Use of Guideline-Recommended Treatments for PTSD Among Community-Based Providers in Texas and Vermont: Implications for the Veterans Choice Program

Impact of cognitive behavioural therapy on neural, inflammatory, & autonomic markers in a sample with PTSD and cardiovascular risk: protocol for a pilot randomised controlled trial

Background: Individuals with posttraumatic stress disorder (PTSD) are at heightened risk for cardiovascular disease (CVD) compared to the general population. Inflammation and autonomic dysfunction are candidate mechanisms of CVD risk in PTSD; however, these mechanisms have not been well-characterised in the PTSD-CVD link. Further, these mechanisms may operate through altered stress-related neural activity (SNA). Yet, it remains unknown if changes in PTSD are associated with changes in CVD risk mechanisms.Objective: This manuscript describes the design and procedures of a pilot randomised controlled trial to assess the impact of a first-line treatment for PTSD (Cognitive Processing Therapy; CPT) versus waitlist control on mechanisms of CVD risk. Further, this study will test the hypothesis that CPT reduces CVD risk through its effects on inflammation and autonomic function and that these changes are driven by changes in SNA.Methods: Adults with PTSD and CVD risk (N = 30) will be randomised to CPT or waitlist control. Participants complete two laboratory visits (baseline and post-treatment) that include surveys, brain and peripheral imaging via 18F-fluorodeoxyglucose positron emission tomography (FDG-PET), and resting measures of autonomic function. Primary outcomes include arterial inflammation and heart rate variability. Secondary outcomes include leukopoiesis (bone marrow uptake), heart rate, and blood pressure. The indirect effects of PTSD treatment on changes in inflammation and autonomic function through SNA will also be examined.Conclusions: This study seeks to characterise candidate neuroimmune mechanisms of the PTSD-CVD link to identify treatment targets and develop personalised interventions to reduce CVD events in PTSD populations.Trial registration: ClinicalTrials.gov identifier: NCT06429293..

Implementation strategies to improve posttraumatic stress disorder care in rural veterans

PURPOSE

Prior research has noted treatment inequalities in the care of rural veterans with posttraumatic stress disorder (PTSD). This project sought to increase the delivery, or reach, of recommended PTSD treatments in 2 rural health care systems of the Department of Veterans Affairs (VA) using implementation facilitation.

METHODS

The quality improvement project involved 6 months of facilitation to 2 low-reach PTSD clinics within 2 VA health care systems. The clinics were matched to a control clinic at another regional system similar in reach, rurality, and patient volume. We compared the delivery of evidence-based psychotherapies (EBPs) for PTSD at 3 timepoints: baseline, 6 months, and 1 year using difference-in-difference effect estimation. Facilitators and barriers of EBP reach were identified through interviews with clinic staff and informed specific implementation plans. We also measured reductions in benzodiazepine prescriptions and polypharmacy to determine the impact of an academic detailing intervention aimed at improving PTSD prescribing practices at the 2 sites.

FINDINGS

EBP reach at 6 months more than doubled in the 2 PTSD clinics that received facilitation, while our control clinic experienced a decrease in EBP reach (DID = 24.6; SE = 6.71%). Both intervention clinics identified similar administrative barriers to the delivery of EBPs, offering useful information for improvement at other rural clinics. The use of academic detailing as part of our facilitation intervention further appears to have positively impacted care.

CONCLUSIONS

In this preliminary work, facilitation is a promising strategy for increasing the delivery of PTSD EBPs to veterans seen in under-resourced rural VA clinics.

Prevalence and Correlates of VA-Purchased Community Care Use Among Post-9/11-Era Veterans With Traumatic Brain Injury

OBJECTIVE

Post-9/11-era veterans with traumatic brain injury (TBI) have greater health-related complexity than veterans overall, and may require coordinated care from TBI specialists such as those within the Department of Veterans Affairs (VA) healthcare system. With passage of the Choice and MISSION Acts, more veterans are using VA-purchased care delivered by community providers who may lack TBI training. We explored prevalence and correlates of VA-purchased care use among post-9/11 veterans with TBI.

SETTING

Nationwide VA-purchased care from 2016 through 2019.

