Trauma-focused treatment in a state system of care: is it worth the cost?

Current Research on Matching Trauma-Focused Therapies to Veterans: A Scoping Review

INTRODUCTION

Trauma-focused (psycho)therapies (TFTs) are often used to treat post-traumatic stress disorder (PTSD) of (military) veterans, including prolonged exposure (PE), cognitive processing therapy (CPT), and eye movement desensitization and reprocessing. However, research thus far has not conclusively determined predictors of TFTs' success in this population. This scoping review's objectives are 1) to explore whether it is possible, based on currently available evidence, to match TFTs to veterans to maximize their outcomes, (2) to identify possible contraindications and adaptations of TFTs for this population, and (3) to identify gaps in the literature to guide future research.

MATERIALS AND METHODS

Standard scoping review methodology was used. "White" and "gray" literature searches resulted in 4963 unique items identified. Following title and abstract screening and full-text analysis, 187 sources were included in the review. After data extraction, a narrative summary was used to identify common themes, discrepancies between sources, and knowledge gaps.

RESULTS

Included publications most often studied CPT and PE rather than eye movement desensitization and reprocessing. These TFTs were at least partly effective with mostly moderate effect sizes. Attrition rates were slightly higher for PE versus CPT. There was variance in the methodological quality of the included studies.

CONCLUSION

The current literature on TFTs to treat PTSD in veterans contains several knowledge gaps, including regarding treatment matching. Future research should examine effectiveness of these treatments using multiple sources of outcomes, longer time periods, combination with other treatment, outcomes outside of PTSD symptoms (such as functioning), and resilience.

Validating the Child Trauma Screen Among a Cross-Sectional Sample of Youth and Caregivers in Pediatric Primary Care

Pediatric primary care providers have an important role in addressing the health effects of trauma, yet routine screening is rare. This study evaluated whether the 10-item Child Trauma Screen (CTS) could identify youth experiencing posttraumatic stress disorder (PTSD) symptoms. Participants were 107 caregiver-youth pairs aged 7 to 17 years old, 55.8% male, and 76.4% Hispanic who were recruited at an urban pediatric primary care clinic. Youth and caregivers separately completed the CTS and the UCLA PTSD Reaction Index for DSM-5 (RI-5) prior to their medical visit. Half of youth experienced at least one type of trauma, and one sixth reported elevated PTSD symptoms. The CTS was highly correlated with the RI-5 on PTSD symptom severity, and correctly classified 85% of youth based on likely PTSD diagnosis. The brief CTS can accurately identify youth suffering from PTSD symptoms, and may be particularly feasible to implement in busy primary care practices.

Cost analysis in implementation studies of evidence-based practices for mental health and substance use disorders: a systematic review

Background

This study is a systematic literature review of cost analyses conducted within implementation studies on behavioral health services. Cost analysis of implementing evidence-based practices (EBP) has become important within implementation science and is critical for bridging the research to practice gap to improve access to quality healthcare services. Costing studies in this area are rare but necessary since cost can be a barrier to implementation and sustainment of EBP.

Methods

We followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology and applied the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist. Key search terms included: (1) economics, (2) implementation, (3) EBP, and (4) behavioral health. Terms were searched within article title and abstracts in: EconLit, SocINDEX, Medline, and PsychINFO. A total of 464 abstracts were screened independently by two authors and reduced to 37 articles using inclusion and exclusion criteria. After a full-text review, 18 articles were included.

Results

Findings were used to classify costs into direct implementation, direct services, and indirect implementation. While all studies included phases of implementation as part of their design, only five studies examined resources across multiple phases of an implementation framework. Most studies reported direct service costs associated with adopting a new practice, usually summarized as total EBP cost, cost per client, cost per clinician, and/or cost per agency. For studies with detailed analysis, there were eleven direct cost categories represented. For five studies that reported costs per child served, direct implementation costs varied from $886 to $9470 per child, while indirect implementation costs ranged from $897 to $3805 per child.

Conclusions

This is the first systematic literature review to examine costs of implementing EBP in behavioral healthcare settings. Since 2000, 18 studies were identified that included a cost analysis. Given a wide variation in the study designs and economic methods, comparison across studies was challenging, which is a major limitation in the field, as it becomes difficult to replicate studies or to estimate future costs to inform policy decisions related to budgeting. We recommend future economic implementation studies to consider standard economic costing methods capturing costs across implementation framework phases to support comparisons and replicability.

