Documentation of Evidence-Based Psychotherapy and Care Quality for PTSD in the Department of Veterans Affairs

Rural Veterans with HIV and Alcohol Use Disorder receive less video telehealth than urban Veterans

PURPOSE

Alcohol use disorder (AUD) is highly prevalent among Veterans with HIV. Rural Veterans with HIV are at especially high risk for not receiving appropriate treatment. This retrospective cohort cross-sectional study aimed to investigate patterns of mental health treatment utilization across delivery modality among Veterans diagnosed with HIV and AUD. It was hypothesized that rural Veterans with HIV and AUD would receive a lower rate of mental health treatment delivered via video telehealth than urban Veterans with HIV and AUD.

METHODS

A national Veterans Health Association administrative database was used to identify a cohort of Veterans diagnosed with HIV and AUD (N = 2,075). Geocoding was used to categorize rural Veterans (n = 246) and urban Veterans (n = 1,829). Negative binomial regression models tested associations between rurality and mental health treatment delivered via face-to-face, audio-only, and video telehealth modalities.

FINDINGS

Results demonstrated that rural Veterans with HIV and AUD received fewer mental health treatment sessions delivered via telehealth than urban Veterans with HIV and AUD (incidence rate ratio = 0.62; 95% confidence intervals [0.44, 0.87]; P < .01). No differences were found in terms of treatment delivered face-to-face or by audio-only.

CONCLUSIONS

Rural Veterans with HIV and AUD represent a vulnerable subpopulation of Veterans who may most benefit from video telehealth. Efforts to increase access and improve the uptake of evidence-based mental health treatment delivered via video telehealth are needed.

Adapting dose-response methodology to improve clinical trial design for psychotherapies

OBJECTIVE

Conventional randomized controlled trials (RCTs) have long served as the foundation of research in clinical psychology; however, most treatments for eating disorders show only modest effects on reduction of symptoms and maintenance of long-term remission. New options for psychotherapy treatment development research, beyond continuing to pursue additive or subpopulation approaches, are needed.

METHODS

One option is to apply dose-response designs, which are commonplace in studies of pharmacology, toxicology, and medical research, and characterized by the evaluation of the amount of exposure (dose) to an intervention, and the resulting changes in body function or health (response).

RESULTS

Eating disorder interventions are particularly well-suited for dose-response treatment designs. The deadly nature of eating disorders makes it imperative that patients are not turned away for not being "ready" to engage with treatment. By identifying optimal doses, research will likely yield a more parsimonious course of treatment, which will lend itself to reduced costs, greater uptake, and reduced drop-out.

DISCUSSION

Limited use of within-subject designs in trials for patients with eating disorders has produced fast-track efficacy studies and omitted key elements in the treatment development pathway. To decrease reliance on RCT's, dose-response methods should be applied as an alternative study design.

PUBLIC SIGNIFICANCE

Eating disorders are associated with medical and psychiatric comorbidities, poor quality of life, and high mortality. Access to evidence-based services for patients with eating disorders is limited, and identifying additional effective treatment options can be difficult because of challenges inherent to randomized-controlled trials. This manuscript describes an alternative trial methodology to maximize the information that can be gathered prior to utilizing a standard large-scale efficacy design.

Evaluation of implementation facilitation integrated into a national mentoring programme to improve access to evidence-based psychotherapy for post-traumatic stress disorder within the veterans health administration: a quality improvement report

Despite the resources dedicated to specialised mental healthcare for patients with post-traumatic stress disorder (PTSD) within the US Veterans Health Administration, evidence-based psychotherapies (EBPs) for PTSD have been underutilised, as evidenced by low EBP reach to patients. A research-operation collaboration evaluated whether implementation facilitation delivered by regional PTSD mentors as part of a national mentoring programme improved EBP reach compared with less-intensive quality improvement interventions. We used a non-equivalent comparison-group design that included all PTSD clinics with low EBP reach at baseline (n=51). Clinics were grouped into one of four quality improvement conditions according to self-selection by regional PTSD mentors: facilitation (n=6), learning collaborative (n=15), mentoring as usual in the regions that had facilitation-target clinics (n=15) and mentoring as usual in other regions (n=15). The primary outcome was EBP reach among therapy patients with PTSD at preintervention baseline and postintervention sustainment periods. We used the ratio of odds ratios (ROR) between the two time periods to evaluate the effectiveness of facilitation compared with the other conditions, adjusting for patient-level and clinic-level confounders. 26 126 veterans with PTSD received psychotherapy in one of 51 low-reach PTSD clinics during preintervention baseline and postintervention sustainment periods. The odds of a patient receiving an EBP increased over time across conditions. The adjusted ORs of a patient receiving an EBP from baseline to sustainment were 1.35-1.69 times larger in clinics that received facilitation compared with the three comparison conditions (adjusted RORs of comparison condition versus facilitation ranged from 0.59 (95% CI 0.47 to 0.75) to 0.74 (95% CI 0.58 to 0.94)). Implementation facilitation can be integrated into a national programme for quality improvement for PTSD specialty care and may be particularly useful when less-intensive approaches are not sufficiently effective.

