contact is feasible; however, different methods or designs are necessary to achieve acceptable participant engagement and follow-up rates. Peer support shows potential for increasing engagement in web-based interventions and reducing symptoms. Future research should investigate when and for whom peer support for eHealth is helpful. Problem-solving confidence should be further investigated as a mechanism of action for web-based problem-solving training.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03555435; http://clinicaltrials.gov/ct2/show/NCT03555435.

Mobile Intervention to Improve Sleep and Functional Health of Veterans With Insomnia: Randomized Controlled Trial

Background

Insomnia is a prevalent and debilitating disorder among veterans. Cognitive behavioral therapy for insomnia (CBTI) can be effective for treating insomnia, although many cannot access this care. Technology-based solutions and lifestyle changes, such as physical activity (PA), offer affordable and accessible self-management alternatives to in-person CBTI.

Objective

This study aims to extend and replicate prior pilot work to examine whether the use of a mobile app for CBTI (cognitive behavioral therapy for insomnia coach app [CBT-i Coach]) improves subjective and objective sleep outcomes. This study also aims to investigate whether the use of the CBT-i Coach app with adjunctive PA improves sleep outcomes more than CBT-i Coach alone.

Methods

A total of 33 veterans (mean age 37.61 years, SD 9.35 years) reporting chronic insomnia were randomized to use either the CBT-i Coach app alone or the CBT-i Coach app with a PA intervention over 6 weeks, with outcome measures of objective and subjective sleep at pre- and posttreatment.

Results

Although the PA manipulation was unsuccessful, both groups of veterans using the CBT-i Coach app showed significant improvement from baseline to postintervention on insomnia (P<.001), sleep quality (P<.001), and functional sleep outcomes (P=.002). Improvements in subjective sleep outcomes were similar in those with and without posttraumatic stress disorder and mild-to-moderate sleep apnea. We also observed a significant but modest increase in objective sleep efficiency (P=.02).

Conclusions

These findings suggest that the use of a mobile app–delivered CBTI is feasible and beneficial for improving sleep outcomes in veterans with insomnia, including those with comorbid conditions such as posttraumatic stress disorder or mild-to-moderate sleep apnea.

Trial Registration

ClinicalTrials.gov NCT03305354; https://clinicaltrials.gov/ct2/show/NCT03305354

A brief intervention for PTSD versus treatment as usual: Study protocol for a non-inferiority randomized controlled trial

BACKGROUND

Although existing treatment methods are effective in alleviating PTSD symptoms, several barriers to care exist, such as waiting times, avoidant tendencies, shame and stigma, potentially leading to fewer people seeking therapy or premature dropouts. A potential solution to battling these barriers is Brain Working Recursive Therapy (BWRT), a single-session exposure-oriented intervention for PTSD. Although not yet subjected to empirical investigation, clinical experiences suggest an often immediate and long-lasting effect following the intervention related to patient's symptomatology and functional abilities.

METHODS

The current study protocol outlines a plan to conduct the first non-inferiority randomized controlled trial aimed to explore the efficacy of BWRT compared to treatment as usual (TAU), operationalized as any evidence-based trauma treatment method administered in Norwegian out-patient clinics. Eighty-two participants will be allocated at a 1:1 ratio to one of the following treatment conditions: (1) BWRT or (2) treatment as usual. Participants will be compared on several variables, including changes in PTSD symptoms (primary objective), and changes in perceived quality of life, rumination, functional and cognitive ability (secondary objective). Data collection will take place baseline (T1), within three weeks post treatment (T2) and at 6-month follow-up (T3).

DISCUSSION

Should BWRT prove to be non-inferior to treatment as usual, this brief intervention may be an important contribution to future psychological treatment for PTSD, by making trauma treatment more accessible and battling current barriers to care.

TRIAL REGISTRATION

191548, 24.05.2021. ClinicalTrials.gov PRS: Release Confirmation.

"There's a huge benefit just to know that someone cares:" a qualitative examination of rural veterans' experiences with TelePain

BACKGROUND

Veterans in the United States are at an increased risk of chronic pain and have higher reported pain prevalence and severity than nonveterans. This qualitative study aims to examine veterans' perspectives on the acceptability of receiving pain care through TelePain, a telehealth program implemented by the Veterans Health Administration (VA) that offers specialty pain care to rural veterans in their homes or in a video conferencing room at a nearby outpatient clinic.