"This Is the Result of Something Else": Experiences of Men That Abused Drugs and Had Experienced Childhood Trauma

Drug abuse is a serious public health issue that may have irreversible consequences. Research has revealed that childhood psychological trauma can promote addictive behaviors in adulthood and that drugs are often used as a coping mechanism. Men are less likely to report trauma and seek help than women. The purpose of this qualitative study was to explore the experience of men in Iceland who have abused drugs and experienced childhood psychological trauma, to increase knowledge and deepen the understanding of trauma and addiction. Participants were seven men who had both experienced childhood trauma and had a history of drug abuse. Two interviews were conducted with each participant. The main findings suggest that participants abused drugs as a coping mechanism due to the trauma experienced in childhood. For some participants, seeking companionship was a key component of their drug use. Participants were mostly dissatisfied with treatment resources in Iceland; waiting lists were long and too much focus was on religion. Five main themes were identified: emotional impact, self-medication for pain, gender expectations, impermanence of thoughts, and loss of a sense of wholeness. Increased societal and professional awareness of the linkage between trauma and drug abuse is needed, as are additional resources specific to men who have experienced childhood trauma and drug abuse. It is important to integrate trauma focused services into health-care settings to educate health-care professionals on trauma and the consequences thereof, in addition to utilizing screening tools such as the Adverse Childhood Experience Questionnaire for those seeking assistance.

Disseminating Trauma-Focused Cognitive Behavioral Therapy with a Systematic Self-care Approach to Addressing Secondary Traumatic Stress: PRACTICE What You Preach

This pilot study evaluated the effectiveness of Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) training programs augmented with a systematic "PRACTICE What You Preach" (PWYP) self-care focus, which has trainees personally utilize the coping skills they teach their clients. Participants were 115 clinicians/supervisors who completed a PWYP TF-CBT training program. Pre- to post-training analyses documented significant increases in participants' competency and fidelity in implementing TF-CBT (ps < .001), significantly more frequent use of coping skills including instrumental social support (p < .01), active coping (p < .001), humor (p < .01), and restraint (p < .01), and significant decreases in secondary traumatic stress (STS; p < .001). Children's symptoms of PTSD (ps < .001) and behavior problems (p < .05) also decreased significantly. This preliminary evidence suggests that training augmented with PWYP may enhance clinicians'/supervisors' personal coping and reduce their levels of STS without compromising treatment implementation efforts and client outcomes.

Health-Related Quality of Life and Costs of Posttraumatic Stress Disorder in Adolescents and Young Adults in Germany

BACKGROUND

Posttraumatic stress disorder (PTSD) is one of the psychopathological consequences of sexual and/or physical abuse. The economic burden is assumed to be high, whereas health-related quality of life and education is negatively affected. This study aims to determine health care costs, health-related quality of life, and educational interruption in adolescents and young adults with PTSD after sexual and/or physical abuse in Germany.

METHODS

This analysis used data of 87 participants aged 14-21 years of a randomized controlled trial. Health care utilization, health-related quality of life (EQ-5D-5L), sick leave days, productivity, and delay or failure to achieve educational aims were assessed. Health care costs from a payer perspective were calculated using unit costs for the year 2014.

RESULTS

Mean health care costs for a six-month period were 5,243€ (SE 868€). In particular, costs of inpatient stays in psychiatric hospitals, general hospitals and rehabilitation as well as child welfare institutions were high. In addition, health-related quality of life was lower due to anxiety/depression, resulting in a mean EQ-5D index and EQ-VAS score of 0.70 and 61.0, respectively. Furthermore, participants reported on average 27 sick leave days, a productivity loss of 61%, and a delay in education attainment as well as having been unable to achieve educational aims.

CONCLUSION

PTSD in adolescents and young adults is associated with a high economic burden. Health-related quality of life was substantially reduced. Furthermore, delay and productivity losses in education were observed.

CLINICAL TRIAL REGISTRATION

German Clinical Trials Register identifier: DRKS00004787; date of registration: 18th March 2013; https://www.drks.de.

Economic evaluations and cost analyses in posttraumatic stress disorder: a systematic review

BACKGROUND

Posttraumatic stress disorder is associated with a high economic burden. Costs of treatment are known to be high, and cost-effectiveness has been analysed for several treatment options.

OBJECTIVE

As no review on economic aspects of posttraumatic stress disorder exists, the aim of this study was to systematically review costs-of-illness studies and economic evaluations of therapeutic treatment for posttraumatic stress disorder, and to assess their quality.