Factors Associated with Engaging in Evidence-Based Psychotherapy During the First Year of Posttraumatic Stress Disorder Treatment Between 2017 and 2019

To address the burden of posttraumatic stress disorder (PTSD), the Veterans Health Administration (VHA) implemented evidence-based psychotherapies (EBPs) for PTSD at all VHA medical centers. Prior investigations show EBP utilization has increased following the initial nationwide implementation. However, most patients still do not engage in EBPs and those who do often have substantial delays between diagnosis and treatment which is associated with poorer treatment outcomes. The goal of the current study is to identify patient and clinical factors associated with initiating EBP and completing a minimally adequate dose of treatment within the first year of a new PTSD diagnosis. Overall, 263,018 patients started PTSD treatment between 2017 and 2019 and 11.6% (n = 30,462) initiated EBP during their first year of treatment. Of those who initiated EBP, 32.9% (n = 10,030) received a minimally adequate dose. Older patients were less likely to initiate EBP, but more likely to receive an adequate dose when they did initiate. Black, Hispanic/Latino/a, and Pacific Islander patients' likelihood of initiating EBP was not significantly different than White patients, but these patients were less likely to receive an adequate dose. Patients with comorbid depressive disorders, bipolar disorder, psychotic disorders, or substance use disorders were less likely to initiate EBP, while patients reporting MST were more likely to initiate EBP. This study identifies several patient-level disparities that could be prioritized to increase EBP utilization. In our evaluation, most patients did not engage in EBP during their first year of PTSD treatment, which is consistent with previous evaluations of EBP utilization. Future research should focus on understanding the flow of patients from PTSD diagnosis to treatment to support effective PTSD care delivery.

The potential of ketamine for posttraumatic stress disorder: a review of clinical evidence

Posttraumatic stress disorder (PTSD) is a devastating condition, for which there are few pharmacological agents, often with a delayed onset of action and poor efficacy. Trauma-focused psychotherapies are further limited by few trained providers and low patient engagement. This frequently results in disease chronicity as well as psychiatric and medical comorbidity, with considerable negative impact on quality of life. As such, off-label interventions are commonly used for PTSD, particularly in chronic refractory cases. Ketamine, an N-methyl-D-aspartate (NDMA) receptor antagonist, has recently been indicated for major depression, exhibiting rapid and robust antidepressant effects. It also shows transdiagnostic potential for an array of psychiatric disorders. Here, we synthesize clinical evidence on ketamine in PTSD, spanning case reports, chart reviews, open-label studies, and randomized trials. Overall, there is high heterogeneity in clinical presentation and pharmacological approach, yet encouraging signals of therapeutic safety, efficacy, and durability. Avenues for future research are discussed.

Who improves in trauma-focused treatment: A cluster analysis of treatment response in VA patients undergoing PE and CPT

BACKGROUND

Although most veterans with posttraumatic stress disorder (PTSD) benefit from evidence-based treatments, questions persist concerning the profiles of those at risk for poor outcomes. To help address these gaps, this study analyzed a large clinical cohort of veterans receiving prolonged exposure (PE) or cognitive processing therapy (CPT).

METHODS

Cluster analysis using Ward's method with Euclidian distances identified clinically meaningful subgroups of veterans in a national cohort (n = 20,848) using variables maintained in the electronic medical record. The clusters were then compared via one-way analysis of variance and Tukey's HSD on indicators of treatment progress including PTSD symptom change, clinical recovery, clinically significant change, remission, and treatment completion.

RESULTS

Effect size differences on clinical outcome measures for PE and CPT were negligible. Less than half of veterans achieved at least a 15-point reduction in PCL-5 score and half completed treatment. We identified 10 distinct clusters. Higher rates of PTSD service-connected disability were linked to poorer outcomes across multiple clusters, especially when combined with Post-Vietnam service era. Non-White race was also linked with poorer clinical outcomes. Factors associated with better outcomes included a greater proportion of female veterans, especially when combined with recent service era, and longer PTSD diagnosis duration.

CONCLUSIONS

This study suggests the need to improve PTSD treatment outcomes for non-White and male veterans, examine treatment response in Post-Vietnam era veterans, and consider ways in which the service connection process could hinder treatment response. The results from this study also indicate the benefits of integrating elements of clinical complexity into an analytic approach.

Improvements to PTSD quality metrics with natural language processing

RATIONALE AIMS AND OBJECTIVES

As quality measurement becomes increasingly reliant on the availability of structured electronic medical record (EMR) data, clinicians are asked to perform documentation using tools that facilitate data capture. These tools may not be available, feasible, or acceptable in all clinical scenarios. Alternative methods of assessment, including natural language processing (NLP) of clinical notes, may improve the completeness of quality measurement in real-world practice. Our objective was to measure the quality of care for a set of evidence-based practices using structured EMR data alone, and then supplement those measures with additional data derived from NLP.

METHOD

As a case example, we studied the quality of care for posttraumatic stress disorder (PTSD) in the United States Department of Veterans Affairs (VA) over a 20-year period. We measured two aspects of PTSD care, including delivery of evidence-based psychotherapy (EBP) and associated use of measurement-based care (MBC), using structured EMR data. We then recalculated these measures using additional data derived from NLP of clinical note text.