METHODS

The VA electronic health record was used to identify patients who were referred to TelePain from rural clinics located in Washington, Oregon, and Alaska between 12/01/2019 and 03/31/2020. The study team completed 16 semi-structured interviews with rural veterans about their experiences with TelePain. After interview transcripts were recorded digitally and transcribed, Atlas.ti was used to organize data and facilitate qualitative coding. Interview transcripts were analyzed using thematic analysis.

RESULTS

Veterans reported general satisfaction with receiving pain care through telehealth and valued having supportive, knowledgeable providers who provided useful information and resources. In addition, veterans appreciated the convenience of telehealth. Barriers to care included problems with program follow-up, negative perceptions of mental health care for pain, and preference for in-person care. Although some patients suggested that telehealth audio and video could be improved, most patients did not have any significant problems with telehealth technology.

CONCLUSIONS

In this sample of rural veterans who used TelePain, many reported satisfaction with the program and positive experiences with providers. Targets for quality improvement include streamlining the program's referral and scheduling process and improving patient motivation to engage in psychological pain treatments. Results indicate that delivering pain services over telehealth is an acceptable modality for this patient population.

Satisfaction of the Use of Telehealth and Access to Care for Veterans During the COVID-19 Pandemic

Background: While many health care providers have shifted toward telehealth services in response to the COVID-19 pandemic, little is known about the perception and acceptance of such services, particularly among vulnerable populations. Veterans, who are at increased risk of physical and mental health needs, may benefit from the use and availability of telehealth services. Materials and Methods: Cross sectional survey data related to telehealth use, satisfaction, and access were collected through an online survey. Participants from previous research studies and veterans receiving care at a national veteran behavioral health organization were invited to participate. Results: A total of 404 veterans participated. Before the pandemic, many veterans had never used telehealth for physical (72%) or mental (76%) health care. Since the start of the pandemic, 62% of participants reported they received some care through telehealth services. Most participants found telehealth valuable and helpful (82%), indicated the technology was well explained (77%), and felt that issues were resolved quickly and easily (67%). Access to care was limited among participants who utilize massage therapy (64%), dental care (53%), routine checkups (50%), acupuncture (50%), and physical therapy (48%). Discussion: These findings showed an increase in the use of telehealth services and overwhelming satisfaction among veterans. Despite this, some veterans indicated barriers to receiving physical and mental health care. Conclusions: This provides an opportunity to expand the use of telehealth services to meet the health care needs of veterans. Barriers to care should be addressed to minimize the impact on the well-being of veterans.

Factors influencing utilization and perception of health care: a qualitative study among traumatized Yazidi refugees in Germany

BACKGROUND

Ensuring adequate utilization of healthcare services for displaced populations is critical, yet there are well-documented treatment gaps. Yazidi women captured by the Islamic State (IS) were subjected to extreme trauma and violence. This study aims to understand perceptions of healthcare providers and utilization of these services among women who experienced extreme trauma.

METHODS

This is a qualitative study with voluntary participation offered to approximately 400 women resettled through the Special Quota Program. An empirical approach was used to collect data and a grounded theory approach was used for content analysis. Participants ranked their interactions with providers on a Likert scale. Posttraumatic stress disorder (PTSD) symptoms were assessed using the impact of event scale-revised questionnaire.

RESULTS

A total of 116 Yazidi women participated in this study. The women experienced an average of 6.8 months of captivity by IS and 93% met criteria for probable PTSD. Eighty-three percent of the women interacted with a physician; 80% found this interaction helpful. Sixty-nine percent interacted with psychologists; 61% found this interaction helpful. Six themes emerged: "reminders of trauma" and "hopelessness" in relation to the traumatic experience; "immediate relief" and "healing through pharmaceutical treatment" in relation to provider interventions, and "support" and "cultural differences" in relation to interactions with providers.

CONCLUSIONS

There exist major barriers to care for Yazidi women who experienced extreme trauma, particularly in regards to psychiatric care. Perceptions of healthcare providers and perceived effectiveness of therapy are critical factors that must be taken into consideration to improve healthcare utilization and outcomes.

