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Kehle-Forbes SM, Baier AL, Ackland PE, Spoont M, Polusny MA, Schnurr PP, Galovski T, Meis L. "It made me feel more alive": A qualitative analysis of quality of life improvements following completion of trauma-focused therapy for posttraumatic stress disorder. J Trauma Stress 2024. [PMID: 39095940 DOI: 10.1002/jts.23091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2024] [Revised: 06/25/2024] [Accepted: 06/26/2024] [Indexed: 08/04/2024]
Abstract
Posttraumatic stress disorder (PTSD) is associated with poor quality of life. Although randomized clinical trial data show improvements in quality of life following trauma-focused therapies (TFTs), including prolonged exposure therapy (PE) and cognitive processing therapy (CPT), less is known about how these improvements are experienced from the trauma survivor's perspective. A national sample of 60 veterans who recently completed TFT as part of routine care at U.S. Department of Veterans Affairs facilities participated in semistructured qualitative interviews during which the impact of treatment on quality of life was explored. Following a mixed deductive/inductive approach, six interrelated themes describing changes in quality of life emerged: full participation in social activities, greater emotional intimacy in relationships, improvements in parenting, expanded engagement in hobbies and community, increased occupational commitment and confidence, and more joy in life. The data highlight the positive impact of treatment on quality of life and provide depth to quantitative findings demonstrating improvements in quality of life following TFT.
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Affiliation(s)
- Shannon M Kehle-Forbes
- National Center for PTSD Women's Health Sciences Division at VA Boston Healthcare System, Boston, Massachusetts, USA
- Center for Care Delivery & Outcomes Research, Minneapolis VA Healthcare System, Minneapolis, Minnesota, USA
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Allison L Baier
- National Center for PTSD Women's Health Sciences Division at VA Boston Healthcare System, Boston, Massachusetts, USA
- Department of Psychiatry, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Princess E Ackland
- Center for Care Delivery & Outcomes Research, Minneapolis VA Healthcare System, Minneapolis, Minnesota, USA
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Michele Spoont
- Center for Care Delivery & Outcomes Research, Minneapolis VA Healthcare System, Minneapolis, Minnesota, USA
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Melissa A Polusny
- Center for Care Delivery & Outcomes Research, Minneapolis VA Healthcare System, Minneapolis, Minnesota, USA
- Department of Psychiatry and Behavioral Sciences, University of Minnesota, Minneapolis, Minnesota, USA
| | - Paula P Schnurr
- National Center for PTSD Executive Division, White River Junction, Vermont, USA
- Department of Psychiatry, Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire, USA
| | - Tara Galovski
- National Center for PTSD Women's Health Sciences Division at VA Boston Healthcare System, Boston, Massachusetts, USA
- Department of Psychiatry, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Laura Meis
- National Center for PTSD Women's Health Sciences Division at VA Boston Healthcare System, Boston, Massachusetts, USA
- Center for Care Delivery & Outcomes Research, Minneapolis VA Healthcare System, Minneapolis, Minnesota, USA
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
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Baier AL, Nugent S, Horton DM, Salameh H, Kehle-Forbes SM. Rates and reasons for veteran mental health service utilization following completion of evidence-based trauma-focused treatment for PTSD. Psychol Serv 2024; 21:560-568. [PMID: 37917477 PMCID: PMC11063117 DOI: 10.1037/ser0000815] [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] [Indexed: 11/04/2023]
Abstract
Despite the effectiveness of prolonged exposure (PE) and cognitive processing therapy (CPT) for posttraumatic stress disorder (PTSD) in reducing symptoms of PTSD and co-occurring symptoms, emerging research suggests continued mental health service utilization (MHSU) following the completion of these interventions. Reasons for continued MHSU remain unknown despite its relevance to PE/CPT outcomes and implementation. The present study employed a mixed methods approach to explore rates and reasons for VA MHSU post PE/CPT. A national sample of 5,634 U.S. veterans who completed either PE or CPT were identified to quantitatively determine the frequency, type, and location of MHSU in the 12 months following PE/CPT completion. A random subsample of 60 veterans completed semistructured qualitative interviews to explore reasons for MHSU post PE/CPT. Findings suggest high MHSU; 98.4% of veterans attended at least one mental health appointment in the year following completion of PE/CPT, with an average attending 27.64 appointments in the year following treatment completion. Qualitatively, veterans, particularly those with low-to-moderate residual symptoms, described a preference for additional treatment to continue practicing and applying skills learned in treatment. Veterans expressed low self-efficacy to maintain treatment gains without support and accountability from their therapists and viewed ongoing treatment as a safety net until they felt more confident in their skills and stability of gains. Veterans with high residual symptoms indicated needing additional PTSD-specific treatment or treatment for a co-occurring condition. Notably, some veterans reported no additional treatment needs, despite continued engagement in care. Evidence-based strategies for facilitating self-efficacy and ongoing application of PE/CPT principles posttreatment are needed. (PsycInfo Database Record (c) 2024 APA, all rights reserved).