RESULTS

There were 2 098 389 VA patients with a diagnosis of PTSD between 2000 and 2019, 72% (n = 1 515 345) of whom had not previously received EBP for PTSD and were treated after a 2015 mandate to document EBP using templates that generate structured EMR data. Using structured EMR data, we determined that 3.2% (n = 48 004) of those patients met our EBP for PTSD quality standard between 2015 and 2019, and 48.1% (n = 23 088) received associated MBC. With the addition of NLP-derived data, estimates increased to 4.1% (n = 62 789) and 58.0% (n = 36 435), respectively.

CONCLUSION

Healthcare quality data can be significantly improved by supplementing structured EMR data with NLP-derived data. By using NLP, health systems may be able to fill the gaps in documentation when structured tools are not yet available or there are barriers to using them in clinical practice.

Stress, PTSD, and COVID-19: the Utility of Disaster Mental Health Interventions During the COVID-19 Pandemic

Purpose of review

In the context of an ongoing, highly uncertain pandemic, disaster mental health measures can increase community capacity for resilience and well-being, support formal mental health treatment, and help address the risk for mental health reactions in high-stress occupations. The purpose of this review is to summarize the literature on disaster mental health interventions that have been helpful both prior to and during the pandemic in a broad range of applications, including for use with high-stress occupations in an effort to mitigate risk for post-traumatic stress disorder (PTSD) and other mental health sequelae.

Recent findings

Evidence-based and evidence-informed disaster mental health interventions, frameworks, and treatments have been studied in pilot studies, non-randomized trials, and randomized clinical trials prior to and in the context of the current COVID-19 pandemic. The studies have demonstrated feasibility and acceptability of these modalities and improved perceived support, as well as significant reductions in distress, and mental health symptoms such as depression, anxiety, and PTSD.

Summary

A disaster mental health approach to the COVID-19 pandemic can generate opportunities for prevention and support at multiple levels with timely interventions tailored for different concerns, cultures, and available resources.

Investigation of Therapist Effects on Patient Engagement in Evidence-Based Psychotherapies for Posttraumatic Stress Disorder in the Veterans Health Administration

The present study examined whether certain Veterans Health Administration (VHA) therapists have more success than others in keeping patients engaged in evidence-based psychotherapies for posttraumatic stress disorder (PTSD). Our objective was to use multilevel modeling to quantify the variability between therapists in two indicators of patient engagement: early dropout (i.e., < 3 sessions) and adequate dose (i.e., ≥ 8 sessions). The phenomenon of systematic variability between therapists in patients' treatment experience and outcomes is referred to as "therapist effects." The sample included the 2,709 therapists who provided individual cognitive processing therapy (CPT) or prolonged exposure (PE) to 18,461 veterans with PTSD across 140 facilities in 2017. Data were extracted from administrative databases. For CPT, therapist effects accounted for 10.9% of the variance in early dropout and 8.9% of the variance in adequate dose. For PE, therapist effects accounted for 6.0% and 8.8% of the variance in early dropout and adequate dose, respectively. Facility only accounted for an additional 1.1%-3.1% of the variance in early dropout and adequate dose. For CPT, patients' odds of receiving an adequate dose almost doubled, OR = 1.41/0.72 = 1.96, if they were seen by a therapist in the highest compared with the lowest retention decile. For PE, the odds of a patient receiving an adequate dose were 84% higher, OR = 1.38/0.75 = 1.84, when treated by a therapist in the highest compared with the lowest retention decile. Therapist skills and work environment may contribute to variability across therapists in early dropout and adequate dose.

Rates and predictors of psychotherapy receipt among U.S. veterans with comorbid posttraumatic stress disorder and substance use disorders

Introduction

Veterans with comorbid posttraumatic stress disorder (PTSD) and substance use disorder (SUD) have complex needs and often do not receive adequate mental health treatment. The purpose of this study was to examine rates and predictors of PTSD-only, SUD-only, or PTSD and SUD psychotherapy receipt among newly diagnosed Veterans with PTSD and SUD.

Design and setting

An administrative dataset including Veterans Health Administration (VHA) users.

Participants

The sample comprised 32,779 United States Veterans with a new PTSD and a new SUD diagnosis in fiscal year 2015.

Measurement

Multinomial logistic regression was used to identify predictors of receipt of any and adequate psychotherapy for PTSD, SUD, or PTSD and SUD across settings. Binomial logistic regression was used to identify predictors of PTSD psychotherapy among those who received any psychotherapy.

Findings

A total of 13,824 (42.17%) Veterans in this sample received any PTSD- or SUD-related therapy in the year following diagnosis. Low rates of veterans received an adequate dose of PTSD-related psychotherapy (6.58%), SUD-related psychotherapy (7.72%), or both PTSD and SUD-related psychotherapy (<1%) In adjusted models, older age, service-connected disability, and psychiatric comorbidities were associated with decreased odds of treatment. Specific types of SUDs, including alcohol, cocaine, and opioid use disorders, along with receipt of diagnosis in a PTSD or SUD clinic, were associated with increased odds of treatment.

Conclusions

Low rates of PTSD and SUD related psychotherapy highlight a need to better engage and retain Veterans with these disorders in care. Predictors of decreased treatment utilization, such as older age, service connection, and bipolar and major depressive disorders, may inform efforts by the VHA to further target and engage Veterans with indicated treatments.