PARTICIPANTS

Post-9/11-era veterans with clinician-confirmed TBI based on VA's Comprehensive TBI Evaluation (N = 65 144).

DESIGN

This was a retrospective, observational study.

MAIN MEASURES

Proportions of veterans who used VA-purchased care and both VA-purchased and VA-delivered outpatient care, overall and by study year. We employed multivariable logistic regression to assess associations between veterans' sociodemographic, military history, and clinical characteristics and their likelihood of using VA-purchased care from 2016 through 2019.

RESULTS

Overall, 51% of veterans with TBI used VA-purchased care during the study period. Nearly all who used VA-purchased care (99%) also used VA-delivered outpatient care. Veterans' sociodemographic, military, and clinical characteristics were associated with their likelihood of using VA-purchased care. Notably, in adjusted analyses, veterans with moderate/severe TBI (vs mild), those with higher health risk scores, and those diagnosed with posttraumatic stress disorder, depression, anxiety, substance use disorders, or pain-related conditions had increased odds of using VA-purchased care. Additionally, those flagged as high risk for suicide also had higher odds of VA-purchased care use.

CONCLUSIONS

Veterans with TBI with greater health-related complexity were more likely to use VA-purchased care than their less complex counterparts. The risks of potential care fragmentation across providers versus the benefits of increased access to care are unknown. Research is needed to examine health and functional outcomes among these veterans.

VA-Delivered or VA-Purchased Care: Important Factors for Veterans Navigating Care Decisions

BACKGROUND/OBJECTIVE

The VA MISSION Act aimed to increase Veterans' access to care by allowing eligible Veterans to use VA-paid care from non-VA providers ("VA-purchased care"). We interviewed Veterans who were eligible for both VA-delivered and VA-purchased care to examine factors they consider when making decisions about whether to use VA-delivered or VA-purchased care.

METHODS

We conducted semi-structured interviews with 28 Veterans across the USA who were eligible for VA-delivered and VA-purchased care, using deductive and inductive analysis to develop themes. Participants were recruited from a survey about healthcare access and decision-making. More than half of participants lived in rural areas, 21 were men, and 25 were > 50 years old.

KEY RESULTS

Veteran participants identified (1) high-quality relationships with providers based on mutual trust, empathy, authenticity, and continuity of care, and (2) a positive environment or "eco-system of care" characterized by supportive interactions with staff and other Veterans, and exemplary customer service as integral to their decisions about where to receive care. These preferences influenced their engagement with VA and non-VA providers. We discovered corresponding findings related to Veterans' information needs. When making decisions around where to receive care, participants said they would like more information about VA and non-VA providers and services, and about coordination of care and referrals, including understanding processes and implications of utilizing VA-purchased care.

DISCUSSION/CONCLUSION

Current VA-purchased care eligibility determinations focus on common access metrics (e.g., wait times, distance to care). Yet, Veterans discussed other important factors for navigating care decisions, including patient-provider relationship quality and the larger healthcare environment (e.g., interactions with staff and other Veterans). Our findings point to the need for health systems to collect and provide information on these aspects of care to ensure care decisions reflect what is important to Veterans when navigating where to receive care.

Comparison of mental health outcomes of augmenting medications for patients with posttraumatic stress disorder: A national veterans affairs study

RATIONALE

Posttraumatic stress disorder (PTSD) is highly prevalent among veterans. Many veterans with PTSD respond well to serotonin reuptake inhibitors (SRIs). Nonresponders may be prescribed augmenting medications, which are not as well-studied in PTSD.

AIMS AND OBJECTIVES

We used Veterans Health Administration electronic records to compare mental health outcomes (PTSD symptoms and rates of mental health hospitalizations and psychiatric emergency room visits) in patients with PTSD who were prescribed four different groups of augmenting medications (atypical antipsychotics, mirtazapine, prazosin or tricyclic antidepressants) in addition to SRIs-from the year before to the year after the start of the augmenting medication.

METHOD

We included data from 169,982 patients with a diagnosis of PTSD (excluding patients with comorbid bipolar or psychotic disorders) seen in Veterans Affairs care from 2007 to 2015 who were taking an SRI and filled a new prescription for one of the four augmenting medications for at least 60 days.