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Affiliation(s)
- Allison L. Baier
- National Center for PTSD Women's Health Sciences Division at VA Boston Healthcare System, Boston, MA, USA
- Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Sean Nugent
- Center for Care Delivery & Outcomes Research, Minneapolis VA Healthcare System, Minneapolis, MN, USA
| | - David M. Horton
- Center for Care Delivery & Outcomes Research, Minneapolis VA Healthcare System, Minneapolis, MN, USA
| | - Hope Salameh
- Center for Care Delivery & Outcomes Research, Minneapolis VA Healthcare System, Minneapolis, MN, USA
| | - Shannon M. Kehle-Forbes
- National Center for PTSD Women's Health Sciences Division at VA Boston Healthcare System, Boston, MA, USA
- Center for Care Delivery & Outcomes Research, Minneapolis VA Healthcare System, Minneapolis, MN, USA
- University of Minnesota, Department of Medicine, Minneapolis, MN, USA
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Adams SW, Layne CM, Contractor AA, Allwood MA, Armour C, Inslicht SS, Maguen S. The Middle-Out Approach to reconceptualizing, assessing, and analyzing traumatic stress reactions. J Trauma Stress 2024; 37:433-447. [PMID: 38049964 DOI: 10.1002/jts.23005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 11/15/2023] [Accepted: 11/15/2023] [Indexed: 12/06/2023]
Abstract
Alternative models of traumatic stress and broader psychopathology have been proposed to address issues of heterogeneity, comorbidity, clinical utility, and equitable representation. However, systematic and practical methods and guidelines to organize and apply these models remain scarce. The Middle-Out Approach is a novel, integrative, contextually informed framework for organizing and applying existing empirical methods to evaluate current and alternative traumatic stress reactions. Rather than beginning to identify traumatic stress reactions from the top-down (i.e., disorder-first approach) or bottom-up (i.e., symptom-first approach), constructs are evaluated from the middle out (i.e., presentation-first approach), unconstrained by higher-order disorders or lower-order diagnostic symptoms. This approach provides innovation over previous methods at multiple levels, including the conceptualization of traumatic stress reactions as well as the type of assessments and data sources used and how they are used in statistical analyses. Conceptualizations prioritize the identification of middle-order phenotypes, representing person-centered clinical presentations, which are informed by the integration of multidimensional, transdiagnostic, and multimodal (e.g., psychosocial, physiological) assessments and/or data sources. Integrated data are then analyzed concurrently using person-centered statistical models to identify precise, discrete, and representative health outcomes within broader heterogeneous samples. Subsequent variable-centered analyses are then used to identify culturally sensitive and contextually informed correlates of phenotypes, their clinical utility, and the differential composition within and between broader traumatic stress reactions. Examples from the moral injury literature are used to illustrate practical applications that may increase clinical utility and the accurate representation of health outcomes for diverse individuals and communities.
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Affiliation(s)
- Shane W Adams
- Mental Illness Research Education and Clinical Center (MIRECC), VA San Francisco Health Care System, San Francisco, California, USA
- Department of Psychiatry, University of California-San Francisco, San Francisco, California, USA
| | - Christopher M Layne
- College of Psychology, Nova Southeastern University, Fort Lauderdale, Florida, USA
| | | | - Maureen A Allwood
- Department of Psychology, John Jay College of Criminal Justice-City University of New York, New York, New York, USA
| | - Chérie Armour
- School of Psychology, Queens University Belfast, Belfast, Northern Ireland, UK
| | - Sabra S Inslicht
- Department of Psychiatry, University of California-San Francisco, San Francisco, California, USA
- Mental Health Service, VA San Francisco Health Care System, San Francisco, California, USA
| | - Shira Maguen
- Department of Psychiatry, University of California-San Francisco, San Francisco, California, USA
- Mental Health Service, VA San Francisco Health Care System, San Francisco, California, USA
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Hooyer K, Hamblen J, Kehle-Forbes SM, Larsen SE. "Pitching" posttraumatic stress disorder treatment: A qualitative study of how providers discuss evidence-based psychotherapies with patients. J Trauma Stress 2024. [PMID: 38812334 DOI: 10.1002/jts.23058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 03/25/2024] [Accepted: 04/15/2024] [Indexed: 05/31/2024]
Abstract
The two widely available evidence-based psychotherapies (EBPs) for posttraumatic stress disorder (PTSD) are cognitive processing therapy and prolonged exposure. Although the U.S. Department of Veterans Affairs (VA) has invested in intensive clinical training to provide these first-line treatments, most military veterans do not receive these therapies. Prior research indicates that patient interest and motivation depend on how patients are educated, and differences in how information is presented shape their decision-making. To our knowledge, no studies have addressed how clinicians "pitch" EBPs for PTSD and examined whether certain approaches are more effective than others. We recorded and thematically analyzed 25 treatment planning sessions across 10 VA sites in the United States to better understand how providers talk to patients about treatment options. Five themes were identified: using rich description, integrating various forms of questioning to engage the patient, sharing prior patient success stories, using inviting and direct language, and tailoring therapy talk to fit patient needs. Providers learning to offer EBPs can use these strategies to serve as a "menu" of options that will allow them to present EBPs in a way that appeals to a particular patient.