Geographic Variation in Initiation of Evidence-based Psychotherapy Among Veterans With PTSD

Introduction

The United States Department of Veterans Affairs (VA) has invested in implementation of evidence-based psychotherapy (EBP) for post-traumatic stress disorder (PTSD) for over a decade, resulting in slow but steady uptake of these treatments nationally. However, no prior research has investigated the geographic variation in initiation of EBP. Our objectives were to determine whether there is geographic variation in the initiation of EBP for PTSD in the VA and to identify patient and clinic factors associated with EBP initiation.

Materials and Methods

We identified VA patients with PTSD who had not received EBP as of January 2016 (N = 946,667) using retrospective electronic medical records data and determined whether they initiated EBP by December 2017. We illustrated geographic variation in EBP initiation using national and regional maps. Using multivariate logistic regression, we determined patient, regional, and nearest VA facility predictors of initiating treatment. This study was approved by the Veterans Institutional Review Board of Northern New England.

Results

Nationally, 4.8% (n = 45,895) initiated EBP from 2016 to 2017, and there was geographic variation, ranging from none to almost 30% at the 3-digit ZIP code level. The strongest patient predictors of EBP initiation were the negative predictor of being older than 65 years (OR = 0.47; 95% CI, 0.45-0.49) and the positive predictor of reporting military-related sexual trauma (OR = 1.96; 95% CI, 1.90-2.03). The strongest regional predictors of EBP initiation were the negative predictor of living in the Northeast (OR = 0.89; 95% CI, 0.86-0.92) and the positive predictor of living in the Midwest (OR = 1.47; 95% CI, 1.44-1.51). The only nearest VA facility predictor of EBP initiation was the positive predictor of whether the facility was a VA Medical Center with a specialized PTSD clinic (OR = 1.23; 95% CI, 1.20-1.26).

Conclusion

Although less than 5% of VA patients with PTSD initiated EBP, there was regional variation. Patient factors, region of residence, and nearest VA facility characteristics were all associated with whether patients initiated EBP. Strengths of this study include the use of national longitudinal data, while weaknesses include the potential for misclassification of PTSD diagnoses as well as the potential for misidentification of EBP. Our work indicates geographic areas where access to EBP for PTSD may be poor and can help target work improving access. Future studies should also assess completion of EBP for PTSD and related symptomatic and functional outcomes across geographic areas.

National cross-sectional cohort study of the relationship between quality of mental healthcare and death by suicide

Background

Patient safety-based interventions aimed at lethal means restriction are effective at reducing death by suicide in inpatient mental health settings but are more challenging in the outpatient arena. As an alternative approach, we examined the association between quality of mental healthcare and suicide in a national healthcare system.

Methods

We calculated regional suicide rates for Department of Veterans Affairs (VA) Healthcare users from 2013 to 2017. To control for underlying variation in suicide risk in each of our 115 mental health referral regions (MHRRs), we calculated standardised rate ratios (SRRs) for VA users compared with the general population. We calculated quality metrics for outpatient mental healthcare in each MHRR using individual metrics as well as an Overall Quality Index. We assessed the correlation between quality metrics and suicide rates.

Results

Among the 115 VA MHRRs, the age-adjusted, sex-adjusted and race-adjusted annual suicide rates varied from 6.8 to 92.9 per 100 000 VA users, and the SRRs varied between 0.7 and 5.7. Mean regional-level adherence to each of our quality metrics ranged from a low of 7.7% for subspecialty care access to a high of 58.9% for care transitions. While there was substantial regional variation in quality, there was no correlation between an overall index of mental healthcare quality and SRR.

Conclusion

There was no correlation between overall quality of outpatient mental healthcare and rates of suicide in a national healthcare system. Although it is possible that quality was not high enough anywhere to prevent suicide at the population level or that we were unable to adequately measure quality, this examination of core mental health services in a well-resourced system raises doubts that a quality-based approach alone can lower population-level suicide rates.

Measurement Strategies for Evidence-Based Psychotherapy for Posttraumatic Stress Disorder Delivery: Trends and Associations with Patient-Reported Outcomes

We sought to develop a quality standard for the delivery of psychotherapy for posttraumatic stress disorder (PTSD) that is both consistent with the underlying evidence supporting psychotherapy as a treatment for PTSD and associated with the best levels of symptom improvement. We quantified psychotherapy receipt during the initial year of PTSD treatment in a 10-year national cohort of Department of Veterans Affairs (VA) users who completed patient-reported outcome measurement as part of routine practice. We added progressively stringent measurement requirements. The most stringent requirement was associated with superior outcomes. Quality of psychotherapy for PTSD in the VA improved over time.