Presence of PTSD is Associated with Clinical and Functional Impact in Veterans with Depression Treated in Community-Based Clinics

Providers in non-traditional mental health settings (e.g., primary care, community medical clinics) face challenges involving patients who often present with multiple mental health conditions, but require rapid assessment and treatment. To help address this challenge, this study characterized differences in health symptom severity and mental health treatment perceptions between depressed Veterans with and without posttraumatic stress disorder (PTSD) served in community medical clinics. Relative to depressed Veterans without PTSD (N = 62), depressed Veterans with PTSD (N = 122) endorsed greater depression, suicidal ideation, anxiety, pain, and insomnia symptoms, as well as lower functioning. Veterans with depression and PTSD also reported greater mental health needs, prior utilization of mental health services, and higher perceived importance of mental health treatment. Results highlight the complexity of comorbid mental health conditions frequently seen in community medical care clinics and suggest that patients with comorbid mental health difficulties may present with a complex array of mental health symptoms.

Pilot trial of a transdiagnostic computerized anxiety sensitivity intervention among VA primary care patients

People in need of mental health treatment do not access care at high rates or in a timely manner, inclusive of Veterans at Department of Veteran's Affairs (VA) medical centers. Barriers to care have been identified, and one potential solution is the use of technology-based interventions within primary care. This study evaluated the Cognitive Anxiety Sensitivity Treatment (CAST), a previously developed computerized treatment that has shown efficacy in community samples for mental health symptoms including: anxiety, depression, post-traumatic stress, and suicidal ideation. VA primary care patients with elevated anxiety sensitivity (N = 25) were recruited to participate in a mixed-method open pilot to examine acceptability, usability, and preliminary effectiveness in a VA primary care setting. Participants completed an initial visit, that included the intervention, and a one-month follow-up. Veterans found CAST to be generally acceptable, with strong usability ratings. Qualitative analyses identified areas of strength and areas for improvement for use with VA primary care Veterans. Repeated measures ANCOVAs revealed significant effects for symptoms of anxiety, depression, traumatic-stress, and suicidal ideation. CAST could potentially have a large public health impact if deployed across VA medical centers as a first-step intervention for a range of mental health presenting concerns.

Barriers and Facilitators to Help-Seeking for Individuals With Posttraumatic Stress Disorder: A Systematic Review

Posttraumatic stress disorder (PTSD) brings with it diagnostic symptoms that can be debilitating and persist for years. Left untreated, PTSD can have far-reaching and damaging consequences for the individual, families, communities, and society at large. Although early detection and intervention are recognized as key to the effective treatment of PTSD, many individuals who suffer from PTSD do not seek essential health services. The aim of the present study was to identify the barriers and facilitators to help-seeking for individuals with PTSD, based on existing literature. A systematic review, modeled on the Joanna Briggs Institute methodology for systematic reviews, examined studies cited in PsycINFO, Medline, Embase, CINAHL, and PILOTS published from January 1980 to January 2019. Eligible studies measured barriers and facilitators to help-seeking for adults with PTSD. Two reviewers independently screened citations, and double data extraction was exercised. Of 2,391 potentially relevant citations, 21 studies, published between 1989 and 2018 and based in six countries, were included. Seventeen studies focused on military as a target population. We identified 10 principal barrier and facilitator themes: trauma-related; treatment; therapist or provider; knowledge; access; health care system; sociocultural environment; values, beliefs, and priorities; past experiences; and medical care needs and illness burden. In identifying prominent barriers and facilitators to help-seeking for individuals with PTSD, this review highlights opportunities to inform policies and programs that promote PTSD knowledge and recognition, reduce public and personal stigma, improve access and quality of care, and encourage support for patients and families living with PTSD.

