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Fortney JC, Kaysen DL, Engel CC, Cerimele JM, Nolan JP, Chase E, Blanchard BE, Hauge S, Bechtel J, Moore DL, Taylor A, Acierno R, Nagel N, Sripada RK, Painter JT, DeBeer BB, Bluett E, Teo AR, Morland LA, Heagerty PJ. Sequenced Treatment Effectiveness for Posttraumatic Stress (STEPS) Trial: A protocol for a pragmatic comparative effectiveness trial with baseline results. Contemp Clin Trials 2024; 144:107606. [PMID: 38866094 DOI: 10.1016/j.cct.2024.107606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2024] [Revised: 05/16/2024] [Accepted: 06/09/2024] [Indexed: 06/14/2024]
Abstract
BACKGROUND There have only been two efficacy trials reporting a head-to-head comparison of medications and psychotherapy for PTSD, and neither was conducted in primary care. Therefore, this protocol paper describes a pragmatic trial that compares outcomes of primary care patients randomized to initially receive a brief trauma-focused psychotherapy or a choice of three antidepressants. In addition, because there are few trials examining the effectiveness of subsequent treatments for patients not responding to the initial treatment, this pragmatic trial also compares the outcomes of those switching or augmenting treatments. METHOD Patients screening positive for PTSD (n = 700) were recruited from the primary care clinics of 7 Federally Qualified Health Centers (FQHC) and 8 Department of Veterans Affairs (VA) Medical Centers and randomized in the ratio 1:1:2 to one of three treatment sequences: 1) selective serotonin reuptake inhibitor (SSRI) followed by augmentation with Written Exposure Therapy (WET), 2) SSRI followed by a switch to serotonin-norepinephrine reuptake inhibitor (SNRI), or 3) WET followed by a switch to SSRI. Participants complete surveys at baseline, 4 months, and 8 months. The primary outcome is PTSD symptom severity as measured by the PTSD Checklist (PCL-5). RESULTS Average PCL-5 scores (M = 52.8, SD = 11.1) indicated considerable severity. The most common bothersome traumatic event for VA enrollees was combat (47.8%), and for FQHC enrollees was other (28.2%), followed by sexual assault (23.4%), and child abuse (19.8%). Only 22.4% were taking an antidepressant at baseline. CONCLUSION Results will help healthcare systems and clinicians make decisions about which treatments to offer to patients.
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Affiliation(s)
- John C Fortney
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, WA, USA; VA Health Systems Research, Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound, Seattle, WA, USA.
| | - Debra L Kaysen
- Departments of Psychiatry and Behavioral Sciences and Public Mental Health & Population Sciences, School of Medicine, Stanford University, Palo Alto, CA, USA
| | - Charles C Engel
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, WA, USA; VA Health Systems Research, Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound, Seattle, WA, USA
| | - Joseph M Cerimele
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, WA, USA; VA Health Systems Research, Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound, Seattle, WA, USA
| | | | - Erin Chase
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, WA, USA
| | - Brittany E Blanchard
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, WA, USA
| | - Stephanie Hauge
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, WA, USA
| | - Jared Bechtel
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, WA, USA
| | - Danna L Moore
- School of Economic Sciences, Washington State University, Pullman, WA, USA
| | - Ashley Taylor
- Primary Care Behavioral Health, VA Bedford Healthcare System, Bedford, MA, USA
| | - Ron Acierno
- Ralph H. Johnson VA Healthcare System, USA; Psychiatry and Behavioral Sciences, McGovern Medical School, University of Texas Health Science Center, Houston, TX, USA
| | - Nancy Nagel
- Primary Care Mental Health Integration, Cincinnati VA Medical Center, Cincinnati, OH, USA
| | - Rebecca K Sripada
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA; VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Jacob T Painter
- Health Systems Research Center for Mental Health and Outcomes Research, Central Arkansas Veterans Healthcare System, North Little Rock, AR, USA; College of Pharmacy, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Bryann B DeBeer
- Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Denver, CO, USA; VA Rocky Mountain Mental Illness, Research, Education, and Clinical Center for Suicide Prevention, Denver, CO, USA
| | - Ellen Bluett
- University of Montana, Family Medicine Residency
| | - Alan R Teo
- Department of Psychiatry, Oregon Health & Science University, Portland, OR, USA; Center to Improve Veteran Involvement in Care, Health Systems Research, VA Portland Health Care System, Portland, OR, USA
| | - Leslie A Morland
- Department of Psychiatry, Medical University of South Carolina, Charleston, SC, USA; VA San Diego Healthcare System, San Diego, CA, USA
| | - Patrick J Heagerty
- Department of Biostatistics, School of Public Health, University of Washington, Seattle, WA, USA
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Abstract
OBJECTIVE The Recovery Assessment Scale (RAS) is one of the most used recovery measures in recovery-oriented practice evaluation of people with mental health conditions. Although its psychometric properties have been extensively studied, one critical piece of information that is missing from the literature is evidence of its longitudinal factorial invariance-that is, whether the RAS measures the same recovery construct across time. The authors empirically tested the longitudinal factorial invariance assumption for the RAS. METHODS Structural equation modeling was used to test the longitudinal factorial invariance of the RAS with data longitudinally obtained at three time points from 167 people with severe mental illness. RESULTS The longitudinal factorial invariance assumption was supported (i.e., configural, metric, partial scalar, factor variance and covariance invariance). CONCLUSIONS This study found empirical evidence that the RAS can measure the same recovery construct over time and thus meets one of the important prerequisites for longitudinal assessment.