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Affiliation(s)
- Katinka Hooyer
- Department of Family and Community Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Jessica Hamblen
- Executive Division, National Center for PTSD, White River Junction, Vermont, USA
- Geisel School of Medicine at Dartmouth, Dartmouth College, Hanover, New Hampshire, USA
| | - Shannon M Kehle-Forbes
- Women's Health Sciences Division, National Center for PTSD, Boston, Massachusetts, USA
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, Minnesota, USA
- University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Sadie E Larsen
- Department of Family and Community Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
- Executive Division, National Center for PTSD, White River Junction, Vermont, USA
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Stevenson BL, Lee JY, Oslin DW, Polusny MA, Kehle-Forbes SM. The impact of substance use on posttraumatic stress disorder symptoms and treatment discontinuation. J Trauma Stress 2024; 37:257-266. [PMID: 38085564 DOI: 10.1002/jts.23002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 11/08/2023] [Accepted: 11/10/2023] [Indexed: 04/04/2024]
Abstract
This study examined the impact of ongoing substance use during posttraumatic stress disorder (PTSD) and substance use disorder (SUD) treatment on PTSD symptoms and treatment discontinuation. The study represents a secondary analysis of U.S. military veterans (N = 183) who participated in a randomized clinical trial for the treatment of both PTSD and SUD. Veterans mostly identified as Black (53.8%) or White (41.9%) and male (92.4%). Substance use, PTSD symptoms, and treatment discontinuation were measured at 4-week intervals throughout treatment. Predictors were the percentage of days with alcohol, cannabis, and other substance use (primarily cocaine and opioids) and the average number of alcoholic drinks per drinking day. Outcomes were PTSD symptoms and treatment discontinuation at concurrent and prospective assessments. Multilevel models accounted for the nested structure of the longitudinal data. Alcohol, cannabis, and other substance use did not predict PTSD symptoms or treatment discontinuation prospectively. Concurrently, we observed that as a participant's percentage of drinking days increased by 34.7% (i.e., 1 standard deviation), PTSD symptoms during the same period were 0.07 standard deviations higher (i.e., 1 point on the PCL), B = 0.03, p = .033. No other substances were related to PTSD symptoms concurrently. The findings demonstrate that PTSD symptoms improved regardless of substance use during exposure-based PTSD and SUD treatment, and treatment discontinuation was not associated with substance use. This study suggests that substance use during treatment cannot directly explain the poorer treatment outcomes observed in the literature on comorbid PTSD/SUD compared to PTSD-only populations.
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Affiliation(s)
- Brittany L Stevenson
- Minneapolis Veterans Affairs Healthcare System, Minneapolis, Minnesota, USA
- Department of Psychiatry and Behavioral Sciences, University of Minnesota, Minneapolis, Minnesota, USA
| | - Jenny Y Lee
- Minneapolis Veterans Affairs Healthcare System, Minneapolis, Minnesota, USA
| | - David W Oslin
- Philadelphia VA Medical Center and VISN 4 Mental Illness Research, Education, and Clinical Center (MIRECC), Philadelphia, Pennsylvania, USA
| | - Melissa A Polusny
- Minneapolis Veterans Affairs Healthcare System, Minneapolis, Minnesota, USA
- Department of Psychiatry and Behavioral Sciences, University of Minnesota, Minneapolis, Minnesota, USA
| | - Shannon M Kehle-Forbes
- Minneapolis Veterans Affairs Healthcare System, Minneapolis, Minnesota, USA
- Women's Health Sciences Division at VA Boston, National Center for PTSD, Boston, Massachusetts, USA
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
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Kline AC, Otis NP, Norman SB, Hunt WM, Walter KH. Dropout in a clinical trial for comorbid PTSD and MDD among US service members: Are pretreatment characteristics predictive? Psychother Res 2024:1-13. [PMID: 38497740 DOI: 10.1080/10503307.2024.2325519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 02/26/2024] [Indexed: 03/19/2024] Open
Abstract
OBJECTIVE Despite effective treatment options for posttraumatic stress disorder (PTSD), many patients do not complete therapy. This includes U.S. active duty service members, yet factors linked to attendance in this population remain understudied and dropout remains difficult to predict. Additionally, most studies have not examined samples with PTSD and co-occurring major depressive disorder (MDD) despite high rates of comorbidity. METHOD The current study explored predictors of dropout among service members with comorbid PTSD and MDD (N = 94) randomized to cognitive processing therapy enhanced with behavioral activation (BA + CPT) or CPT as part of a clinical trial. RESULTS Using the Fournier approach, only two predictors were associated with lower dropout risk among over 20 examined: shorter duration between pretreatment assessment and Session 1 (p = .041) and past 3-month PTSD treatment engagement (p = .036). CONCLUSION Results suggest the possible utility of early momentum in starting therapy and leveraging recent treatment to improve attendance. However, this study also highlights the possible limitations of commonly assessed pretreatment factors in predicting attendance and current challenges in measuring dropout risk. Strategies to improve prediction, such as shifting focus to assess modifiable factors and processes more proximal to dropout during treatment, may be needed.Trial registration: ClinicalTrials.gov identifier: NCT02874131.
