1
|
Tilhou AS, Burns M, Chachlani P, Chen Y, Dague L. How Does Telehealth Expansion Change Access to Healthcare for Patients With Different Types of Substance Use Disorders? SUBSTANCE USE & ADDICTION JOURNAL 2024; 45:473-485. [PMID: 38494728 PMCID: PMC11179974 DOI: 10.1177/29767342241236028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
BACKGROUND Patients with substance use disorders (SUDs) exhibit low healthcare utilization despite high medical need. Telehealth could boost utilization, but variation in uptake across SUDs is unknown. METHODS Using Wisconsin Medicaid enrollment and claims data from December 1, 2018, to December 31, 2020, we conducted a cohort study of telemedicine uptake in the all-ambulatory and the primary care setting during telehealth expansion following the COVID-19 public health emergency (PHE) onset (March 14, 2020). The sample included continuously enrolled (19 months), nonpregnant, nondisabled adults aged 19 to 64 years with opioid (OUD), alcohol (AUD), stimulant (StimUD), or cannabis (CannUD) use disorder or polysubstance use (PSU). Outcomes: total and telehealth visits in the week, and fraction of visits in the week completed by telehealth. Linear and fractional regression estimated changes in in-person and telemedicine utilization. We used regression coefficients to calculate the change in telemedicine utilization, the proportion of in-person decline offset by telemedicine uptake ("offset"), and the share of visits completed by telemedicine ("share"). RESULTS The cohort (n = 16 756) included individuals with OUD (34.8%), AUD (30.1%), StimUD (9.5%), CannUD (9.5%), and PSU (19.7%). Total and telemedicine utilization varied by group post-PHE. All-ambulatory: total visits dropped for all, then rose above baseline for OUD, PSU, and AUD. Telehealth expansion was associated with visit increases: OUD: 0.489, P < .001; PSU: 0.341, P < .001; StimUD: 0.160, P < .001; AUD: 0.132, P < .001; CannUD: 0.115, P < .001. StimUD exhibited the greatest telemedicine share. Primary care: total visits dropped for all, then recovered for OUD and CannUD. Telemedicine visits rose most for PSU: 0.021, P < .001; OUD: 0.019, P < .001; CannUD: 0.011, P < .001; AUD: 0.010, P < .001; StimUD: 0.009, P < .001. PSU and OUD exhibited the greatest telemedicine share, while StimUD exhibited the lowest. Telemedicine fully offset declines for OUD only. CONCLUSIONS Telehealth expansion helped maintain utilization for OUD and PSU; StimUD and CannUD showed less responsiveness. Telehealth expansion could widen gaps in utilization by SUD type.
Collapse
Affiliation(s)
- Alyssa Shell Tilhou
- Department of Family Medicine, Boston University Medical Center, Boston, MA, USA
| | - Marguerite Burns
- Department of Population Health Sciences, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, USA
| | - Preeti Chachlani
- Institute for Research on Poverty, University of Wisconsin-Madison, Madison, WI, USA
| | - Ying Chen
- Department of Risk and Insurance, Wisconsin School of Business, University of Wisconsin-Madison, Madison, WI, USA
| | - Laura Dague
- The Bush School of Government and Public Service, Texas A&M University, College Station, TX, USA
| |
Collapse
|
2
|
Meredith LS, Wong EC, Marx BP, Han B, Korn AR, Tobin JN, Cassells A, Williamson S, Franco M, Overa CC, Holder T, Lin TJ, Sloan DM. Design of a hybrid implementation effectiveness cluster randomized controlled trial of delivering written exposure therapy for PTSD in underserved primary care settings. Contemp Clin Trials 2024; 138:107435. [PMID: 38211725 PMCID: PMC11146292 DOI: 10.1016/j.cct.2024.107435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 12/28/2023] [Accepted: 01/07/2024] [Indexed: 01/13/2024]
Abstract
INTRODUCTION Posttraumatic stress disorder (PTSD) results in substantial costs to society. Prevalence of PTSD among adults is high, especially among those presenting to primary care settings. Evidence-based psychotherapies (EBPs) for PTSD are available but dissemination and implementation within primary care settings is challenging. Building Experience for Treating Trauma and Enhancing Resilience (BETTER) examines the effectiveness of integrating Written Exposure Therapy (WET) within primary care collaborative care management (CoCM). WET is a brief exposure-based treatment that has the potential to address many challenges of delivering PTSD EBPs within primary care settings. METHODS The study is a hybrid implementation effectiveness cluster-randomized controlled trial in which 12 Federally Qualified Health Centers (FQHCs) will be randomized to either CoCM plus WET (CoCM+WET) or CoCM only with 60 patients within each FQHC. The primary aim is to evaluate the effectiveness of CoCM+WET to improve PTSD and depression symptom severity. Secondary treatment outcomes are mental and physical health functioning. The second study aim is to examine implementation of WET within FQHCs using FQHC process data and staff interviews pre- and post-intervention. Exploratory aims are to examine potential moderators and mediators of the intervention. Assessments occur at baseline, and 3- and 12-month follow-up. CONCLUSION The study has the potential to impact practice and improve clinical and public health outcomes. By establishing the effectiveness and feasibility of delivering a brief trauma-focused EBP embedded within CoCM in primary care, the study aims to improve PTSD outcomes for underserved patients. TRIAL REGISTRATION (Clinicaltrials.govNCT05330442).
Collapse
Affiliation(s)
- Lisa S Meredith
- RAND Corporation, Santa Monica, CA, United States of America; VA HSR&D Center for Healthcare Innovation, Implementation & Policy, Sepulveda, CA, United States of America.