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Affiliation(s)
- Sadaaki Fukui
- Indiana University School of Social Work, Indianapolis (Fukui); Department of Psychology, Indiana University-Purdue University, Indianapolis (Salyers)
| | - Michelle P Salyers
- Indiana University School of Social Work, Indianapolis (Fukui); Department of Psychology, Indiana University-Purdue University, Indianapolis (Salyers)
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Fortney JC, Heagerty PJ, Bauer AM, Cerimele JM, Kaysen D, Pfeiffer PN, Zielinski MJ, Pyne JM, Bowen D, Russo J, Ferro L, Moore D, Nolan JP, Fee FC, Heral T, Freyholtz-London J, McDonald B, Mullins J, Hafer E, Solberg L, Unützer J. Study to promote innovation in rural integrated telepsychiatry (SPIRIT): Rationale and design of a randomized comparative effectiveness trial of managing complex psychiatric disorders in rural primary care clinics. Contemp Clin Trials 2020; 90:105873. [PMID: 31678410 DOI: 10.1016/j.cct.2019.105873] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 10/23/2019] [Accepted: 10/24/2019] [Indexed: 01/17/2023]
Abstract
OBJECTIVE Managing complex psychiatric disorders like PTSD and bipolar disorder is challenging in Federally Qualified Health Centers (FQHCs) delivering care to U.S residents living in underserved rural areas. This protocol paper describes SPIRIT, a pragmatic comparative effectiveness trial designed to compare two approaches to managing PTSD and bipolar disorder in FQHCs. INTERVENTIONS Treatment comparators are: 1) Telepsychiatry Collaborative Care, which integrates consulting telepsychiatrists into primary care teams, and 2) Telepsychiatry Enhanced Referral, where telepsychiatrists and telepsychologists treat patients directly. METHODS Because Telepsychiatry Enhanced Referral is an adaptive intervention, a Sequential, Multiple Assignment, Randomized Trial design is used. Twenty-four FQHC clinics without on-site psychiatrists or psychologists are participating in the trial. The sample is patients screening positive for PTSD and/or bipolar disorder who are not already engaged in pharmacotherapy with a mental health specialist. Intervention fidelity is measured but not controlled. Patient treatment engagement is measured but not required, and intent-to-treat analysis will be used. Survey questions measure treatment engagement and effectiveness. The Short-Form 12 Mental Health Component Summary (SF-12 MCS) is the primary outcome. RESULTS A third (34%) of those enrolled (n = 1004) are racial/ethnic minorities, 81% are not fully employed, 68% are Medicaid enrollees, 7% are uninsured, and 62% live in poverty. Mental health related quality of life (SF-12 MCS) is 2.5 standard deviations below the national mean. DISCUSSION We hypothesize that patients randomized to Telepsychiatry Collaborative Care will have better outcomes than those randomized to Telepsychiatry Enhanced Referral because a higher proportion will engage in evidence-based treatment.
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Affiliation(s)
- John C Fortney
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, WA, USA; Department of Veterans Affairs, Health Services Research and Development, Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, WA, USA.
| | - Patrick J Heagerty
- Department of Biostatistics, School of Public Health, University of Washington, Seattle, WA, USA
| | - Amy M Bauer
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, WA, USA
| | - Joseph M Cerimele
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, WA, USA
| | - Debra Kaysen
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, WA, USA
| | - Paul N Pfeiffer
- University of Michigan Medical School, Ann Arbor, MI, USA; Department of Veterans Affairs, Health Services Research and Development, Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Melissa J Zielinski
- Department of Psychiatry, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Jeffrey M Pyne
- Department of Psychiatry, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA; Department of Veterans Affairs, Health Services Research and Development, Center for Mental Healthcare and Outcomes Research, Little Rock, AR, USA
| | - Deb Bowen
- Department of Bioethics and Humanities, University of Washington, Seattle, WA, USA
| | - Joan Russo
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, WA, USA
| | - Lori Ferro
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, WA, USA
| | - Danna Moore
- Social and Economic Sciences Research Center at Washington State University, Pullman, WA, USA
| | | | - Florence C Fee
- NHMH - No Health without Mental Health, San Francisco, CA, Arlington, VA, USA
| | | | | | - Bernadette McDonald
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, WA, USA
| | - Jeremey Mullins
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, WA, USA
| | - Erin Hafer
- Community Health Plan of Washington, Seattle, WA, USA
| | | | - Jürgen Unützer
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, WA, USA
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