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Affiliation(s)
- Alexander C Kline
- Psychological Health and Readiness, Naval Health Research Center, San Diego, CA, USA
- Leidos, Inc., San Diego, CA, USA
| | - Nicholas P Otis
- Psychological Health and Readiness, Naval Health Research Center, San Diego, CA, USA
- Leidos, Inc., San Diego, CA, USA
| | - Sonya B Norman
- Department of Psychiatry, University of California San Diego, San Diego, CA, USA
- National Center for PTSD, Executive Division, White River Junction, VT, USA
- VA San Diego Healthcare System, San Diego, CA, USA
| | - W Michael Hunt
- Directorate of Mental Health, Naval Medical Center San Diego, San Diego, CA, USA
| | - Kristen H Walter
- Psychological Health and Readiness, Naval Health Research Center, San Diego, CA, USA
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Modlin NL, Creed M, Sarang M, Maggio C, Rucker JJ, Williamson V. Trauma-Informed Care in Psychedelic Therapy Research: A Qualitative Literature Review of Evidence-Based Psychotherapy Interventions in PTSD and Psychedelic Therapy Across Conditions. Neuropsychiatr Dis Treat 2024; 20:109-135. [PMID: 38268571 PMCID: PMC10807282 DOI: 10.2147/ndt.s432537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Accepted: 11/10/2023] [Indexed: 01/26/2024] Open
Abstract
Introduction Post-traumatic stress disorder (PTSD) is associated with significant patient burden. While pharmacotherapies and evidence-based psychotherapy interventions (EBPI) are effective, studies consistently highlight inadequate outcomes and high treatment dropout. Psychedelic therapy (PT) has shown preliminary promise across difficult-to-treat conditions, including MDMA-assisted therapy for PTSD, however trials of classical psychedelics in PTSD are lacking. Understanding patients' experiences of EBPI could help promote safety in PT. Aim To systematically review qualitative research on patients' subjective experience of EBPI for PTSD, and of PT, and examine areas of overlap and divergence between them. Methods Systematic literature searches for studies published between 2010 and 2023 were conducted on OVID, PubMed, Web of Science, and PsycInfo. Included were original studies in English that presented qualitative data of patient experiences of EBPI in PTSD, or PT for any indication. Extracted data from included studies were analysed using thematic synthesis. Syntheses were completed separately for EBPI and PT, before similarities and differences between the therapies were identified. Results 40 research articles were included for review: 26 studies on EBPI for PTSD, and 14 studies on PT. EBPI studied were CBT, EMDR, CPT and PE. Psychedelic compounds studied were psilocybin, ibogaine, LSD, MDMA and ketamine, for treatment of substance use disorders, anxiety relating to physical illness, depression, and PTSD. Core themes from patient experiences of EBPI: 1) patient burden in PTSD treatment; 2) readiness; 3) key mechanisms of change; 4) psychological safety and trust. Themes identified in the review of PT: 1) indirect trauma processing; 2) reorganisation of self-narratives via processes of relatedness and identification; 3) key treatment characteristics. Conclusion This study suggests overlap between patients' experience of EBPI and PT in terms of key mechanisms of change, the importance of psychological safety and readiness to engage in treatment. Trauma-informed care paradigms and practices may improve safety and acceptability of PT research.
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Affiliation(s)
- Nadav Liam Modlin
- The Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, SE5 8AF, UK
| | - Michael Creed
- The Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, SE5 8AF, UK
- South London and Maudsley NHS Foundation Trust, Maudsley Hospital, Denmark Hill, London, SE5 8AZ, UK
| | - Maria Sarang
- The Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, SE5 8AF, UK
| | - Carolina Maggio
- The Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, SE5 8AF, UK
| | - James J Rucker
- The Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, SE5 8AF, UK
- South London and Maudsley NHS Foundation Trust, Maudsley Hospital, Denmark Hill, London, SE5 8AZ, UK
| | - Victoria Williamson
- King’s Centre for Military Health Research, King’s College London, London, SE5 9RJ, UK
- Department of Experimental Psychology, Anna Watts Building, University of Oxford, Oxford, OX2 6 GG, UK
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Alpert E, Gowdy-Jaehnig A, Galovski TE, Meis LA, Polusny MA, Ackland PE, Spoont M, Valenstein-Mah H, Orazem RJ, Schnurr PP, Chard KM, Kehle-Forbes SM. Treatment-related beliefs and reactions among trauma-focused therapy completers and discontinuers: A qualitative examination. Psychol Serv 2024:2024-41582-001. [PMID: 38166295 PMCID: PMC11215002 DOI: 10.1037/ser0000831] [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] [Indexed: 01/04/2024]
Abstract
Prolonged exposure (PE) and cognitive processing therapy (CPT) for posttraumatic stress disorder (PTSD) are effective, but some patients do not respond adequately, and dropout rates are high. Patients' beliefs about treatment and perceptions of treatment components influence treatment outcomes and may be amenable to change through intervention. The present study sought to identify beliefs and reactions to PE and CPT that differentiated completers who screened negative for a PTSD diagnosis after treatment (PTSD-), completers who screened positive for a PTSD diagnosis after treatment (PTSD+), and discontinuers who attended six or fewer sessions. Thematic analysis was used to identify themes in qualitative data collected via retrospective semistructured interviews with 51 completers (19 PTSD- after treatment, 32 PTSD+ after treatment) and 66 discontinuers of PE/CPT. Participants were demographically diverse veterans across service eras. Treatment-related beliefs and reactions differentiating these groups included perceived helpfulness of treatment, self-efficacy in engaging in treatment, anticipatory anxiety and concerns, interpretations of ongoing symptoms, and perceived consequences of treatment on functioning. Further, some patterns seemed to differ in early treatment sessions compared to during the active components of treatment. Findings point to potentially malleable targets that could be intervened upon to improve trauma-focused treatment outcomes. (PsycInfo Database Record (c) 2024 APA, all rights reserved).