Barriers and Facilitators to Seeking Mental Health Care Among First Responders: "Removing the Darkness"

BACKGROUND: First responders (FRs) are at significant risk for developing mental health (MH) problems due to the nature, frequency, and intensity of duty-related traumatic exposure. However, their culture strongly esteems strength and self-reliance, which often inhibits them from seeking MH care. AIMS: This study explored factors that influenced FRs' perceptions of MH problems and engagement in MH services. METHODS: A community-based approach and individual ethnographic qualitative interviews were used. Recruitment of a convenience sample of firefighters and emergency medical technicians/paramedics from across Arkansas was facilitated by our community partners. Interviews were analyzed using content analysis and constant comparison. RESULTS: Analysis generated three broad factors that influenced FRs' perception of MH problems and engagement in MH services: (a) Knowledge, (b) Barriers to help-seeking, and (c) Facilitators to help-seeking. Knowledge was an overarching factor that encompassed barriers and facilitators: A lack of knowledge was a barrier to help-seeking but increased knowledge served as a facilitator. Barriers included five subthemes: Can't show weakness, Fear of confidentiality breech, Therapist: negative experience, Lack of access and availability, and Family burden. Facilitators included five subthemes: Realizing "I'm not alone," Buy-in, Therapist: positive experience, Problems got too bad, and Recommendations. CONCLUSIONS: Findings provide unique perspectives from FRs about how to best address their MH needs. First responders, as well as mental health care providers, need a more thorough understanding of these issues in order to mitigate barriers and facilitate help-seeking. As advocates, educators, and health care providers, psychiatric nurses are well-positioned to care for this at-risk population.

Operation Veterans to Social Workers: A Military Social Work Certificate Program

Service members, Veterans, and their families have special needs for mental health services, but the nation lacks a sufficient pool of social workers competent in military culture. Noting the need for military cultural competency and an increasing number of student Veterans, a graduate school of social work created a military social work training program embedded in an existing MSW program. Operation Veterans to Social Workers (OVSW) were designed to increase culturally competent mental health services to this population by recruiting Veteran MSW students into a Military Social Work certificate program that included a specialized field placement with a trauma-informed clinical focus.

Timing of evidence-based psychotherapy for posttraumatic stress disorder initiation among Iraq and Afghanistan war veterans in the Veterans Health Administration

OBJECTIVE

Cognitive processing therapy (CPT) and prolonged exposure therapy (PE) were widely disseminated to treat posttraumatic stress disorder (PTSD) in the Veterans Health Administration (VHA). However, few Iraq and Afghanistan war veterans (Operation Enduring Freedom [OEF], Operation Iraqi Freedom [OIF], Operation New Dawn [OND]) diagnosed with PTSD have received CPT/PE and many initiate CPT/PE after substantial delay. Veterans who do not initiate CPT/PE or initiate CPT/PE after delay may have poorer treatment outcomes. This study aimed to identify predictors of CPT/PE initiation and timing.

METHODS

Participants included OEF/OIF/OND veterans diagnosed with PTSD who received psychotherapy between 2001 and 2017 in the VHA (n = 265,566). Logistic regression analysis was utilized to predict initiating CPT/PE (vs. no CPT/PE). Multinomial logistic regression analysis was utilized to predict not initiating or initiating delayed CPT/PE versus "early CPT/PE" (< 1 year after first mental health visit). Analyzed predictors included demographic, military, and clinical complexity variables (e.g., comorbidities, reported military sexual trauma [MST] history).

RESULTS

Seventy-Seven percent of veterans did not initiate CPT/PE, with 7.4% initiating early and 15.4% initiating delayed CPT/PE. Reported MST history (odds ratio [OR] = 1.45, 95% CI [1.39, 1.51]) and history of suicidal ideation/attempt (OR = 1.42, 95% CI [1.38, 1.46]) were strong predictors of CPT/PE initiation versus no CPT/PE. Comorbid pain (relative risk ratio [RRR] = 1.35, 95% CI [1.30, 1.42]) and depressive disorders (RRR = 1.37, 95% CI [1.32, 1.43]) were associated with increased likelihood of delayed versus early CPT/PE.

CONCLUSIONS

Most veterans in our study did not initiate CPT/PE. Generally, clinical complexity variables increased likelihood of initiating CPT/PE and initiating CPT/PE more than 1 year after first mental health visit. Additional research is needed to understand whether CPT/PE delay results from receipt of alternative intervention due to clinical complexity variables. (PsycINFO Database Record (c) 2020 APA, all rights reserved).