| | - Eunice C Wong
- RAND Corporation, Santa Monica, CA, United States of America
| | - Brian P Marx
- National Center for PTSD, Behavioral Science Division at VA Boston Healthcare, Boston, MA, United States of America; Boston University Chobanian & Avedisian School of Medicine, Boston, MA, United States of America
| | - Bing Han
- Kaiser Permanente Southern California, Department of Research & Evaluation, Pasadena, CA, United States of America
| | - Ariella R Korn
- RAND Corporation, Boston, MA 02116, United States of America
| | - Jonathan N Tobin
- Clinical Directors Network (CDN), New York, NY, United States of America; The Rockefeller University Center for Clinical and Translational Science, New York, NY, United States of America
| | - Andrea Cassells
- Clinical Directors Network (CDN), New York, NY, United States of America
| | | | - Meghan Franco
- Pardee RAND Graduate School, Santa Monica, CA, United States of America
| | - Cleo Clarize Overa
- Clinical Directors Network (CDN), New York, NY, United States of America
| | - Tameir Holder
- Clinical Directors Network (CDN), New York, NY, United States of America
| | - T J Lin
- Clinical Directors Network (CDN), New York, NY, United States of America
| | - Denise M Sloan
- National Center for PTSD, Behavioral Science Division at VA Boston Healthcare, Boston, MA, United States of America; Boston University Chobanian & Avedisian School of Medicine, Boston, MA, United States of America
| |
Collapse
|
3
|
Valentine SE, Fuchs C, Olesinski EA, Sarkisova N, Godfrey LB, Elwy AR. Formative evaluation prior to implementation of a brief treatment for posttraumatic stress disorder in primary care. Implement Sci Commun 2023; 4:48. [PMID: 37143109 PMCID: PMC10161536 DOI: 10.1186/s43058-023-00426-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 04/04/2023] [Indexed: 05/06/2023] Open
Abstract
BACKGROUND Successful implementation of evidence-based treatments (EBT) for posttraumatic stress disorder (PTSD) in primary care may address treatment access and quality gaps by providing care in novel and less stigmatized settings. Yet, PTSD treatments are largely unavailable in safety net primary care. We aimed to collect clinician stakeholder data on organizational, attitudinal, and contextual factors relevant to EBT implementation. METHODS Our developmental formative evaluation was guided by the Consolidated Framework for Implementation Research (CFIR), including (a) surveys assessing implementation climate and attitudes towards EBTs and behavioral health integration and (b) semi-structured interviews to identify barriers and facilitators to implementation and need for augmentation. Participants were hospital employees (N = 22), including primary care physicians (n = 6), integrated behavioral health clinicians (n = 8), community wellness advocates (n = 3), and clinic leadership (n = 5). We report frequency and descriptives of survey data and findings from directed content analysis of interviews. We used a concurrent mixed-methods approach, integrating survey and interview data collected simultaneously using a joint display approach. A primary care community advisory board (CAB) helped to refine interview guides and interpret findings. RESULTS Stakeholders described implementation determinants of the EBT related to the CFIR domains of intervention characteristics (relative advantage, adaptability), outer setting (patient needs and resources), inner setting (networks and communication, relative priority, leadership engagement, available resources), and individuals involved (knowledge and beliefs, cultural considerations). Stakeholders described strong attitudinal support (relative advantage), yet therapist time and capacity restraints are major PTSD treatment implementation barriers (available resources). Changes in hospital management were perceived as potentially allowing for greater access to behavioral health services, including EBTs. Patient engagement barriers such as stigma, mistrust, and care preferences were also noted (patient needs and resources). Recommendations included tailoring the intervention to meet existing workflows (adaptability), system alignment efforts focused on improving detection, referral, and care coordination processes (networks and communication), protecting clinician time for training and consultation (leadership engagement), and embedding a researcher in the practice (available resources). CONCLUSIONS Our evaluation identified key CFIR determinants of implementation of PTSD treatments in safety net integrated primary care settings. Our project also demonstrates that successful implementation necessitates strong stakeholder engagement.
Collapse
Affiliation(s)
- Sarah E Valentine
- Department of Psychiatry, Boston Medical Center, Boston, MA, USA.
- Department of Psychiatry, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA.
| | - Cara Fuchs
- Department of Psychiatry, Boston Medical Center, Boston, MA, USA
- Department of Psychiatry, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | | | | | - Laura B Godfrey
- Department of Psychiatry, Boston Medical Center, Boston, MA, USA
| | - A Rani Elwy
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, RI, USA.
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, USA.
| |
Collapse
|
4
|
Ng LC, Miller AN, Bowers G, Cheng Y, Brigham R, Him Tai M, Smith AM, Mueser KT, Fortuna LR, Coles M. A pragmatic feasibility trial of the Primary Care Intervention for PTSD: A health service delivery model to reduce health disparities for low-income and BIPOC youth. Behav Res Ther 2023; 165:104310. [PMID: 37040669 DOI: 10.1016/j.brat.2023.104310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 02/27/2023] [Accepted: 03/29/2023] [Indexed: 04/09/2023]
Abstract
OBJECTIVE This study is a non-randomized pragmatic trial to assess the feasibility and acceptability of the Primary Care Intervention for Posttraumatic stress disorder (PCIP) (Srivastava et al., 2021), an Integrated Behavioral Health Care treatment for PTSD in adolescents. METHOD Following routine clinic procedures, youth who were suspected of having trauma-related mental health symptoms were referred by their primary care providers to integrated care social workers for evaluation. The integrated care social workers referred the first 23 youth whom they suspected of having PTSD to the research study. Twenty youth consented to the study and 19 completed the pre-assessment (17 female; mean age = 19.32, SD = 2.11; range 14-22 years). More than 40% identified as Black and a third as Hispanic/Latinx. PCIP mechanisms and clinical outcomes were assessed pre- and post-treatment, and at one-month follow-up. Participants and therapists completed post-treatment qualitative interviews to assess feasibility and acceptability, and treatment sessions were audio recorded to assess fidelity. RESULTS Findings suggest high acceptability, satisfaction, and feasibility of the PCIP delivered in "real-life" safety net pediatric primary care. Integrated care social workers had high treatment fidelity. Despite the small sample size, there was significant improvement in symptom scores of anxiety (g = 0.68, p = 0.02) and substance use (g = 0.36, p = 0.04) from pre to post, and depression symptoms (g = 0.38, p = 0.04) from pre to follow-up. Qualitative data from patients who completed exit interviews and integrated social workers indicated high satisfaction with the treatment, with some participants reporting that the integrated intervention was more acceptable and less stigmatizing than seeking mental health care outside of primary care. CONCLUSIONS The PCIP may improve treatment engagement and access for vulnerable youth. Promising findings of high acceptability, feasibility, and initial clinical effectiveness suggest that PCIP warrants larger-scale study as part of routine care in pediatric integrated care.