Evaluation of an Implementation Intervention to Increase Reach of Evidence-Based Psychotherapies for PTSD in US Veterans Health Administration PTSD Clinics

To evaluate an implementation intervention to increase the uptake, referred to as reach, of two evidence-based psychotherapies (EBP) for posttraumatic stress disorder (PTSD) in Veterans Health Administration (VHA) PTSD specialty clinics. The implementation intervention was external facilitation guided by a toolkit that bundled strategies associated with high EBP reach in prior research. We used a prospective quasi-experimental design. The facilitator worked with local champions at two low-reach PTSD clinics. Each intervention PTSD clinic was matched to three control clinics. We compared the change in EBP reach from 6-months pre- to post-intervention using Difference-in-Difference (DID) effect estimation. To incorporate possible clustering effects and adjust for imbalanced covariates, we used mixed effects logistic regression to model the probability of EBP receipt. Analyses were conducted separately for PTSD and other mental health clinics. 29,446 veterans diagnosed with PTSD received psychotherapy in the two intervention and six control sites in the two 6-month evaluation periods. The proportion of therapy patients with PTSD receiving an EBP increased by 16.98 percentage points in the intervention PTSD clinics compared with .45 percentage points in the control PTSD clinics (DID = 16.53%; SE = 2.26%). The adjusted odd ratio of a patient receiving an EBP from pre to post intervention was almost three times larger in the intervention than in the control PTSD clinics (RoR 2.90; 95% CI 2.22-3.80). EBP reach was largely unchanged in other (not PTSD specialty) mental health clinics within the same medical centers. Toolkit-guided external facilitation is a promising intervention to improve uptake of EBPs in VHA. Toolkits that pre-specify targets for clinic change based on prior research may enhance the efficiency and effectiveness of external facilitation. Trial registration ISRCTN registry identifier: ISRCTN65119065. Available at https://www.isrctn.com/search?q=ISRCTN65119065 .

Clinical effectiveness study of a treatment to prepare for trauma-focused evidence-based psychotherapies at a veterans affairs specialty posttraumatic stress disorder clinic

Posttraumatic stress disorder (PTSD) clinics in the Department of Veterans Affairs (VA) often provide psychoeducational or skill-building groups to prepare veterans for trauma-focused PTSD treatments. However, there has been limited evaluation of the effectiveness of this phase-based approach for treatment engagement and symptom reduction. Participants included 575 veterans seeking treatment for PTSD whose treatment outcomes were assessed in a VA outpatient PTSD clinic staffed by mental health professionals and trainees. Participants completed self-report measures of baseline characteristics and psychiatric symptoms as part of routine PTSD clinic treatment. We tested the association of preparatory group treatment with engagement in and treatment response to subsequent trauma-focused psychotherapies, cognitive processing therapy (CPT) and prolonged exposure therapy (PE), which are designated by VA as evidence-based psychotherapies (EBP). Following participation in preparatory treatments, 94/391 (24%) of veterans engaged in a subsequent trauma-focused EBP (CPT or PE). Relative to patients who had previously completed a preparatory group, patients initiating a trauma-focused EBP without having first attended preparatory PTSD treatment had similar rates of trauma-focused EBP completion and better treatment response, as measured by decreases on the PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5; PCL-5), F(1, 3009) = 10.89, p = .001, and Patient Health Questionnaire 9 measure of depressive symptoms F(1, 3688) = 6.74, p = .010. Overall, veterans reported greater symptom reduction when engaging in trauma-focused EBP directly, without having previously attended a preparatory group. These data support veteran engagement in trauma-focused EBPs for PTSD without first being encouraged to complete psychoeducational or skill-building groups. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Advances in PTSD Treatment Delivery: Review of Findings and Clinical Considerations for the Use of Telehealth Interventions for PTSD

Purpose of review

Effective treatments for posttraumatic stress disorder (PTSD) remain underutilized and individuals with PTSD often have difficulty accessing care. Telehealth, particularly clinical videoconferencing (CVT), can overcome barriers to treatment and increase access to care for individuals with PTSD. The purpose of this review is to summarize the literature on the delivery of PTSD treatments through office-based and home-based videoconferencing, and outline areas for future research.

Recent findings

Evidence-based PTSD treatments delivered through office-based and home-based CVT have been studied in pilot studies, non-randomized trials, and randomized clinical trials. The studies have consistently demonstrated feasibility and acceptability of these modalities as well as significant reduction in PTSD symptoms, non-inferior outcomes, and comparable dropout rates when compared with traditional face-to-face office-based care. Finally, it has been shown that using CVT does not compromise the therapeutic process.

Summary

Office-based and home-based CVT can be used to deliver PTSD treatments while retaining efficacy and therapeutic process. The use of these modalities can increase the number of individuals that can access efficacious PTSD care.

Home-based delivery of variable length prolonged exposure therapy: A comparison of clinical efficacy between service modalities

OBJECTIVE

This study examined clinical and retention outcomes following variable length prolonged exposure (PE) for posttraumatic stress disorder (PTSD) delivered by one of three treatment modalities (i.e., home-based telehealth [HBT], office-based telehealth [OBT], or in-home-in-person [IHIP]).

METHOD

A randomized clinical trial design was used to compare variable-length PE delivered through HBT, OBT, or IHIP. Treatment duration (i.e., number of sessions) was determined by either achievement of a criterion score on the PTSD Checklist for Diagnostic and Statistical Manual-5 (DSM-5; PTSD Checklist for DSM-5) for two consecutive sessions or completion of 15 sessions. Participants received PE via HBT (n = 58), OBT (n = 59) or IHIP (n = 58). Data were collected between 2012 and 2018, and PTSD was diagnosed using the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5), administered at baseline, posttreatment, and 6 months following treatment completion. The primary clinical outcome was CAPS-5 PTSD severity. Secondary outcomes included self-reported PTSD and depression symptoms, as well as treatment dropout.