RESULTS

Patients evidenced minimal (<2%) reduction in PTSD symptoms and a larger reduction in psychiatric hospitalizations and psychiatric emergency room visits after receiving augmenting medications; this effect was largely similar across the four medication groups. Initiating augmenting medications was preceded by increases in PTSD symptoms, psychiatric hospitalizations and psychiatric emergency room visits. After initiating an augmenting medication, PTSD symptoms/hospitalizations/emergency room visits returned to baseline levels (before the start of the augmenting medication), but generally did not improve beyond baseline.

CONCLUSION

Importantly, these effects could be explained by regression to the mean, additional interventions or confounding. These findings should be further explored with placebo controlled randomized clinical trials.

Initiating Cognitive Processing Therapy (CPT) in Community Settings: A Qualitative Investigation of Therapist Decision-Making

Various organizations have provided treatment guidelines intended to aid therapists in deciding how to treat posttraumatic stress disorder (PTSD). Yet evidence-based psychotherapies (EBPs) for PTSD in the community may be difficult to obtain. Although strides have been made to implement EBPs for PTSD in institutional settings such as the United States Veterans Affairs, community uptake remains low. Factors surrounding clients' decisions to enroll in EBPs have been identified in some settings; however less is known regarding trained therapists' decisions related to offering trauma-focused therapies or alternative treatment options. Thus, the aim of the current study was to examine therapist motivations to initiate CPT in community settings. The present study utilizes data from a larger investigation aiming to support the sustained implementation of Cognitive Processing Therapy (CPT) in community mental health treatment settings. Enrolled therapists participated in phone interviews discussing their opinions of CPT, preferred treatments for PTSD, and process in assessing appropriate PTSD treatments for clients. Semi-structured interviews (N = 29) were transcribed and analyzed using a directed content analysis approach. Several themes emerged regarding therapists' decision-making in selecting PTSD treatments. Therapist motivations to use EBPs for PTSD, primarily CPT, were identified at the client (e.g., perceived compatibility with client-level characteristics), therapist (e.g., time limitations), and clinic levels (e.g., leadership support). The results provide insight into the complex array of factors that affect sustainability of EBPs for PTSD in community settings and inform future dissemination of EBPs, including training efforts in community settings.

A Comparison of Patient-Reported Mental Health Outcomes for the Department of Veterans Affairs' Regional Telehealth and Community Care Programs

Objectives

To compare patient‐reported outcomes for veterans with limited access to Department of Veterans Affairs (VA) mental health services referred to the Veterans Community Care Program (VCCP) or regional telehealth Clinical Resource Hubs‐Mental Health (CRH‐MH).

Data Sources

This national evaluation used secondary data from the VA Corporate Data Warehouse, chart review, and primary data collected by baseline survey between October 8, 2019 and May 27, 2020 and a 4‐month follow‐up survey.

Study Design

A quasi‐experimental longitudinal study design was used to sample 545 veterans with VCCP or CRH‐MH referrals for new treatment episodes. Patient‐reported outcomes included symptom severity, perceived access, utilization, and patient‐centeredness.

Data Collection

During the baseline and follow‐up surveys, all veterans were administered the Patient Health Questionnaire‐8 (PHQ‐8) to assess depression severity, and veterans with a provisional diagnosis of posttraumatic stress disorder (PTSD) were also administered the PTSD Checklist for DSM‐5 (PCL‐5) to assess PTSD symptom severity. The 4‐month follow‐up survey also asked about perceived access using the Perceived Access Inventory, the number of encounters, and patient‐centeredness of care using the Patient‐Centered Care portion of the Veterans Satisfaction Survey.

Principal Findings

Results indicated that compared to VCCP consults, veterans with CRH‐MH consults reported 0.65 (CI₉₅ = 0.51–0.83, p < 0.01) times the number of barriers to care, but a non‐significant lower number of encounters (−0.792, CI₉₅ −2.221, 0.636, p = 0.28). There was no significant (p = 0.24) difference in satisfaction with patient‐centeredness, with both groups “agreeing” on average to positively worded questions. Veterans in both groups experienced little improvement in depression or PTSD symptom severity, and there were no clinically meaningful differences between groups.