Collapse
|
5
|
Murray-Krezan C, Dopp A, Tarhuni L, Carmody MD, Becker K, Anderson J, Komaromy M, Meredith LS, Watkins KE, Wagner K, Page K. Screening for opioid use disorder and co-occurring depression and post-traumatic stress disorder in primary care in New Mexico. Addict Sci Clin Pract 2023; 18:6. [PMID: 36707910 PMCID: PMC9881516 DOI: 10.1186/s13722-023-00362-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 01/18/2023] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Identifying patients in primary care services with opioid use disorder and co-occurring mental health disorders is critical to providing treatment. Objectives of this study were to (1) assess the feasibility of recruiting people to screen in-person for opioid use disorder and co-occurring mental health disorders (depression and/or post-traumatic stress disorder) in primary care clinic waiting rooms in preparation for a randomized controlled trial, and (2) compare results of detecting these disorders by universal in-person screening compared to electronic health record (EHR) diagnoses. METHODS This cross-sectional feasibility and pilot study recruited participants from four primary care clinics, two rural and two urban, from three health care organizations in New Mexico. Inclusion criteria were adults (≥ 18 years), attending one of the four clinics as a patient, and who spoke English or Spanish. Exclusion criteria were people attending the clinic for a non-primary care visit (e.g., dental, prescription pick up, social support). The main outcomes and measures were (1) recruitment feasibility which was assessed by frequencies and proportions of people approached and consented for in-person screening, and (2) relative differences of detecting opioid use disorder and co-occurring mental health disorders in waiting rooms relative to aggregate EHR data from each clinic, measured by prevalence and prevalence ratios. RESULTS Over two-weeks, 1478 potential participants were approached and 1145 were consented and screened (77.5% of patients approached). Probable opioid use disorder and co-occurring mental health disorders were identified in 2.4% of those screened compared to 0.8% in EHR. Similarly, universal screening relative to EHR identified higher proportions of probable opioid use disorder (4.5% vs. 3.4%), depression (17.5% vs. 12.7%) and post-traumatic stress disorder (19.0% vs. 3.6%). CONCLUSIONS Universal screening for opioid use disorder, depression, and post-traumatic stress disorder was feasible, and identified three times as many patients with these co-occurring disorders compared to EHR. Higher proportions of each condition were also identified, especially post-traumatic stress disorder. Results support that there are likely gaps in identification of these disorders in primary care services and demonstrate the need to better address the persistent public health problem of these co-occurring disorders.
Collapse
Affiliation(s)
- Cristina Murray-Krezan
- Department of Internal Medicine, Division of Epidemiology, Biostatistics and Preventive Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM, 87131, USA.
- Department of Medicine, Division of General Internal Medicine, School of Medicine, University of Pittsburgh, 200 Meyran Ave, Suite 300, Pittsburgh, PA, 15213, USA.
| | - Alex Dopp
- Health Care Division, RAND Corporation, Santa Monica, CA, 90417-2038, USA
| | - Lina Tarhuni
- Department of Internal Medicine, Division of Epidemiology, Biostatistics and Preventive Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM, 87131, USA
| | - Mary D Carmody
- Department of Internal Medicine, Division of Epidemiology, Biostatistics and Preventive Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM, 87131, USA
| | - Kirsten Becker
- Health Care Division, RAND Corporation, Santa Monica, CA, 90417-2038, USA
| | - Jessica Anderson
- Department of Internal Medicine, Division of Epidemiology, Biostatistics and Preventive Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM, 87131, USA
| | - Miriam Komaromy
- Grayken Center for Addiction, Boston Medical Center, Boston University, Boston, MA, 02118, USA
| | - Lisa S Meredith
- Health Care Division, RAND Corporation, Santa Monica, CA, 90417-2038, USA
| | | | - Katherine Wagner
- Department of Internal Medicine, Division of Epidemiology, Biostatistics and Preventive Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM, 87131, USA
| | - Kimberly Page
- Department of Internal Medicine, Division of Epidemiology, Biostatistics and Preventive Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM, 87131, USA
| |
Collapse
|
6
|
Ranney RM, Gloria R, Metzler TJ, Huggins J, Neylan TC, Maguen S. Brief behavioral treatment for insomnia decreases trauma-related nightmare frequency in veterans. J Clin Sleep Med 2022; 18:1831-1839. [PMID: 35393934 DOI: 10.5664/jcsm.10002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES Trauma-related nightmares are highly prevalent among veterans and are associated with higher severity insomnia and PTSD. Cognitive behavioral therapy for insomnia (CBT-I, typically 6-8 sessions) has been shown to reduce trauma-related nightmares. Brief behavioral treatment for insomnia (BBTI, 4 sessions) has been found to be comparable to CBT-I in decreasing insomnia severity; however, the effects of BBTI on nightmares have not been investigated. The current study tested the effects of BBTI on both trauma-related nightmares and non-trauma-related bad dreams using an active control group, progressive muscle relaxation therapy (PMRT). Additionally, we tested whether baseline trauma-related nightmare frequency and baseline non-trauma-related bad dream frequency moderated changes in insomnia severity. METHODS Participants were 91 military veterans with insomnia disorder randomized to BBTI or PMRT. Participants reported insomnia severity on the Insomnia Severity Index and reported trauma-related nightmare frequency and non-trauma-related bad dream frequency on the Pittsburgh Sleep Quality Index--PTSD Addendum. RESULTS We found that BBTI significantly reduced trauma-related nightmares from baseline to post-treatment while PMRT did not. However, reductions in trauma-related nightmares were not maintained at six month follow up. Neither BBTI nor PMRT reduced non-trauma-related bad dreams from baseline to post-treatment. We also found that neither baseline trauma-related nightmare frequency nor baseline non-trauma-related bad dream frequency moderated changes in insomnia symptom severity. CONCLUSIONS Findings from the current study suggest that BBTI may help to reduce trauma-related nightmares. Further research is needed to better understand potential mechanisms underlying how improved sleep may reduce trauma-related nightmares. CLINICAL TRIAL REGISTRATION Registry: ClinicalTrials.gov; Name: Brief Behavioral Insomnia Treatment Study (BBTI); Identifier: NCT02571452; URL: https://clinicaltrials.gov/ct2/show/NCT02571452.
Collapse
Affiliation(s)
- Rachel M Ranney
- Veterans Affairs San Francisco Health Care System, San Francisco, CA.,Department of Psychiatry and Behavioral Sciences, University of California, San Francisco School of Medicine, San Francisco, CA.,Sierra Pacific Mental Illness Research Education, and Clinical Center, San Francisco, CA
| | - Rebecca Gloria
- Veterans Affairs San Francisco Health Care System, San Francisco, CA
| | - Thomas J Metzler
- Veterans Affairs San Francisco Health Care System, San Francisco, CA.,Department of Psychiatry and Behavioral Sciences, University of California, San Francisco School of Medicine, San Francisco, CA.,Sierra Pacific Mental Illness Research Education, and Clinical Center, San Francisco, CA
| | - Joy Huggins
- Veterans Affairs San Francisco Health Care System, San Francisco, CA
| | - Thomas C Neylan
- Veterans Affairs San Francisco Health Care System, San Francisco, CA.,Department of Psychiatry and Behavioral Sciences, University of California, San Francisco School of Medicine, San Francisco, CA.,Sierra Pacific Mental Illness Research Education, and Clinical Center, San Francisco, CA
| | - Shira Maguen
- Veterans Affairs San Francisco Health Care System, San Francisco, CA.,Department of Psychiatry and Behavioral Sciences, University of California, San Francisco School of Medicine, San Francisco, CA.,Sierra Pacific Mental Illness Research Education, and Clinical Center, San Francisco, CA
| |
Collapse
|
7
|
Monaghan K, Cos T. Integrating physical and mental healthcare: Facilitators and barriers to success. MEDICINE ACCESS @ POINT OF CARE 2021; 5:23992026211050615. [PMID: 36204502 PMCID: PMC9413608 DOI: 10.1177/23992026211050615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 09/16/2021] [Indexed: 11/30/2022] Open
Abstract
Introduction: Effective and appropriate provision of mental healthcare has long been a
struggle globally, resulting in significant disparity between prevalence of
mental illness and access to care. One attempt to address such disparity was
the Patient Protection and Affordable Care Act (PPACA), 2010, mandate in the
United States to integrate physical and mental healthcare in Federally
Qualified Health Centers (FQHCs). The notion of integration is attractive,
as it has demonstrated the potential to improve both access to mental
healthcare and healthcare outcomes. However, while the PPACA mandate set
this requirement for FQHCs, no clear process as to how these centers should
achieve successful integration was identified. Methods: This research employed case study methods to examine the implementation of
this policy in two FQHCs in New England. Data were obtained from in-depth
interviews with leadership, management, and frontline staff at two case
study sites. Results: Study findings include multiple definitions of and approaches for integrating
physical and mental healthcare, mental healthcare being subsumed into,
rather than integrated with, the medical model and multiple facilitators of
and barriers to integration. Conclusion: This study asked questions about what integration means, how it occurs, and
what factors facilitate or pose barriers to integration. Integration is
facilitated by co-location of providers within the same department, a warm
hand-off, collaborative collegial relationships, strong leadership support,
and a shared electronic health record. However, interdisciplinary conflict,
power differentials, job insecurity, communication challenges, and the
subsumption of mental health into the medical model pose barriers to
successful integration.