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Affiliation(s)
- Elizabeth Alpert
- National Center for PTSD Women’s Health Sciences Division at VA Boston Healthcare System, Boston, MA, USA
- Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Alexandra Gowdy-Jaehnig
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, MN, USA
| | - Tara E. Galovski
- National Center for PTSD Women’s Health Sciences Division at VA Boston Healthcare System, Boston, MA, USA
- Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Laura A. Meis
- National Center for PTSD Women’s Health Sciences Division at VA Boston Healthcare System, Boston, MA, USA
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, MN, USA
- University of Minnesota Department of Medicine, Minneapolis, MN, USA
| | - Melissa A. Polusny
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, MN, USA
- University of Minnesota Department of Psychiatry and Behavioral Sciences, Minneapolis, MN, USA
| | - Princess E. Ackland
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, MN, USA
- University of Minnesota Department of Medicine, Minneapolis, MN, USA
| | - Michele Spoont
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, MN, USA
- University of Minnesota Department of Medicine, Minneapolis, MN, USA
- National Center for PTSD Executive Division, White River Junction, VT, USA
| | | | - Robert J. Orazem
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, MN, USA
| | - Paula P. Schnurr
- National Center for PTSD Executive Division, White River Junction, VT, USA
- Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - Kathleen M. Chard
- Cincinnati VA Medical Center, Cincinnati, OH, USA
- University of Cincinnati School of Medicine, Cincinnati, OH, USA
| | - Shannon M. Kehle-Forbes
- National Center for PTSD Women’s Health Sciences Division at VA Boston Healthcare System, Boston, MA, USA
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, MN, USA
- University of Minnesota Department of Medicine, Minneapolis, MN, USA
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Shayani DR, Canale CA, Sloan DM, Hayes AM. Predictors of dropout in cognitive processing therapy for PTSD: An examination of in-session treatment processes. Behav Res Ther 2023; 171:104428. [PMID: 37952284 PMCID: PMC10826797 DOI: 10.1016/j.brat.2023.104428] [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: 06/16/2023] [Revised: 10/20/2023] [Accepted: 11/03/2023] [Indexed: 11/14/2023]
Abstract
Dropout rates for treatments for adult posttraumatic stress disorder (PTSD) are high. Process research can reveal client factors during treatment that predict dropout. An observational coding system was used to code client processes in audio-recorded early sessions of cognitive processing therapy (CPT), a gold-standard treatment for PTSD. Data are from a randomized controlled noninferiority trial of CPT and written exposure therapy (WET), with higher rates of dropout in CPT than WET (39.7% vs. 6.4%). Participants in this study were 53 treatment-seeking adults with PTSD who were in the CPT arm of the trial and completed the CAPS-5 at pretreatment and at least one session. Of these, 15 (28.3%) dropped out of CPT early (completing ≤9 sessions) and 38 (71.7%) completed treatment. Sessions were coded with an observational coding system on a four-point scale (0 = absent to 3 = high) for maladaptive trauma-related responses (overgeneralized beliefs, ruminative processing, avoidance), affective engagement (negative emotions, physiological distress), and adaptive processing (cognitive emotional processing). Binary logistic regressions showed that more physiological distress and cognitive emotional processing predicted lower dropout, whereas more avoidance predicted higher dropout. Negative emotion, ruminative processing, and overgeneralization were not significant predictors. These findings highlight potential early indicators of treatment engagement that could be targeted to reduce dropout and perhaps facilitate further therapeutic change.
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Affiliation(s)
- Danielle R Shayani
- Department of Psychological and Brain Sciences, University of Delaware, Newark, DE, USA.
| | - Caroline A Canale
- Department of Psychological and Brain Sciences, University of Delaware, Newark, DE, USA
| | - Denise M Sloan
- National Center for PTSD, Behavioral Science Division, VA Boston Healthcare System, Boston, MA, USA; Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Adele M Hayes
- Department of Psychological and Brain Sciences, University of Delaware, Newark, DE, USA
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Sayer NA, Wiltsey Stirman S, Rosen CS, Kehle-Forbes S, Spoont MR, Eftekhari A, Chard KM, Kaplan A, Nelson DB. The role of therapy delivery and clinic organizational factors in explaining therapist effects for trauma-focused psychotherapies in the Veterans Health Administration. J Consult Clin Psychol 2023; 91:665-679. [PMID: 37668578 PMCID: PMC10592522 DOI: 10.1037/ccp0000832] [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] [Indexed: 09/06/2023]
Abstract
OBJECTIVE This study estimated the size of therapist effects (TEs) for dropout and clinical effectiveness of two trauma-focused psychotherapies (TFPs) and evaluated whether therapy delivery and clinic organizational factors explained observed TEs. METHOD Participants were 180 therapists (54.4% psychologists, 42.2% social workers) from 137 Veterans Health Administration facilities and 1,735 patients (24.7% women; 27.2% people of color) who completed at least two TFP sessions. Outcomes were dropout (< 8 TFP sessions) and for a subsample (n = 1,273), clinically meaningful improvement and recovery based on posttraumatic stress disorder checklist for DSM-5 (PCL-5) scores. Therapist-level predictors were ascertained through survey, manual chart review, and administrative data. Multilevel models estimated TEs. RESULTS Over half (51.2%) of patients dropped out and those who dropped out were less likely to meet criteria for clinically meaningful improvement or recovery (ps < .001). Adjusting for case-mix and TFP type, therapists accounted for 5.812% (p < .001) of the unexplained variance in dropout. The average dropout rate for the 45 therapists in the top performing quartile was 27.0%, while the average dropout rate for the 45 therapists in the bottom performing quartile was 78.8%. Variation between therapists was reduced to 2.031% (p = .140) when therapists' mean of days between sessions, adherence, implementation climate, and caseload were added to multilevel models. TEs were nonsignificant for clinically meaningful improvement and recovery. CONCLUSIONS Interventions targeting therapy delivery and clinic organization have the potential to reduce variation between therapists in TFP dropout, so that more patients stay engaged long enough to experience clinical benefit. (PsycInfo Database Record (c) 2023 APA, all rights reserved).