Conclusions

Overall findings indicate that the CRH‐MH and VCCP generate similar patient‐reported outcomes. Future research should compare the quality and cost of care delivered by the VCCP and CRH‐MH programs.

Serving Veterans in their Communities: Evaluation of an Online Resource for Behavioral Health Care Providers

Many veterans receive behavioral health care services from providers in their communities. The Community Provider Toolkit (the Toolkit) is a website developed by the National Center for PTSD and the Department of Veterans Affairs intended to provide community mental health care providers with key veteran-focused educational resources. This mixed-methods study examined the potential impact of the Toolkit on provider knowledge and behaviors. Sixty-four clinicians in the community who currently or plan to provide services to veterans were surveyed. The majority of providers found the website useful and easy to navigate. After visiting the site, many providers found additional online and educational resources that they would add to a hypothetical treatment plan. Forty-five providers completed a 1-month follow-up survey focused on use of the Toolkit. Results indicate that the Toolkit may be a valuable tool for increasing provider knowledge about veteran-specific resources.

Preventive Care Delivery After the Veterans Choice Program

INTRODUCTION

The Veterans Choice Program expanded Veteran access to community care. The Veterans Choice Program may negatively impact the receipt of preventive care services owing to care fragmentation. This study assesses 10 measures of preventive care in Veterans with the Department of Veterans Affairs coverage before and after the Veterans Choice Program.

METHODS

The study population included Veterans who responded to the National Health Interview Survey during the 2 time periods before and after Veterans Choice Program implementation: January 2011-October 2014 and November 2015-December 2018. Outcomes were preventive care services categorized as cardiovascular risk reduction (cholesterol monitoring, blood pressure monitoring, aspirin use), infectious disease prevention (influenza vaccination and HIV testing), and diabetes care (fasting blood glucose monitoring, podiatry visits, ophthalmology visits, influenza vaccination, and pneumonia vaccination). Two different analyses were conducted: (1) unadjusted and multivariable-adjusted pre-post analysis and (2) difference-in-differences analyses. Analyses were conducted in 2019.

RESULTS

Measures of cardiovascular risk reduction and influenza vaccination were not statistically different before and after Veterans Choice Program implementation using the 2 different analytic approaches. In unadjusted pre-post analysis, after Veterans Choice Program implementation, Veterans with Veterans Affairs coverage had increased HIV testing (66.1%‒75.4%, p=0.008), podiatry visits (22.4%‒38.3%, p=0.01), and ophthalmology visits (62.2%‒77.2%, p=0.02). Using multivariable adjustment for participant sociodemographic factors, Veterans Choice Program implementation was associated with higher odds of podiatry visits (AOR=2.28, 95% CI=1.24, 4.20, p=0.009) and ophthalmology visits (AOR=2.11, 95% CI=1.13, 3.94, p=0.02) among Veterans with diabetes. In difference-in-differences analyses, Veterans Choice Program implementation was associated with increased podiatry visits (AOR=2.95, 95% CI=1.49, 5.83, p=0.002) among Veterans with diabetes and Veterans Affairs coverage compared with that among those with other coverage types, but no statistically significant effect was observed for ophthalmology visits.

CONCLUSIONS

Veterans with Veterans Affairs coverage and diabetes had an increase in podiatry visits after Veterans Choice Program implementation. There was no evidence that Veterans Choice Program implementation had a negative impact on the receipt of preventive care services among Veterans with Veterans Affairs coverage.

On being a client with posttraumatic stress disorder: Interactions with treatment providers and institutional barriers

Premature dropout from psychological treatment for posttraumatic stress disorder (PTSD) is common. Little research has sought to understand perceptions of treatment and barriers to treatment in this population. This study analyzed anonymous posts among an online community of individuals with PTSD (93 forum users comprising 158 posts regarding treatment providers and 40 forum users comprising 50 posts regarding institutional barriers). Results indicated that individuals with PTSD desire greater clarity about expectations for treatment, collaboration toward treatment goals, open discussion of client-therapist boundaries, and increased validation among therapists in response to trauma disclosure. Individuals with PTSD also reported multiple systemic issues that were barriers to treatment including a lack of available services in their area, being placed on a waitlist for long periods of time, the cost of treatment as a financial burden, and poor crisis response in emergency rooms. Findings indicated areas of growth for treatment providers which will help inform future treatment studies in improving care and treatment adherence among individuals with PTSD.