RESULTS

The clinical effectiveness of PE did not differ by treatment modality across any time point; however, there was a significant difference in treatment dropout. Veterans in the HBT (odds ratio [OR] = 2.67; 95% confidence interval [CI] = 1.10, 6.52; p = .031) and OBT (OR = 5.08; 95% CI = 2.10; 12.26; p < .001) conditions were significantly more likely than veterans in IHIP to drop out of treatment.

CONCLUSIONS

Providers can effectively deliver PE through telehealth and in-home, in-person modalities although the rate of treatment completion was higher in IHIP care.

Evidence-based psychotherapy trends among posttraumatic stress disorder patients in a national healthcare system, 2001-2014

BACKGROUND

Although evidence-based psychotherapies (EBPs) for posttraumatic stress disorder (PTSD) were implemented starting in 2005 in the veterans health administration (VHA), the largest national healthcare system in the U.S., the rate of initiation (uptake) and prevalence of these treatments in each calendar year have not been determined. We aimed to elucidate two metrics of EBP utilization, uptake and prevalence, following implementation.

METHODS

Cohort study of Iraq and Afghanistan veterans in VHA (N = 181,620) with a PTSD diagnosis and ≥1 psychotherapy-coded outpatient visit from 2001 to 2014. Using natural language processing techniques, annual and cumulative uptake and prevalence rates from 2001 to 2014 were calculated for each of the two EBPs for PTSD, cognitive processing therapy (CPT) and prolonged exposure (PE) therapy.

RESULTS

Annual uptake of CPT increased during most years, reaching a maximum of 11.1%. Annual uptake of PE showed little change until 2008 and then increased, reaching a maximum of 4.4%. The annual prevalence of CPT increased throughout the study, reaching a maximum of 14.6%. The annual prevalence of PE increased to a maximum of 5.0% in 2010, but then flattened and declined. Annual uptake of minimally adequate CPT increased a to maximum of 5% in 2014. Annual uptake of minimally adequate PE increased to a maximum of 1.2% in 2010. The cumulative prevalence of CPT was 19.9% and cumulative prevalence for PE was 7.5%.

CONCLUSIONS

Access to EBPs for PTSD modestly increased for Iraq and Afghanistan veterans after nationwide implementation efforts. Further expanding the reach to veterans is critical, given low rates of minimally adequate EBPs for PTSD.

When to Change the Treatment Plan: An Analysis of Diminishing Returns in VA Patients Undergoing Prolonged Exposure and Cognitive Processing Therapy

Evidence-based treatments for posttraumatic stress disorder (PTSD) often produce significant symptom reduction within eight sessions. However, some patients take longer to respond and a better understanding of predictors of later response can help guide treatment. In the current study, the cohort consisted of all VA patients with a PTSD diagnosis who received at least eight sessions of documented evidence-based treatment within a 6-month period in FY16-FY17 and had at least two PTSD symptom assessments. We examined the proportion of patients who achieved meaningful change (defined as at least 50% reduction in self-reported PTSD symptoms), both within the first eight sessions and subsequently. Fourteen percent of patients achieved meaningful change within eight sessions and 10% subsequently. Symptom change within the first eight sessions was highly predictive of subsequent change. Those who experienced at least 20% symptom reduction by session eight were twice as likely to subsequently achieve meaningful change as compared with all patients who continued treatment. Patients receiving service-connected disability compensation were less likely and White patients more likely to achieve meaningful change. Without some degree of symptom reduction by session eight, patients are unlikely to achieve meaningful change if treatment is not enhanced or changed.

Factors Associated With Receipt of Cognitive-Behavioral Therapy or Prolonged Exposure Therapy Among Individuals With PTSD

OBJECTIVE

The aim of this study was to systematically review variables associated with initiation of trauma-centered cognitive-behavioral therapy (TC-CBT) among individuals with posttraumatic stress disorder (PTSD).

METHODS

PubMed, PsycINFO, Web of Science, Published International Literature on Traumatic Stress (PILOTS), and Scopus were searched in a systematic manner up to 2018, and 26 relevant studies were recovered and analyzed.

RESULTS

The average weighted initiation rate was 6% in larger hospital systems with a high rate of trauma and 28% in outpatient mental health settings (range 4%-83%). Older age (odds ratio [OR]=1.56, 95% confidence interval [CI]=0.51-1.61), female gender (OR=1.18, 95% CI=1.08-1.27), black or other racial-ethnic minority group (OR=1.16, 95% CI=1.03-1.28), Veterans Affairs PTSD service connection status (OR=2.30, 95% CI=2.18-2.42), mental health referral (OR=2.28, 95% CI=1.05-3.50), greater staff exposure to TC-CBT (OR=2.30, 95% CI=2.09-2.52), adaptability of TC-CBT to staff workflow (OR=4.66, 95% CI=1.60-7.72), greater PTSD severity (OR=1.46, 95% CI=1.13-1.78), and comorbid depression (OR=1.21, 95% CI=1.14-1.29) increased the likelihood of TC-CBT initiation, whereas delayed treatment reduced the likelihood of TC-CBT initiation (OR=0.93, 95% CI=0.92-0.95). Qualitative studies showed that mental health beliefs (stigma and lack of readiness), provider organizational factors (low availability, privacy issues), and patient lack of time (logistics) were perceived as barriers to initiation by patients and providers.