METHOD

A systematic literature search was performed in March 2017 and was last updated in February 2020 in the databases PubMed, PsychInfo and NHS Economic Evaluation Database. Cost-of-illness studies and economic evaluations of treatment for posttraumatic stress disorder were selected. Extracted cost data were categorized as direct costs and indirect costs and inflated to 2015 US-$ purchasing power parities (PPP). Quality was assessed using an adapted cost-of-illness studies quality checklist, the Consensus on Health Economic Criteria list, and the questionnaire to assess relevance and credibility of modelling studies by the International Society for Pharmacoeconomics and Outcome Research.

RESULTS

In total, 13 cost-of-illness studies and 18 economic evaluations were included in the review. Annual direct excess costs ranged from 512 US-$ PPP to 19,435 US-$ PPP and annual indirect excess costs were 5,021 US-$ PPP per person. Trauma-focused cognitive-behavioural therapy (+selective serotonin re-uptake inhibitor) was found to be cost-effective compared with treatment as usual and no treatment. Overall, included studies were of low and moderate quality. Studies used inappropriate economic study designs and lacked information on the economic perspective used.

CONCLUSIONS

Posttraumatic stress disorder is a major public health problem that causes high healthcare costs. While trauma-focused cognitive-behavioural therapy was found to be cost-effective, further investigations regarding pharmacotherapy and other treatments are necessary.

Developmental Differences in the Association of Peer Relationships with Traumatic Stress Symptoms

Although childhood trauma exposure has a high incidence, traumatic stress often goes untreated in children and youth. We investigated peer relationship quality as a prevention strategy for reducing traumatic stress across different developmental periods. We analyzed longitudinal data from the National Survey of Child and Adolescent Wellbeing (NSCAW I) using a time-varying effect model (TVEM) to investigate the association between peer relationship quality and traumatic stress symptoms across ages 8-17 years. We controlled for a robust set of confounders identified through a Directed Acyclic Graph (DAG). The unique association between peer relationship quality and traumatic stress symptoms was negative and significant from ages 8 to 8.5 years, and again from ages 9.4 to 10.9 years and at age 16.4 to 16.8 years, with maximum associations of - 1.45 T score points at age 8.5 years (95% CI = [- 2.87, - 0.40]), - 1.57 at age 9.4 years (95% CI = [- 3.13,- 0.01]), and - 1.89 at 16.7 years (95% CI = [- 3.70, - 0.09]). Peer relationship quality protected against traumatic stress during specific times during adolescent development. Our results suggest that helping youth establish and maintain positive peer relationships may be a useful prevention approach for helping them cope with trauma experiences.

Enhancing Capacity for Trauma-informed Care in Child Welfare: Impact of a Statewide Systems Change Initiative

Youth involved in the child welfare system (CWS) are disproportionally impacted by the negative effects of exposure to trauma. While efforts to develop trauma-informed CWSs are accelerating, little research is available about the effects of these efforts on system capacity to respond to the needs of youth exposed to trauma. No studies evaluate longer-term effects of these efforts. In 2011, Connecticut implemented CONCEPT, a multi-year initiative to enhance capacity of the state's CWS to provide trauma-informed care. CONCEPT used a multi-component approach including workforce development, deployment of trauma screening procedures, policy change, improved access to evidence-based trauma-focused treatments, and focused evaluation of program effects. Changes in system capacity to deliver trauma-informed care were assessed using statewide stratified random samples of child welfare staff at three time points (Year 1: N = 223, Year 3: N = 231, Year 5: N = 188). Significant improvements across nearly all child welfare domains were observed during the first 3 years of implementation, demonstrating system-wide improvements in capacity to provide trauma-informed care. These gains were maintained through the final year of implementation, with continued improvements in ratings of collaboration between child welfare and behavioral health settings on trauma-related issues observed. Responses documented familiarity with and involvement in many of the CONCEPT activities and initiatives. Staff reported greater familiarity with efforts to increase access to specific evidence-based services (e.g., TF-CBT) or to enhance trauma-related policy and practice guidelines, but less familiarity with efforts to implement new practices (e.g., trauma screening) in various sectors. Staff also reflected on the contribution of these components to enhance system capacity for trauma-informed care.