Factors associated with PTSD symptom improvement among Iraq and Afghanistan veterans receiving evidenced-based psychotherapy

BACKGROUND

Despite availability of evidence-based psychotherapies (EBPs) for posttraumatic stress disorder (PTSD), not all veterans who initiate EBPs experience benefit. Better understanding factors associated with clinically significant improvement can help ameliorate care.

METHODS

A cohort of Iraq and Afghanistan War veterans who initiated an EBP was identified (N = 32,780) with ≥1 post-deployment psychotherapy visit at the Veterans Health Administration from 10/2001-6/2017, a post-deployment PTSD diagnosis, and ≥2 PTSD symptom measures. We used random-effects logistic regression to assess whether patient-level, diagnostic, and treatment factors were associated with achieving symptom improvement.

RESULTS

Increased odds of PTSD symptom improvement were seen in women (OR = 1.19; 95% CI: 1.09--1.29), those who initiated EBP within a year of engaging in mental healthcare compared with the delayed EBP group (OR = 1.20; 95% CI: 1.14--1.28), those who completed at least 8 EBP sessions in 16 weeks (OR = 1.23; 95% CI:1.11--1.36), those who received PE only (vs. CPT or both; OR = 2.23; 95% CI: 1.86--2.68) or CPT individual therapy only (vs. CPT group or both; OR = 1.34; 95% CI: 1.22--1.48), and those with a drug dependence diagnosis (OR = 1.24; 95% CI: 1.11--1.39). Decreased odds of improvement were seen in Black veterans (OR=0.75; 95% CI: 0.69--0.81) and those with service-connected disability (OR = 0.61; 95% CI: 0.52--0.71).

LIMITATIONS

Diagnoses were from medical charts and not confirmed with gold standard assessment tools; we only included veterans with at least two PTSD measurements, which may cause bias.

CONCLUSION

Modifiable factors associated with PTSD improvement (timing, dose, and modality) can be used to improve EBP outcomes.

Confronting challenges to opioid risk mitigation in the U.S. health system: Recommendations from a panel of national experts

BACKGROUND

Amid the ongoing U.S. opioid crisis, achieving safe and effective chronic pain management while reducing opioid-related morbidity and mortality is likely to require multi-level efforts across health systems, including the Military Health System (MHS), Department of Veterans Affairs (VA), and civilian sectors.

OBJECTIVE

We conducted a series of qualitative panel discussions with national experts to identify core challenges and elicit recommendations toward improving the safety of opioid prescribing in the U.S.

DESIGN

We invited national experts to participate in qualitative panel discussions regarding challenges in opioid risk mitigation and how best to support providers in delivery of safe and effective opioid prescribing across MHS, VA, and civilian health systems.

PARTICIPANTS

Eighteen experts representing primary care, emergency medicine, psychology, pharmacy, and public health/policy participated.

APPROACH

Six qualitative panel discussions were conducted via teleconference with experts. Transcripts were coded using team-based qualitative content analysis to identify key challenges and recommendations in opioid risk mitigation.

KEY RESULTS

Panelists provided insight into challenges across multiple levels of the U.S. health system, including the technical complexity of treating chronic pain, the fraught national climate around opioids, the need to integrate surveillance data across a fragmented U.S. health system, a lack of access to non-pharmacological options for chronic pain care, and difficulties in provider and patient communication. Participating experts identified recommendations for multi-level change efforts spanning policy, research, education, and the organization of healthcare delivery.

CONCLUSIONS

Reducing opioid risk while ensuring safe and effective pain management, according to participating experts, is likely to require multi-level efforts spanning military, veteran, and civilian health systems. Efforts to implement risk mitigation strategies at the patient level should be accompanied by efforts to increase education for patients and providers, increase access to non-pharmacological pain care, and support use of existing clinical decision support, including state-level prescription drug monitoring programs.

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.