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Affiliation(s)
- Nina A Sayer
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System
| | - Shannon Wiltsey Stirman
- National Center for Posttraumatic Stress Disorder, Dissemination and Training Division, VA Palo Alto Health Care System
| | - Craig S Rosen
- National Center for Posttraumatic Stress Disorder, Dissemination and Training Division, VA Palo Alto Health Care System
| | - Shannon Kehle-Forbes
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System
| | - Michele R Spoont
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System
| | - Afsoon Eftekhari
- National Center for Posttraumatic Stress Disorder, Dissemination and Training Division, VA Palo Alto Health Care System
| | - Kathleen M Chard
- Posttraumatic Stress Disorder and Anxiety Disorder Division, Cincinnati Veterans Affairs Medical Center
| | - Adam Kaplan
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System
| | - David B Nelson
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System
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Sripada RK, Walters HM. "I wish people could come together like we have," patient and provider perspectives on VA residential PTSD treatment. Psychol Serv 2023; 20:809-819. [PMID: 36136833 PMCID: PMC10249047 DOI: 10.1037/ser0000713] [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] [Indexed: 11/08/2022]
Abstract
Although most posttraumatic stress disorder (PTSD) care in the Veterans health administration (VHA) is provided on an outpatient basis, the VHA has 40 residential rehabilitation treatment programs (RRTPs) designed to treat Veterans who require more intensive and closely monitored care. Unfortunately, the clinical outcomes of these programs are modest, and previous attempts to identify key drivers of outcomes have uncovered few modifiable factors. The present study, informed by the model of resources, life events and changes in psychological state, was designed to identify factors associated with treatment response among RRTP patients and providers. Semistructured interviews were conducted with 24 patients and 12 providers at three regional RRTPs, using interview guides based on the theoretical model. Data were analyzed using rapid analysis. Results showed that patients and providers agreed on several factors critical to RRTP success. These factors included the provision of evidence-based psychotherapy (EBP), support and understanding from fellow patients, and skill and support from providers. Patients and providers also noted the importance of psychological flexibility, openness, and willingness to change. Patients who experienced less symptom improvement over the course of treatment were more likely to report poor therapeutic alliance. These findings underscore the importance of continued emphasis on EBP delivery but also suggest that RRTPs might find additional ways to capitalize on the residential milieu to encourage engagement in treatment and a focus on therapeutic change. (PsycInfo Database Record (c) 2023 APA, all rights reserved).
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Affiliation(s)
- Rebecca K. Sripada
- VA Center for Clinical Management Research, Ann Arbor, MI
- VA Ann Arbor Healthcare System, Ann Arbor, MI
- Department of Psychiatry, University of Michigan, Ann Arbor, MI
| | - Heather M. Walters
- VA Center for Clinical Management Research, Ann Arbor, MI
- VA Ann Arbor Healthcare System, Ann Arbor, MI
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12
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Holder N, Holliday R, Ranney RM, Bernhard PA, Vogt D, Hoffmire CA, Blosnich JR, Schneiderman AI, Maguen S. Relationship of social determinants of health with symptom severity among Veterans and non-Veterans with probable posttraumatic stress disorder or depression. Soc Psychiatry Psychiatr Epidemiol 2023; 58:1523-1534. [PMID: 37173595 DOI: 10.1007/s00127-023-02478-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 03/30/2023] [Indexed: 05/15/2023]
Abstract
PURPOSE Social determinants of health (SDoH) refer to the conditions in the environments in which people live that affect health outcomes and risks. SDoH may provide proximal, actionable targets for interventions. This study examined how SDoH are associated with posttraumatic stress disorder (PTSD) and depression symptoms among Veterans and non-Veterans with probable PTSD or depression. METHODS Four multiple regressions were conducted. Two multiple regressions with Veterans examined the impact of SDoH on PTSD symptoms and on depression symptoms. Two multiple regressions with non-Veterans examined the impact of SDoH on PTSD symptoms and on depression symptoms. Independent variables included demographic characteristics, adverse experiences (in childhood and adulthood), and SDoH (discrimination, education, employment, economic instability, homelessness, justice involvement, and social support). Correlates that were statistically significant (p < 0.05) and clinically meaningful (rpart >|0.10|) were interpreted. RESULTS For Veterans, lower social support (rpart = - 0.14) and unemployment (rpart = 0.12) were associated with greater PTSD symptoms. Among non-Veterans, greater economic instability (rpart = 0.19) was associated with greater PTSD symptoms. In the depression models, lower social support (rpart = - 0.23) and greater economic instability (rpart = 0.12) were associated with greater depression for Veterans, while only lower social support was associated with greater depression for non-Veterans (rpart = - 0.14). CONCLUSION Among Veterans and non-Veterans with probable PTSD or depression, SDoH were associated with PTSD and depression symptoms, particularly social support, economic instability, and employment. Beyond direct treatment of mental health symptoms, addressing social support and economic factors such as instability and employment in the context of PTSD and depression are potential intervention targets that would benefit from future research.
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Affiliation(s)
- Nicholas Holder
- San Francisco Veterans Affairs Health Care System, 4150 Clement Street (116-P), San Francisco, CA, 94121, USA.