Cost-Effectiveness Analysis of Trauma-Focused Cognitive Behavioral Therapy: A Randomized Control Trial among Norwegian Youth

Traumatic events by young people can adversely affect their psychological and social well-being when left untreated. This can result in high costs for society. In this study, we aimed to evaluate whether trauma-focused cognitive behavioral therapy (TF-CBT) is a cost-effective alternative to therapy as usual (TAU). Individual-level data were collected from 2008 to 2013, as part of a randomized control trial in Norwegian youth, 10-18 years of age, presenting with symptoms of posttraumatic stress (N = 156). Health outcomes, costs, and patient and family characteristics were recorded. Health-related quality of life (HRQoL) was measured with the 16D instrument, and quality-adjusted life-years (QALYs) were derived; total costs included the costs of therapy, and last we calculated the incremental cost-effectiveness ratio (ratio of differences in costs and QALYs gained). We performed nonparametric bootstrapping and used the results to draw a cost-effectiveness acceptability curve depicting the probability that TF-CBT is cost-effective. HRQoL increased in both treatment groups, whereas no significant differences in QALYs were observed. Resource use measured in minutes per session was significantly higher in the TF-CBT group; however, total minutes of therapy and costs were not significantly different between the two groups. In addition, use of resources, such as psychological counseling services, welfare services, and medication, was lower in the TF-CBT group posttreatment. The likelihood of TF-CBT being cost-effective varied from 91% to 96%. TF-CBT is likely to be a cost-effective alternative to standard treatment and should be recommended as the guideline treatment for youth with posttraumatic stress disorder.

Measuring Costs to Community-Based Agencies for Implementation of an Evidence-Based Practice

Healthcare reform has led to an increase in dissemination of evidence-based practices. Cost is frequently cited as a significant yet rarely studied barrier to dissemination of evidence-based practices and the associated improvements in quality of care. This study describes an approach to measuring the incremental, unreimbursed costs in staff time and direct costs to community-based clinics implementing an evidence-based practice through participating in a learning collaborative. Initial implementation costs exceeding those for providing "treatment as usual" were collected for ten clinics implementing trauma-focused cognitive behavioral therapy through participation in 10-month learning collaboratives. Incremental implementation costs of these ten community-based clinic teams averaged the equivalent of US$89,575 (US$ 2012). The most costly activities were training, supervision, preparation time, and implementation team meetings. Recommendations are made for further research on implementation costs, dissemination of evidence-based practices, and implications for researchers and policy makers.

Collaborative mental health care for pediatric behavior disorders in primary care: Does it reduce mental health care costs?

OVERVIEW

One recently completed randomized controlled trial (RCT) demonstrated the effectiveness of a doctor-office collaborative care (DOCC), relative to enhanced usual care (EUC), for pediatric behavior problems and attention-deficit/hyperactivity disorder. In this study, we sought to extend the literature by incorporating a cost-analysis component at the conclusion of the aforementioned trial. To our knowledge, it was the first study to examine whether the DOCC model leads to lower costs of mental health services for children.

METHOD

Financial records from the RCT provided cost information about all the 321 child study participants in the 6-month intervention period, and claims data from insurance plans provided cost information about community mental health services for 57 children, whose parents consented to release their claims data, in both pre- and postintervention periods. Both descriptive and multivariate analyses were performed.

RESULTS

The DOCC group had higher intervention costs, but the cost per patient treated in the DOCC group was lower than the EUC group during the 6-month intervention period. In terms of costs of community mental health services, although the 2 groups had similar costs in the 6 months before the RCT intervention, the DOCC group had significantly lower costs during the 6-month intervention period and 6 or 12 months after the intervention, but not in the 18 or 24 months after the intervention.

DISCUSSION

The DOCC model has the potential for cost savings during the intervention period and the follow-up periods immediately after the intervention while improving clinical effectiveness. (PsycINFO Database Record

Applying Trauma-Focused Cognitive-Behavioral Therapy in Group Format

Trauma-focused cognitive-behavioral therapy (TF-CBT), a well-established, evidence-based treatment for children who have experienced trauma, has been increasingly utilized in a group format. Group therapy formats are appealing because they can be highly effective and have the potential to reach larger numbers of clients. Moreover, TF-CBT group delivery may be particularly valuable in reducing the feelings of shame, isolation, and stigma experienced by youth and their caregivers in the aftermath of traumatic experiences. This article reviews the group TF-CBT research, discusses the therapeutic benefits of TF-CBT therapy groups, and provides clinical and logistical guidance for implementing TF-CBT in group format, including a session-by-session protocol. Future directions for research and clinical work in this area are also discussed.