Collapse
Affiliation(s)
| | - Travis Cos
- School of Arts and Sciences, La Salle University, Philadelphia, PA, USA
| |
Collapse
|
8
|
Trauma Screening Is More Common When Primary Care Patients Trust Providers. J Nurse Pract 2021. [DOI: 10.1016/j.nurpra.2021.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
|
9
|
Association of symptom severity, pain and other behavioral and medical comorbidities with diverse measures of functioning among adults with post-traumatic stress disorder. J Psychiatr Res 2021; 134:113-120. [PMID: 33383494 DOI: 10.1016/j.jpsychires.2020.12.063] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 12/17/2020] [Accepted: 12/21/2020] [Indexed: 12/23/2022]
Abstract
Post-traumatic stress disorder (PTSD) is an often disabling mental disorder whose management typically focuses on reducing PTSD symptoms. Chronic pain and other comorbidities that commonly accompany PTSD symptoms may also be independently associated with disability. Using data from the 2012-2013 National Epidemiologic Survey on Alcohol and Related Conditions, we examined the independent association of PTSD symptom severity, pain interference, non-PTSD psychiatric and substance use disorders (SUD), and medical illnesses with each of four domains of function: mental health-related quality of life and physical functioning assessed with the Mental Health Composite Score (MCS) and Physical Function Score (PFS) of the Short Form-12; perceived social support from the Interpersonal Support and Evaluation List-12 (ISEL-12); and self-reported past year employment. Among 1779 individuals representing 11 million U.S. adults who met the Diagnostic and Statistical Manual-5 (DSM-5) criteria for Past Year PTSD, the MCS (41.2; SD 12.5), PFS (44.8; SD 13.2) and ISEL-12 (33.6; SD 7.2) indicated substantial disability when compared to population norms, and only 63.6% were employed. Multiple regression showed the MCS had a modest negative association with PTSD symptoms, pain interference, psychiatric multimorbidity and medical comorbidity although not with SUD. PFS and employment had significant negative associations with pain interference and medical comorbidity. ISEL-12 had a weak negative association with PTSD symptoms and non-PTSD psychiatric comorbidity. Common comorbidities thus significantly influence disability associated with PTSD, often more strongly than PTSD symptoms. PTSD treatment may require integrative multimorbidity management beyond a focus on PTSD symptoms.
Collapse
|
10
|
Implementation of Prolonged Exposure for PTSD: Pilot Program of PE for Primary Care in VA. COGNITIVE AND BEHAVIORAL PRACTICE 2020. [DOI: 10.1016/j.cbpra.2020.09.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
|
11
|
Gehringer R, Freytag A, Krause M, Schlattmann P, Schmidt K, Schulz S, Zezulka SJ, Wolf F, Grininger J, Berger M, Vollmar HC, Gensichen J. Psychological interventions for posttraumatic stress disorder involving primary care physicians: systematic review and Meta-analysis of randomized controlled trials. BMC FAMILY PRACTICE 2020; 21:176. [PMID: 32847509 PMCID: PMC7450546 DOI: 10.1186/s12875-020-01244-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Accepted: 08/11/2020] [Indexed: 11/21/2022]
Abstract
Background Evidence-based psychological interventions for posttraumatic stress disorder (PTSD) are available in specialized settings, but adequate care in primary care is often lacking. The aim of this systematic review was to determine the effectiveness of psychological interventions for PTSD involving primary care physicians (PCPs) and to characterize these interventions as well as their providers. Method A systematic review and meta-analyses of randomized controlled trials (RCTs). Primary outcome were symptoms of PTSD. Results Four RCTs with a total of 774 patients suffering from PTSD symptoms were included, all applying cognitive behavioural based interventions. Three studies with psychological interventions being conducted by case managers were pooled in a meta-analysis. Interventions were not effective in the short term (0–6 months; SMD, − 0.1; 95% CI, − 0.24-0.04; I2 = 0%). Only two studies contributed to the meta-analysis for long term (12–18 months) outcomes yielding a small effect (SMD, − 0.23; 95% CI, − 0.38- -0.08; I2 = 0%). Conclusions Psychological interventions for PTSD in primary care settings may be effective in the long term but number and quality of included studies was limited so the results should be interpreted with caution.
Collapse
Affiliation(s)
- Rebekka Gehringer
- Institute of General Practice and Family Medicine, Jena University Hospital, Friedrich-Schiller-University, Bachstr. 18, 07743, Jena, Germany.