- University of California San Francisco, San Francisco, USA.
| | - Ryan Holliday
- Rocky Mountain Mental Illness Research, Education and Clinical Center for Suicide Prevention, Aurora, USA
- Department of Psychiatry, University of Colorado Anschutz Medical Campus, Aurora, USA
| | - Rachel M Ranney
- San Francisco Veterans Affairs Health Care System, 4150 Clement Street (116-P), San Francisco, CA, 94121, USA
- University of California San Francisco, San Francisco, USA
- Sierra Pacific Mental Illness Research, Education and Clinical Center, San Francisco, USA
| | - Paul A Bernhard
- Health Outcomes Military Exposures Epidemiology Program, Patient Care Services, U.S. Department of Veterans Affairs, Washington, D.C., USA
| | - Dawne Vogt
- Women's Health Sciences Division of the National Center for Posttraumatic Stress Disorder, VA Boston Healthcare System, Boston, USA
- Boston University School of Medicine, Boston, USA
| | - Claire A Hoffmire
- Rocky Mountain Mental Illness Research, Education and Clinical Center for Suicide Prevention, Aurora, USA
- Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora, USA
| | - John R Blosnich
- Suzanne Dworak-Peck School of Social Work, University of Southern California, Los Angeles, USA
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, USA
| | - Aaron I Schneiderman
- Health Outcomes Military Exposures Epidemiology Program, Patient Care Services, U.S. Department of Veterans Affairs, Washington, D.C., USA
| | - Shira Maguen
- San Francisco Veterans Affairs Health Care System, 4150 Clement Street (116-P), San Francisco, CA, 94121, USA
- University of California San Francisco, San Francisco, USA
- Sierra Pacific Mental Illness Research, Education and Clinical Center, San Francisco, USA
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13
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Ackland PE, Koffel EA, Goldsmith ES, Ullman K, Miller WA, Landsteiner A, Stroebel B, Hill J, Wilt TJ, Duan-Porter W. Implementation of Evidence-Based Psychotherapies for Posttraumatic Stress Disorder: A Systematic Review. ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2023; 50:792-812. [PMID: 37326899 DOI: 10.1007/s10488-023-01279-6] [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] [Accepted: 05/29/2023] [Indexed: 06/17/2023]
Abstract
Guidelines strongly recommend trauma-focused therapies to treat posttraumatic stress disorder. Implementation of cognitive processing therapy (CPT) and prolonged exposure (PE) in Veterans Health Administration (VHA) and non-VHA settings began in 2006. We conducted a systematic review of implementation facilitators and challenges and strategies to address barriers. We searched MEDLINE, Embase, PsycINFO, and CINAHL from inception until March 2021 for English-language articles. Two individuals reviewed eligibility and rated quality. Quantitative results were abstracted by one reviewer and verified by a second. Qualitative results were independently coded by two reviewers and finalized through consensus. We used RE-AIM and CFIR frameworks to synthesize findings. 29 eligible studies addressed CPT/PE, mostly conducted in VHA. Training/education with audit/feedback was the primary implementation strategy and was linked to improved provider CPT/PE perceptions and self-efficacy. Use was not widespread. Only six studies tested other implementation strategies with mixed impact. Following VHA implementation, strong support for training, perceived effectiveness for patients and benefits for clinics, and positive patient experiences and relationships with providers were reported. However, barriers persisted including perceived protocol inflexibility, complex referral processes and patient complexity and competing needs. In non-VHA settings, providers perceived fewer barriers, but few were CPT/PE trained. Across both settings, fewer studies targeted patient factors. Training/education with audit/feedback improved perceptions and the availability of CPT/PE, but not consistent use. Studies testing implementation strategies to address post-training challenges, including patient-level factors, are needed. A few studies are underway in VHA to test patient-focused and other implementation strategies. Research assessing actual vs perceived barriers in non-VHA settings is needed to elucidate unique challenges experienced.
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Affiliation(s)
- Princess E Ackland
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, One Veterans Drive, Minneapolis, MN, 55417, USA.
- Department of Medicine, University of Minnesota Medical School, 420 Delaware St SE, Minneapolis, MN, 55455, USA.
| | | | - Elizabeth S Goldsmith
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, One Veterans Drive, Minneapolis, MN, 55417, USA
- Department of Medicine, University of Minnesota Medical School, 420 Delaware St SE, Minneapolis, MN, 55455, USA
| | - Kristen Ullman
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, One Veterans Drive, Minneapolis, MN, 55417, USA
- Veterans Affairs Evidence Synthesis Program, Minneapolis Veterans Affairs Health Care System, One Veterans Drive, Minneapolis, MN, 55417, USA
| | - Wendy A Miller
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, One Veterans Drive, Minneapolis, MN, 55417, USA
- Department of Medicine, University of Minnesota Medical School, 420 Delaware St SE, Minneapolis, MN, 55455, USA
| | - Adrienne Landsteiner
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, One Veterans Drive, Minneapolis, MN, 55417, USA
- Veterans Affairs Evidence Synthesis Program, Minneapolis Veterans Affairs Health Care System, One Veterans Drive, Minneapolis, MN, 55417, USA
| | - Benjamin Stroebel
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, One Veterans Drive, Minneapolis, MN, 55417, USA
- Veterans Affairs Evidence Synthesis Program, Minneapolis Veterans Affairs Health Care System, One Veterans Drive, Minneapolis, MN, 55417, USA
| | - Jessica Hill
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, One Veterans Drive, Minneapolis, MN, 55417, USA
- Veterans Affairs Evidence Synthesis Program, Minneapolis Veterans Affairs Health Care System, One Veterans Drive, Minneapolis, MN, 55417, USA
- Department of Psychology, Binghamton University, Binghamton, NY, 13902, USA
| | - Timothy J Wilt
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, One Veterans Drive, Minneapolis, MN, 55417, USA
- Department of Medicine, University of Minnesota Medical School, 420 Delaware St SE, Minneapolis, MN, 55455, USA
- Veterans Affairs Evidence Synthesis Program, Minneapolis Veterans Affairs Health Care System, One Veterans Drive, Minneapolis, MN, 55417, USA