CONCLUSIONS

TC-CBT initiation increased among patients who were older and female. Initiation was also higher among providers who had more exposure to TC-CBT in their work environment and when TC-CBT fit into their existing workflow.

Stakeholder Preferences on Transdiagnostic Psychosocial Treatment for Trauma-Exposed Veterans

While modular and transdiagnostic approaches may address implementation challenges, there remains limited investigation into the fit within large healthcare systems. The current study examines qualitative interviews from patients, clinicians and administrative stakeholders in the Veterans Administration about experiences with, and views of, the Unified Protocol (UP; Barlow et al. in The unified protocol for transdiagnostic treatment of emotional disorders: therapist guide, Oxford University Press, New York, 2011) to understand potential for implementation. Qualitative interviews were conducted based on an established implementation framework and speak to implementation of transdiagnostic treatment in veterans, including insight into barriers, facilitators, intervention characteristics, patient characteristics, and system level variables. The UP demonstrated promise for improving efficiency, satisfaction and personalizing mental healthcare.

Predictors of Treatment Adequacy During Evidence-Based Psychotherapy for PTSD

OBJECTIVE

The U.S. Department of Veterans Affairs (VA) has placed increased emphasis on the availability and use of evidence-based psychotherapies (EBPs) for posttraumatic stress disorder (PTSD). However, many individuals do not complete a full course of EBP. The current study aimed to quantify the percentage of veterans receiving adequate EBP in VA hospitals and identify factors related to treatment completion.

METHODS

A national sample of 16,559 VA patients who began cognitive processing therapy (CPT) or prolonged exposure (PE) during fiscal year 2015 was obtained via administrative data. Generalized estimating equations were used to evaluate individual-level predictors of treatment adequacy, defined as eight sessions within 14 weeks. Generalized linear models were used to examine facility-level factors.

RESULTS

A total of 5,142 (31.1%) veterans completed eight or more sessions of psychotherapy. Older age was associated with greater odds of completing eight or more sessions (odds ratio OR=1.02, 95% confidence interval [CI]=1.01, 1.02, p<0.001), and comorbid bipolar or psychotic disorders were associated with reduced odds of completion (OR=0.89, 95% CI=0.80, 0.99, p=0.03). The percentage of patients who completed eight or more sessions was higher at facilities with higher percentages of EBP use among all patients with PTSD (β=6.55, SE=1.97, p=0.001) and greater numbers of EBP-certified providers (β=0.004, SE=0.002, p=0.038) and lower at facilities with a higher percentage of patients receiving a PTSD Checklist (β=-1.16, SE=0.46, p=0.011).

CONCLUSIONS

A minority of VA patients with PTSD complete an adequate dose of EBPs for PTSD. Individual and facility-level factors related to treatment adequacy may point to opportunities for intervention.

Factors associated with completing evidence-based psychotherapy for PTSD among veterans in a national healthcare system

Little is known about predictors of initiation and completion of evidence-based psychotherapy (EBP) for posttraumatic stress disorder (PTSD), with most data coming from small cohort studies and post-hoc analyses of clinical trials. We examined patient and treatment factors associated with initiation and completion of EBP for PTSD in a large longitudinal cohort. We conducted a national, retrospective cohort study of all Iraq and Afghanistan War veterans who had a post-deployment PTSD diagnosis from 10/01-9/15 at a Veterans Health Administration facility and had at least one coded post-deployment psychotherapy visit. We examined utilization of PE and CPT (individual or group) during any 24-week period. We used ordered logistic, logistic, and Cox proportional hazards regressions to examine variables associated with EBP initiation, early termination, and completion, and time to completion. Over a 15-year period, of 265,566 veterans with PTSD, 22.8% initiated an EBP, and only 9.1% completed treatment. Completers did so about three years after their initial mental health visit. Factors positively associated with EBP completion included military sexual trauma, older age, race/ethnicity (i.e., African-American race for PE), combat, and multiple deployments. The VHA has become timelier in delivering EBP for PTSD, and several subgroups are more likely to complete EBP.

Which patients initiate cognitive processing therapy and prolonged exposure in department of veterans affairs PTSD clinics?

The United States Department of Veterans Affairs (VA) provides Cognitive Processing Therapy (CPT) and Prolonged Exposure therapy (PE) for PTSD at all of its facilities, but little is known about systematic differences between patients who do and do not initiate these treatments. VA administrative data were analyzed for 6,251 veterans receiving psychotherapy over one year in posttraumatic stress disorder (PTSD) specialty clinics at nine VA medical centers. CPT and PE were initiated by 2,173 (35%) patients. Veterans' probability of initiating either CPT or PE (considered together) was 29% lower (adjusted odds ratio = .61) if they had a psychiatric hospitalization within the same year, and 15% lower (AOR = .78) if they had service-connected disability for PTSD. Veterans' probability of starting CPT or PE was 19% lower (AOR = .74) if they were Hispanic or Latino, 10% lower (AOR = .84), if they were male rather than female, and 9% lower (AOR = .87) if they were divorced, separated or widowed rather than currently married. Probability of receiving CPT or PE was also lower if verans had more co-occurring psychiatric diagnoses (AOR per diagnosis = .88), were older (AOR per every five years = .95), or lived further away from the VA clinic (AOR per every ten miles = .98). Nonetheless, most patients initiating CPT or PE had two or more comorbidities and were service-connected for PTSD. Observed gender, age and ethnic differences in initiation of CPT and PE appear unrelated to clinical suitability and warrant further study.