| | - Antje Freytag
- Institute of General Practice and Family Medicine, Jena University Hospital, Friedrich-Schiller-University, Bachstr. 18, 07743, Jena, Germany
| | - Markus Krause
- Institute of General Practice and Family Medicine, Jena University Hospital, Friedrich-Schiller-University, Bachstr. 18, 07743, Jena, Germany
| | - Peter Schlattmann
- Institute of Medical Statistics, Computer Sciences and Documentation, Jena University Hospital, Friedrich-Schiller-University, Jena, Germany
| | - Konrad Schmidt
- Institute of General Practice and Family Medicine, Jena University Hospital, Friedrich-Schiller-University, Bachstr. 18, 07743, Jena, Germany
| | - Sven Schulz
- Institute of General Practice and Family Medicine, Jena University Hospital, Friedrich-Schiller-University, Bachstr. 18, 07743, Jena, Germany
| | - Sophie Jana Zezulka
- Institute of General Practice and Family Medicine, Jena University Hospital, Friedrich-Schiller-University, Bachstr. 18, 07743, Jena, Germany
| | - Florian Wolf
- Institute of General Practice and Family Medicine, Jena University Hospital, Friedrich-Schiller-University, Bachstr. 18, 07743, Jena, Germany
| | - Jonas Grininger
- Institute of General Practice/Family Medicine, University Hospital of LMU Munich, Munich, Germany
| | - Mathias Berger
- Department of Psychiatry, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Horst Christian Vollmar
- Institute of General Practice and Family Medicine, Jena University Hospital, Friedrich-Schiller-University, Bachstr. 18, 07743, Jena, Germany.,Department of Family Medicine, Ruhr-University of Bochum, Bochum, Germany
| | - Jochen Gensichen
- Institute of General Practice/Family Medicine, University Hospital of LMU Munich, Munich, Germany
| |
Collapse
|
12
|
Hoeft TJ, Stephens KA, Vannoy SD, Unützer J, Kaysen D. Interventions to treat posttraumatic stress disorder in partnership with primary care: A review of feasibility and large randomized controlled studies. Gen Hosp Psychiatry 2019; 60:65-75. [PMID: 31349204 PMCID: PMC7592634 DOI: 10.1016/j.genhosppsych.2019.05.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Revised: 05/24/2019] [Accepted: 05/27/2019] [Indexed: 01/18/2023]
Abstract
OBJECTIVE Evidence-based therapies for posttraumatic stress disorder are underutilized and at times unavailable in specialty settings. We reviewed the literature on interventions to treat PTSD within primary care to make recommendations on their effectiveness as treatment modalities or ways to improve engagement in specialty care. METHOD We searched PubMed, PsychInfo, CINHAL, and Cochrane Reviews databases using search terms related to PTSD and primary care. We excluded clinical guidelines and studies of screening only or subthreshold PTSD. RESULTS 524 articles were identified. Twenty-one papers on 15 interventions met review criteria. Seven interventions focus on individual therapies studied via small feasibility studies to prepare for full-scale intervention research. Eight describe treatment programs in primary care based on collaborative care that included medication management, tracking outcomes, referral services, and for some psychotherapy (versus psychotherapy referral). Ten interventions were feasibility studies which precludes meaningful comparison of effect sizes. Of the four RCTs of treatment programs, only two including some psychotherapy found improvements in PTSD symptoms. CONCLUSION More research is needed to adapt treatment for PTSD to primary care. Collaborative care may be a promising framework for improving the reach of PTSD treatments when psychotherapy is offered within the collaborative care team.
Collapse
Affiliation(s)
- T J Hoeft
- University of Washington, Department of Psychiatry and Behavioral Sciences, United States of America.
| | - K A Stephens
- University of Washington, Department of Psychiatry and Behavioral Sciences, United States of America
| | - S D Vannoy
- University of Massachusetts Boston, Department of Counseling and School Psychology, United States of America
| | - J Unützer
- University of Washington, Department of Psychiatry and Behavioral Sciences, United States of America
| | - D Kaysen
- University of Washington, Department of Psychiatry and Behavioral Sciences, United States of America
| |
Collapse
|
13
|
Possemato K, Kuhn E, Johnson EM, Hoffman JE, Brooks E. Development and refinement of a clinician intervention to facilitate primary care patient use of the PTSD Coach app. Transl Behav Med 2017; 7:116-126. [PMID: 27234150 DOI: 10.1007/s13142-016-0393-9] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Posttraumatic stress disorder (PTSD) is common and undertreated among Veterans Affairs (VA) primary care patients. A brief primary care intervention combining clinician support with a self-management mobile app (Clinician-Supported PTSD Coach, CS-PTSD Coach) may improve patient outcomes. This study developed and refined an intervention to provide clinician support to facilitate use of the PTSD Coach app and gathered VA provider and patient qualitative and quantitative feedback on CS-PTSD Coach to investigate preliminary acceptability and implementation barriers/facilitators. VA primary care providers and mental health leadership (N = 9) completed a survey and interview regarding implementation barriers and facilitators structured according to the Consolidated Framework for Implementation Research (CFIR). Clinicians who delivered CS-PTSD Coach (N = 3) and patients (N = 9) who received it provided feedback on the intervention and implementation process. CS-PTSD Coach has high provider and patient acceptability. Important implementation factors included that CS-PTSD Coach be compatible with the clinics' current practices, have low complexity to implement, be perceived to address patient needs, and have strong support from leadership. Diverse factors related to CS-PTSD Coach delivery facilitate implementation, provide an opportunity to problem-solve barriers, and improve integration of the intervention into primary care.
Collapse
Affiliation(s)
- Kyle Possemato
- Center for Integrated Healthcare, Syracuse VA Medical Center, Syracuse, NY, 13210, USA
| | - Eric Kuhn
- National Center for PTSD (NCPTSD), Dissemination and Training Division, Department of Veterans Affairs Palo Alto Health Care System, Livermore, CA, 94550, USA
| | - Emily M Johnson
- Center for Integrated Healthcare, Syracuse VA Medical Center, Syracuse, NY, 13210, USA.