- Division of Health Policy and Management, University of Minnesota School of Public Health, 420 Delaware St SE, Minneapolis, MN, 55455, USA
| | - Wei Duan-Porter
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, One Veterans Drive, Minneapolis, MN, 55417, USA
- Department of Medicine, University of Minnesota Medical School, 420 Delaware St SE, Minneapolis, MN, 55455, USA
- Veterans Affairs Evidence Synthesis Program, Minneapolis Veterans Affairs Health Care System, One Veterans Drive, Minneapolis, MN, 55417, USA
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14
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Campbell SB, Caska Wallace CM. Development of a brief support and education intervention for loved ones of veterans with posttraumatic stress disorder. J Trauma Stress 2023. [PMID: 36756986 DOI: 10.1002/jts.22914] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 10/28/2022] [Accepted: 11/21/2022] [Indexed: 02/10/2023]
Abstract
Clinical practice guidelines for managing posttraumatic stress disorder (PTSD) encourage incorporating loved ones into treatment, and supportive relationships can increase engagement in mental health care for veterans with PTSD. This study describes the iterative refinement, feasibility/acceptability testing, and national dissemination of a brief support and psychoeducation intervention for loved ones of veterans with PTSD. Loved ones (n = 181; range:1-11 per group) attended and qualitatively rated "PTSD 101 for Family and Friends: A Support and Education Workshop." Open-ended questions were used to gather data on suggestions for improvement and descriptions of helpful content, and the workshop was refined following participant and operational partner feedback using a quality improvement framework. Rating quantitative items on a 1-5 scale, participants found the overall quality (M = 4.76) and relevance (M = 4.82) to be excellent, noting they learned substantial new information (M = 4.45). Sense of support (M = 4.95), intentions to use the material (M = 4.87), PTSD self-efficacy (M = 4.41), and understanding of PTSD (M = 4.76) were rated favorably. Common themes among helpful elements were a sense of shared experience and optimism and increased knowledge of treatments/resources. Suggestions for improvement referenced logistics. Following continual stakeholder feedback and refinement, the workshop represents a novel method for providing loved ones with empirically supported psychoeducation, coping skills, and community. It is being disseminated by the Family Services Section of the Veterans Health Administration Office of Mental Health and Suicide Prevention.
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Affiliation(s)
- Sarah B Campbell
- VA Puget Sound Health Care System, Seattle, Washington, USA.,Department of Psychiatry and Behavioral Sciences University of Washington School of Medicine, Seattle, Washington, USA
| | - Catherine M Caska Wallace
- VA Puget Sound Health Care System, Seattle, Washington, USA.,Coatesville VA Health Care System, Coatesville, Pennsylvania, USA
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15
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Wiltsey Stirman S, La Bash H, Nelson D, Orazem R, Klein A, Sayer NA. Assessment of modifications to evidence-based psychotherapies using administrative and chart note data from the US department of veterans affairs health care system. Front Public Health 2022; 10:984505. [PMID: 36457312 PMCID: PMC9705357 DOI: 10.3389/fpubh.2022.984505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Accepted: 10/25/2022] [Indexed: 11/17/2022] Open
Abstract
Background The US Department of Veterans Affairs (VA) has over 15 years of experience in delivery of evidence-based psychotherapies (EBPs). This paper describes strategies for using clinical documentation and administrative data to understand adherence and modifications to EBPs for Posttraumatic Stress Disorder (PTSD). Methods This study focused on two EBPs for PTSD, Cognitive Processing Therapy (CPT) and Prolonged Exposure (PE). The sample included VA therapists from across the US who provided CPT and PE and the patients they treated over a 1-year period. The data sources for this study were templated EBP chart notes and VA administrative data. We used a manual review of note content and administrative data rules to code therapy adherence and modifications in 7,297 EBP sessions for 1,257 patients seen by 182 therapists. Two trained coders rated each therapy note and resolved discrepancies through consensus. To contextualize and explain variation in adherence and modifications, we conducted brief 30-45-min semi-structured interviews with a purposive subsample of these therapists (n = 32). Findings Combining manual chart review and administrative data allowed for identification of 11 types of modifications. Raters disagreed on adherence for 30% of notes. The disagreement stemmed from the presence of therapy modifications that were not clearly documented, necessitating the development of decision rules and strategies for modification coding. Both therapists and patients contributed to the variance in the extent to which different modifications occurred. Therapist interviews demonstrated therapist awareness of modifying the protocols in the ways identified through chart review. Conclusion Healthcare systems can use data collected as part of routine care to understand how and when EBPs are modified but need to develop scalable strategies to document adaptations and modifications to EBPs in routine care.
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Affiliation(s)
- Shannon Wiltsey Stirman
- National Center for PTSD, VA Palo Alto Healthcare System, Menlo Park, CA, United States,Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, United States,*Correspondence: Shannon Wiltsey Stirman
| | - Heidi La Bash
- National Center for PTSD, VA Palo Alto Healthcare System, Menlo Park, CA, United States
| | - David Nelson
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, MN, United States,Department of Medicine, University of Minnesota, Minneapolis, MN, United States
| | - Robert Orazem
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, MN, United States
| | - Abigail Klein
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, MN, United States
| | - Nina A. Sayer
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, MN, United States,Department of Medicine and Psychiatry, University of Minnesota, Minneapolis, MN, United States
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