Factors associated with the receipt of documented evidence-based psychotherapy for PTSD in VA

OBJECTIVES

The VA has mandated that evidence-based psychotherapies (EBPs) be offered to patients with PTSD, but only a small minority of the psychotherapy delivered to VA patients with PTSD is a documented EBP. It is unknown what factors are associated with receiving a documented EBP.

METHOD

Patients who received an EBP in FY2015 that was documented using a templated progress note (N = 21,808) were compared with patients who received psychotherapy for PTSD that was not documented using a template (N = 251,886).

RESULTS

Among psychotherapy recipients, VA patients with markers of clinical complexity such as service connection for PTSD, comorbid bipolar or psychotic disorder, longer duration of PTSD diagnosis, and a benzodiazepine prescription for PTSD had lower odds of receiving a documented EBP.

CONCLUSIONS

Recipients of documented EBPs differed from those who did not receive documented EBPs on several sociodemographic characteristics and indicators of treatment need. A limitation of our study is that some individuals in the group without EBP documentation may still have received an EBP, but did not receive EBP documentation in the electronic health record. Nevertheless, our results suggest that high-need or complex VA patients with PTSD may be less likely to receive documented EBPs.

Measuring Use of Evidence-Based Psychotherapy for PTSD in VA Residential Treatment Settings with Clinician Survey and Electronic Medical Record Templates

OBJECTIVE

Available studies on implementation of evidence-based psychotherapy (EBP) for patients attending Department of Veterans Affairs (VA) residential post-traumatic stress disorder (PTSD) programs rely on therapist self-report of EBP delivery. Patient-level data on receipt of EBP are needed both to corroborate therapist self-report and to understand patient factors that predict receipt of EBPs for PTSD.

MATERIALS AND METHODS

We identified 159 therapists from 38 VA residential PTSD programs who responded to a survey about EBP implementation during the 2015 fiscal year (FY15). Therapists self-reported their use of two EBPs, including prolonged exposure delivered in an individual format (PE-I) and cognitive processing therapy delivered in individual and group formats (CPT-I and CPT-G). Using electronic medical record (EMR) templates mandated for EBP documentation in FY15, we measured contemporaneous patient-level receipt of EBPs for PTSD. We assessed the degree of correlation between therapist self-reported EBP delivery and patient receipt of EBT as measured by EMR templates using polychoric correlation coefficients. We determined patient and therapist factors that predicted the receipt of EBPs with multivariable logistic regression, using random effects and robust standard error estimation, and controlling for site. The Veterans IRB of Northern New England provided a waiver of informed consent; as this was a retrospective review, no patients or therapists were contacted, and all data were stored, transmitted, and analyzed on secure VA servers. The VA Connecticut Health Care System Human Research Protection Program approved secondary use of therapist survey data for this project.

RESULTS

When EMR template use became mandated in FY15, the proportion of patients in residential PTSD programs who received at least one EBP session that was recorded with an EMR template increased dramatically from 8.8% to 33.9%. There was adequate correlation and between survey-based and EMR-based measures of EBP receipt, with polychoric correlation values of 0.77 for PE-I, 0.69 for CPT-I, and 0.82 for CPT-G. Multiple patient factors were positive (e.g., female gender) and negative (e.g., depressive disorders) predictors of receipt of EBPs, even after controlling for site. Among therapist factors, only EBP consultant or trainer status was a positive predictor of EBP provision and only therapist race was a negative predictor of EBT provision after controlling for site.

CONCLUSION

Following a FY15 mandate, EMR templates documenting EBP delivery were widely used by therapists working in VA residential PTSD programs. EBP receipt measured using EMR templates was consistent with therapist self-report of EBT delivery. There were several patient-level predictors of EBP receipt and therapist-level predictors of EBP delivery. However, therapists most likely to deliver EBPs were clustered at a limited number of sites.

A systematic digital approach to implementation and dissemination of eating disorders interventions to large populations identified through online screening: implications for post-traumatic stress

BACKGROUND

We describe an approach to implementation and dissemination that focuses on changing outcomes variables within a large, defined population and attempts to provide cost-effective opportunities and resources-which might include the provision of both digital and traditional interventions-to address individual needs and interests. We present a case example of how aspects of this model are being applied to increase reach, engagement and outcomes for individuals who complete a national eating disorders screen, and are likely to have an eating disorder but who are not in treatment. We then describe how this model can apply to post-traumatic stress (PTS) and conclude with a discussion of limitations and issues with the model.

METHODS

The National Eating Disorders Association (NEDA) provides online screening for eating disorders.

RESULTS

From February 2017 through March 2018, over 200,000 individuals completed the NEDA screen. Of these, 96% screened positive or at risk for an eating disorder, and most of those who screened positive for a clinical/subclinical eating disorder were not currently in treatment. Less than 10% engaged in self-help or guided self-help online digital program, or expressed interest in calling a helpline for referral to treatment.

CONCLUSIONS

A systematic digital approach to implementation and dissemination has the potential to increase the number of individuals who benefit from interventions in defined populations. Uptake rates need to be improved.