| | - Julia E Hoffman
- National Center for PTSD (NCPTSD), Dissemination and Training Division, Department of Veterans Affairs Palo Alto Health Care System, Livermore, CA, 94550, USA
| | - Emily Brooks
- Center for Integrated Healthcare, Syracuse VA Medical Center, Syracuse, NY, 13210, USA
| |
Collapse
|
14
|
Johnson EM, Possemato K, Barrie KA, Webster B, Wade M, Stecker T. Veterans’ Thoughts About PTSD Treatment and Subsequent Treatment Utilization. Int J Cogn Ther 2017. [DOI: 10.1521/ijct_2017_10_02] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Emily M. Johnson
- Center for Integrated Healthcare, Syracuse VA Medical Center, Syracuse, New York
| | - Kyle Possemato
- Center for Integrated Healthcare, Syracuse VA Medical Center, Syracuse, New York
| | - Kimberly A. Barrie
- Center for Integrated Healthcare, Syracuse VA Medical Center, Syracuse, New York
| | - Brad Webster
- Center for Integrated Healthcare, Syracuse VA Medical Center, Syracuse, New York
| | - Michael Wade
- Center for Integrated Healthcare, Syracuse VA Medical Center, Syracuse, New York
| | - Tracy Stecker
- Medical University of South Carolina, and Charleston Health Equity and Rural Outreach Innovation Center, Ralph H. Johnson VA Medical Center, Charleston, South Carolina
| |
Collapse
|
15
|
Meredith LS, Eisenman DP, Han B, Green BL, Kaltman S, Wong EC, Sorbero M, Vaughan C, Cassells A, Zatzick D, Diaz C, Hickey S, Kurz JR, Tobin JN. Impact of Collaborative Care for Underserved Patients with PTSD in Primary Care: a Randomized Controlled Trial. J Gen Intern Med 2016; 31:509-17. [PMID: 26850413 PMCID: PMC4835392 DOI: 10.1007/s11606-016-3588-3] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Revised: 09/04/2015] [Accepted: 01/04/2016] [Indexed: 01/18/2023]
Abstract
BACKGROUND The effectiveness of collaborative care of mental health problems is clear for depression and growing but mixed for anxiety disorders, including posttraumatic stress disorder (PTSD). We know little about whether collaborative care can be effective in settings that serve low-income patients such as Federally Qualified Health Centers (FQHCs). OBJECTIVE We compared the effectiveness of minimally enhanced usual care (MEU) versus collaborative care for PTSD with a care manager (PCM). DESIGN This was a multi-site patient randomized controlled trial of PTSD care improvement over 1 year. PARTICIPANTS We recruited and enrolled 404 patients in six FQHCs from June 2010 to October 2012. Patients were eligible if they had a primary care appointment, no obvious physical or cognitive obstacles to participation, were age 18-65 years, planned to continue care at the study location for 1 year, and met criteria for a past month diagnosis of PTSD. MAIN MEASURES The main outcomes were PTSD diagnosis and symptom severity (range, 0-136) based on the Clinician-Administered PTSD Scale (CAPS). Secondary outcomes were medication and counseling for mental health problems, and health-related quality of life assessed at baseline, 6 months, and 12 months. KEY RESULTS Patients in both conditions improved similarly over the 1-year evaluation period. At 12 months, PTSD diagnoses had an absolute decrease of 56.7% for PCM patients and 60.6% for MEU patients. PTSD symptoms decreased by 26.8 and 24.2 points, respectively. MEU and PCM patients also did not differ in process of care outcomes or health-related quality of life. Patients who actually engaged in care management had mental health care visits that were 14% higher (p < 0.01) and mental health medication prescription rates that were 15.2% higher (p < 0.01) than patients with no engagement. CONCLUSIONS A minimally enhanced usual care intervention was similarly effective as collaborative care for patients in FQHCs.
Collapse
Affiliation(s)
- Lisa S Meredith
- RAND Corporation, 1776 Main Street, Santa Monica, CA, 90407-2138, USA. .,VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy, Sepulveda, CA, USA.
| | - David P Eisenman
- RAND Corporation, 1776 Main Street, Santa Monica, CA, 90407-2138, USA.,Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Bing Han
- RAND Corporation, 1776 Main Street, Santa Monica, CA, 90407-2138, USA
| | - Bonnie L Green
- Department of Psychiatry, Georgetown University Medical Center, Washington, DC, USA
| | - Stacey Kaltman
- Department of Psychiatry, Georgetown University Medical Center, Washington, DC, USA
| | - Eunice C Wong
- RAND Corporation, 1776 Main Street, Santa Monica, CA, 90407-2138, USA
| | | | - Christine Vaughan
- RAND Corporation, 1776 Main Street, Santa Monica, CA, 90407-2138, USA
| | | | - Douglas Zatzick
- Department of Psychiatry and Behavioral Sciences, Harborview Injury Prevention and Research Center, School of Medicine, University of Washington, Seattle, WA, USA
| | | | - Scot Hickey
- RAND Corporation, 1776 Main Street, Santa Monica, CA, 90407-2138, USA
| | | | - Jonathan N Tobin
- Clinical Directors Network (CDN), New York, NY, USA.,Department of Epidemiology and Population Health, Albert Einstein College of Medicine of Yeshiva University, Bronx, NY, USA.,Center for Clinical & Translational Science, The Rockefeller University, New York, NY, USA
| |
Collapse
|
16
|
Prevalence, Detection and Correlates of PTSD in the Primary Care Setting: A Systematic Review. J Clin Psychol Med Settings 2016; 23:160-80. [DOI: 10.1007/s10880-016-9449-8] [Citation(s) in RCA: 129] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
|
17
|
Lilienthal K, Possemato K, Funderburk J, Wade M, Eaker A, Beehler GP. Predisposing Characteristics, Enabling Factors, and Need as Predictors of Integrated Behavioral Health Utilization. J Behav Health Serv Res 2016; 44:263-273. [DOI: 10.1007/s11414-016-9496-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
|
18
|
Possemato K, Kuhn E, Johnson E, Hoffman JE, Owen JE, Kanuri N, De Stefano L, Brooks E. Using PTSD Coach in primary care with and without clinician support: a pilot randomized controlled trial. Gen Hosp Psychiatry 2016; 38:94-8. [PMID: 26589765 DOI: 10.1016/j.genhosppsych.2015.09.005] [Citation(s) in RCA: 92] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Revised: 09/14/2015] [Accepted: 09/16/2015] [Indexed: 11/26/2022]
Abstract
OBJECTIVE This study aims to evaluate the feasibility and potential effectiveness of two approaches to using the PTSD Coach mobile application in primary care: Self-Managed PTSD Coach and Clinician-Supported PTSD Coach. This study also aims to gather preliminary data to investigate if clinician support improves the benefits of using PTSD Coach on posttraumatic stress disorder (PTSD) severity and specialty mental healthcare utilization. METHOD Twenty primary care veterans with PTSD symptoms were randomized to either Self-Managed PTSD Coach consisting of one 10-min session providing instructions for application use or Clinician-Supported PTSD Coach consisting of four 20-min sessions focused on setting symptom reduction goals and helping veterans fully engage with application content. RESULTS Research procedures and intervention conditions appear feasible as indicated by high rates of assessment and intervention retention and high clinician fidelity and satisfaction. Both treatments resulted in reductions in PTSD symptoms, with 7 Clinician-Supported PTSD Coach and 3 Self-Managed PTSD Coach participants reporting clinically significant improvements. Clinician-Supported PTSD Coach resulted in more specialty PTSD care use postintervention and possibly greater reductions in PTSD symptoms. CONCLUSIONS Both PTSD Coach interventions are feasible and potentially helpful. The addition of clinician support appears to increase the effectiveness of self-management alone. A larger-scale randomized controlled trial is warranted to confirm these encouraging preliminary findings.
Collapse
Affiliation(s)
- Kyle Possemato
- Center for Integrated Healthcare, Syracuse Veterans Affairs Medical Center, 800 Irving Avenue, Syracuse, NY 13210, USA.
| | - Eric Kuhn
- National Center for Posttraumatic Stress Disorder, Dissemination and Training Division, Department of Veteran Affairs Palo Alto Health Care System, 3801 Miranda Avenue, Palo Alto, CA 94304, USA
| | - Emily Johnson
- Center for Integrated Healthcare, Syracuse Veterans Affairs Medical Center, 800 Irving Avenue, Syracuse, NY 13210, USA
| | - Julia E Hoffman
- National Center for Posttraumatic Stress Disorder, Dissemination and Training Division, Department of Veteran Affairs Palo Alto Health Care System, 3801 Miranda Avenue, Palo Alto, CA 94304, USA
| | - Jason E Owen
- National Center for Posttraumatic Stress Disorder, Dissemination and Training Division, Department of Veteran Affairs Palo Alto Health Care System, 3801 Miranda Avenue, Palo Alto, CA 94304, USA
| | - Nitya Kanuri
- National Center for Posttraumatic Stress Disorder, Dissemination and Training Division, Department of Veteran Affairs Palo Alto Health Care System, 3801 Miranda Avenue, Palo Alto, CA 94304, USA
| | - Leigha De Stefano
- Center for Integrated Healthcare, Syracuse Veterans Affairs Medical Center, 800 Irving Avenue, Syracuse, NY 13210, USA
| | - Emily Brooks
- Center for Integrated Healthcare, Syracuse Veterans Affairs Medical Center, 800 Irving Avenue, Syracuse, NY 13210, USA
| |
Collapse
|
19
|
Cigrang JA, Rauch SAM, Mintz J, Brundige A, Avila LL, Bryan CJ, Goodie JL, Peterson AL. Treatment of active duty military with PTSD in primary care: A follow-up report. J Anxiety Disord 2015; 36:110-4. [PMID: 26519833 DOI: 10.1016/j.janxdis.2015.10.003] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Revised: 09/25/2015] [Accepted: 10/08/2015] [Indexed: 10/22/2022]
Abstract
First-line trauma-focused therapies offered in specialty mental health clinics do not reach many veterans and active duty service members with posttraumatic stress disorder (PTSD). Primary care is an ideal environment to expand access to mental health care. Several promising clinical case series reports of brief PTSD therapies adapted for primary care have shown positive results, but the long-term effectiveness with military members is unknown. The purpose of this study was to determine the long-term outcome of an open trial of a brief cognitive-behavioral primary care-delivered protocol developed specifically for deployment-related PTSD in a sample of 24 active duty military (15 men, 9 women). Measures of PTSD symptom severity showed statistically and clinically significant reductions from baseline to posttreatment that were maintained at the 6-month and 1-year follow-up assessments. Similar reductions were maintained in depressive symptoms and ratings of global mental health functioning.
Collapse
Affiliation(s)
| | - Sheila A M Rauch
- Emory University School of Medicine and Atlanta VA Medical Center, Atlanta, Georgia, USA.
| | - Jim Mintz
- University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA.
| | - Antoinette Brundige
- University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA.
| | - Laura L Avila
- San Antonio Military Medical Center, Joint Base San Antonio-Fort Sam Houston, Texas, USA.
| | - Craig J Bryan
- National Center for Veterans Studies and University of Utah, Salt Lake City, Utah, USA.
| | - Jeffrey L Goodie
- Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA.
| | - Alan L Peterson
- University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA; South Texas Veterans Health Care System, San Antonio, Texas, USA; University of Texas at San Antonio, San Antonio, Texas, USA.
| | | |
Collapse
|
20
|
Possemato K, Bergen-Cico D, Treatman S, Allen C, Wade M, Pigeon W. A Randomized Clinical Trial of Primary Care Brief Mindfulness Training for Veterans with PTSD. J Clin Psychol 2015; 72:179-93. [PMID: 26613203 DOI: 10.1002/jclp.22241] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVES Primary care (PC) patients typically do not receive adequate posttraumatic stress disorder (PTSD) treatment. This study tested if a brief mindfulness training (BMT) offered in PC can decrease PTSD severity. METHOD VA PC patients with PTSD (N = 62) were recruited for a randomized clinical trial comparing PCBMT with PC treatment as usual. PCBMT is a 4-session program adapted from mindfulness-based stress reduction. RESULTS PTSD severity decreased in both conditions, although PCBMT completers reported significantly larger decreases in PTSD and depression from pre- to posttreatment and maintained gains at the 8-week follow-up compared with the control group. Exploratory analyses revealed that the describing, nonjudging, and acting with awareness facets of mindfulness may account for decreases in PTSD. CONCLUSION Our data support preliminary efficacy of BMT for Veterans with PTSD. Whether PCBMT facilitates engagement into, or improves outcomes of, full-length empirically supported treatment for PTSD remains to be evaluated.
Collapse
Affiliation(s)
- Kyle Possemato
- Upstate New York Veterans' Affairs Healthcare System.,Syracuse University
| | - Dessa Bergen-Cico
- Upstate New York Veterans' Affairs Healthcare System.,Syracuse University
| | - Scott Treatman
- Upstate New York Veterans' Affairs Healthcare System.,Crouse Hospital
| | - Christy Allen
- Upstate New York Veterans' Affairs Healthcare System.,Northern Illinois University.,University of Rochester Medical Center School of Medicine and Dentistry
| | - Michael Wade
- Upstate New York Veterans' Affairs Healthcare System
| | - Wilfred Pigeon
- Upstate New York Veterans' Affairs Healthcare System.,Canandaigua Veterans' Affairs Medical Center.,University of Rochester Medical Center School of Medicine and Dentistry
| |
Collapse
|
21
|
Long AC, Kross EK, Davydow DS, Curtis JR. Posttraumatic stress disorder among survivors of critical illness: creation of a conceptual model addressing identification, prevention, and management. Intensive Care Med 2014; 40:820-9. [PMID: 24807082 PMCID: PMC4096314 DOI: 10.1007/s00134-014-3306-8] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2014] [Accepted: 04/15/2014] [Indexed: 01/16/2023]
Abstract
Quality of life is frequently impaired among survivors of critical illness, and psychiatric morbidity is an important element contributing to poor quality of life in these patients. Among potential manifestations of psychiatric morbidity following critical illness, symptoms of posttraumatic stress are prevalent and intricately linked to the significant stressors present in the intensive care unit (ICU). As our understanding of the epidemiology of post-ICU posttraumatic stress disorder improves, so must our ability to identify those at highest risk for symptoms in the period of time following critical illness and our ability to implement strategies to prevent symptom development. In addition, a focus on strategies to address clinically apparent psychiatric morbidity will be essential. Much remains to be understood about the identification, prevention, and management of this significant public health problem. This article addresses the importance of uniformity in future epidemiologic studies, proposes framing of risk factors into those likely to be modifiable versus non-modifiable, and provides an assessment of modifiable risk factors in the context of a novel conceptual model that offers insight into potential strategies to attenuate symptoms of posttraumatic stress among survivors of critical illness.
Collapse
Affiliation(s)
- Ann C. Long
- Harborview Medical Center, Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington, Seattle, WA
| | - Erin K. Kross
- Harborview Medical Center, Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington, Seattle, WA
| | - Dimitry S. Davydow
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA
| | - J. Randall Curtis
- Harborview Medical Center, Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington, Seattle, WA
| |
Collapse
|
22
|
Klassen BJ, Porcerelli JH, Markova T. The effects of PTSD symptoms on health care resource utilization in a low-income, urban primary care setting. J Trauma Stress 2013; 26:636-9. [PMID: 24030861 DOI: 10.1002/jts.21838] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Individuals with posttraumatic stress disorder (PTSD) symptoms engage in greater rates of health care utilization. Existing literature is limited, however, because the number of visits to health care providers is exclusively used as an outcome. Low-income women (N = 96) screening positive for PTSD symptoms (n = 23; 23.9%) were compared to those who did not (n = 73) on a range of health care utilization outcomes obtained through a chart review. Significant PTSD symptoms were associated with more complaints per visit, ordered labs, and prescribed medications--beyond the effects of age, depression symptoms, and chronic illness. Individuals with PTSD symptoms are a challenge to primary care as currently practiced. Collaboration with mental health professionals and specific primary care procedures to diagnose and treat PTSD are needed.
Collapse
Affiliation(s)
- Brian J Klassen
- Department of Psychology, Wayne State University, Detroit, Michigan, USA
| | | | | |
Collapse
|
23
|
Abstract
Posttraumatic stress disorder (PTSD) is common in primary care but it is frequently not detected or treated adequately. There is insufficient evidence to recommend universal screening for PTSD in primary care, but clinicians should remain alert to PTSD among patients exposed to trauma, and among those with other psychiatric disorders, irritable bowel syndrome, multiple somatic symptoms and chronic pain. A two-stage process of screening (involving the PC-PTSD), and, for those with a positive screen, a diagnostic evaluation (using the PTSD-Checklist), can detect most patients with PTSD with few false positives. Evidence-based recommendations are provided for treatment in primary care or referral to mental health.
Collapse
|
24
|
Managing behavioral health needs of veterans with traumatic brain injury (TBI) in primary care. J Clin Psychol Med Settings 2013. [PMID: 23184276 DOI: 10.1007/s10880-012-9345-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Traumatic brain injury (TBI) is a frequent occurrence in the United States, and has been given particular attention in the veteran population. Recent accounts have estimated TBI incidence rates as high as 20 % among US veterans who served in Afghanistan or Iraq, and many of these veterans experience a host of co-morbid concerns, including psychiatric complaints (such as depression and post-traumatic stress disorder), sleep disturbance, and substance abuse which may warrant referral to behavioral health specialists working in primary care settings. This paper reviews many common behavioral health concerns co-morbid with TBI, and suggests areas in which behavioral health specialists may assess, intervene, and help to facilitate holistic patient care beyond the acute phase of injury. The primary focus is on sequelae common to mild and moderate TBI which may more readily present in primary care clinics.
Collapse
|
25
|
RESPECT-PTSD: re-engineering systems for the primary care treatment of PTSD, a randomized controlled trial. J Gen Intern Med 2013; 28:32-40. [PMID: 22865017 PMCID: PMC3539037 DOI: 10.1007/s11606-012-2166-6] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2011] [Revised: 05/23/2012] [Accepted: 06/18/2012] [Indexed: 10/28/2022]
Abstract
BACKGROUND Although collaborative care is effective for treating depression and other mental disorders in primary care, there have been no randomized trials of collaborative care specifically for patients with Posttraumatic stress disorder (PTSD). OBJECTIVE To compare a collaborative approach, the Three Component Model (3CM), with usual care for treating PTSD in primary care. DESIGN The study was a two-arm, parallel randomized clinical trial. PTSD patients were recruited from five primary care clinics at four Veterans Affairs healthcare facilities and randomized to receive usual care or usual care plus 3CM. Blinded assessors collected data at baseline and 3-month and 6-month follow-up. PARTICIPANTS Participants were 195 Veterans. Their average age was 45 years, 91% were male, 58% were white, 40% served in Iraq or Afghanistan, and 42% served in Vietnam. INTERVENTION All participants received usual care. Participants assigned to 3CM also received telephone care management. Care managers received supervision from a psychiatrist. MAIN MEASURES PTSD symptom severity was the primary outcome. Depression, functioning, perceived quality of care, utilization, and costs were secondary outcomes. KEY RESULTS There were no differences between 3CM and usual care in symptoms or functioning. Participants assigned to 3CM were more likely to have a mental health visit, fill an antidepressant prescription, and have adequate antidepressant refills. 3CM participants also had more mental health visits and higher outpatient pharmacy costs. CONCLUSIONS Results suggest the need for careful examination of the way that collaborative care models are implemented for treating PTSD, and for additional supports to encourage primary care providers to manage PTSD.
Collapse
|
26
|
The effects of age on initiation of mental health treatment after positive PTSD screens among Veterans Affairs primary care patients. Gen Hosp Psychiatry 2012; 34:654-9. [PMID: 22898446 DOI: 10.1016/j.genhosppsych.2012.07.002] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2012] [Revised: 07/05/2012] [Accepted: 07/07/2012] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The objective was to examine differences by age in mental health treatment initiation in Veterans Health Administration (VA) primary care patients after positive posttraumatic stress disorder (PTSD) screens. METHODS This was a retrospective cohort study of 71,039 veterans who were administered PTSD screens during primary care encounters in 2007 at four Pacific Northwest VA medical center sites and who had no specialty mental health clinic visits or PTSD diagnoses recorded in the year before screening. Main outcome measures were attendance of any specialty mental health clinic visits or receipt of any antidepressant medication in the year after a positive PTSD screen. RESULTS Older veterans, compared with veterans less than 30 years old, were less likely to attend any specialty mental health visits after positive PTSD screens [adjusted odds ratios (ORs) ranged from .57 to .12, all P<.001], and veterans 75 years and older were less likely to receive any antidepressant medication (adjusted OR=.56, P<.001). CONCLUSIONS Initiation of mental health treatment among veterans who screen positive for PTSD varies significantly by age. Further research should examine whether this is due to differences in base rates of PTSD, treatment preferences, provider responses to screens or other age-related barriers to mental health treatment.
Collapse
|
27
|
Ostacoli L, Carletto S, Borghi M, Cavallo M, Rocci E, Zuffranieri M, Malucchi S, Bertolotto A, Zennaro A, Furlan PM, Picci RL. Prevalence and Significant Determinants of Post-traumatic Stress Disorder in a Large Sample of Patients with Multiple Sclerosis. J Clin Psychol Med Settings 2012; 20:240-6. [DOI: 10.1007/s10880-012-9323-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
|