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Saulnier KG, Panaite V, Ganoczy D, Kim HM, Zivin K, Hofer T, Piette JD, Pfeiffer PN. Depression symptom outcomes and re-engagement among VA patients who discontinue care while symptomatic. Gen Hosp Psychiatry 2023; 85:87-94. [PMID: 37862961 DOI: 10.1016/j.genhosppsych.2023.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 10/12/2023] [Accepted: 10/12/2023] [Indexed: 10/22/2023]
Abstract
OBJECTIVE Evaluate outcomes of Veterans who discontinued treatment with at least moderate ongoing depressive symptoms. METHOD Veterans with elevated depression symptoms from 29 Department of Veterans Affairs facilities completed baseline surveys and follow-up assessments for one year. Analyses examined rates and predictors of treatment discontinuation, treatment re-engagement, and subsequent symptoms among patients who remained out of care. RESULTS A total of 242 (17.8%; n = 1359) participants discontinued treatment while symptomatic, with Black participants, participants with less severe depression, and participants receiving only psychotherapy (versus combined psychotherapy and antidepressant medications) discontinuing at higher rates. Among all participants who discontinued treatment (n = 445), 45.8% re-engaged within the following six months with participants receiving combined treatment re-engaging at higher rates. Of participants who discontinued while symptomatic within the first 6 months of the study and did not return to care (n = 112), 68.8% remained symptomatic at 12 months. Lower baseline treatment expectancy and greater depression symptom severity were associated with remaining symptomatic while untreated. CONCLUSIONS Black race, lower symptom severity, and treatment modality may help identify patients at higher risk for discontinuing care while symptomatic, whereas patients with lower treatment expectations may be at greater risk for remaining out of care despite continuing symptoms.
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Affiliation(s)
- K G Saulnier
- VA Serious Mental Illness Treatment Resource and Evaluation Center, Ann Arbor, MI, USA; VA Ann Arbor Healthcare System, Ann Arbor, MI, USA; University of Michigan Medical School, Ann Arbor, MI, USA.
| | - V Panaite
- James A. Haley Veterans' Hospital, Tampa, FL, USA
| | - D Ganoczy
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - H M Kim
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA; University of Michigan Consulting for Statistics, Computing, and Analytics Research, Ann Arbor, MI, USA
| | - K Zivin
- University of Michigan Medical School, Ann Arbor, MI, USA; VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA; School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - T Hofer
- University of Michigan Medical School, Ann Arbor, MI, USA; VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - J D Piette
- University of Michigan Medical School, Ann Arbor, MI, USA; VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA; School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - P N Pfeiffer
- VA Ann Arbor Healthcare System, Ann Arbor, MI, USA; University of Michigan Medical School, Ann Arbor, MI, USA; VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
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Gross GM, Smith N, Holliday R, Rozek DC, Hoff R, Harpaz-Rotem I. Racial Disparities in Clinical Outcomes of Veterans Affairs Residential PTSD Treatment Between Black and White Veterans. Psychiatr Serv 2022; 73:126-132. [PMID: 34369806 DOI: 10.1176/appi.ps.202000783] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Racial disparities across various domains of health care are a long-standing public health issue that affect a variety of clinical services and health outcomes. Mental health research has shown that prevalence rates of posttraumatic stress disorder (PTSD) are high for Black veterans compared with White veterans, and some studies suggest poorer clinical outcomes for Black veterans with PTSD. The aim of this study was to examine the impact of racial disparities longitudinally in the U.S. Department of Veterans Affairs (VA) residential rehabilitation treatment programs (RRTPs). METHODS Participants included 2,870 veterans treated nationally in VA PTSD RRTPs in fiscal year 2017. Veterans provided demographic data upon admission to the program. Symptoms of PTSD and depression were collected at admission, discharge, and 4-month follow-up. Hierarchical linear modeling was used to examine symptom change throughout and after treatment. RESULTS Black veterans experienced attenuated PTSD symptom reduction during treatment as well as greater depression symptom recurrence 4 months after discharge, relative to White veterans. CONCLUSIONS This study adds to the body of literature that has documented poorer treatment outcomes for Black compared with White veterans with PTSD. Although both Black and White veterans had an overall reduction in symptoms, future research should focus on understanding the causes, mechanisms, and potential solutions to reduce racial disparities in mental health treatment.
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Affiliation(s)
- Georgina M Gross
- U.S. Department of Veterans Affairs Northeast Program Evaluation Center, West Haven, Connecticut (Gross, Smith, Hoff, Harpaz-Rotem); Yale University School of Medicine, New Haven, Connecticut (Gross, Smith, Hoff, Harpaz-Rotem); Rocky Mountain Mental Illness Research, Education and Clinical Center for Veteran Suicide Prevention, Aurora, Colorado (Holliday); University of Colorado Anschutz Medical Campus, Aurora (Holliday); UCF RESTORES, University of Central Florida, Orlando (Rozek)
| | - Noelle Smith
- U.S. Department of Veterans Affairs Northeast Program Evaluation Center, West Haven, Connecticut (Gross, Smith, Hoff, Harpaz-Rotem); Yale University School of Medicine, New Haven, Connecticut (Gross, Smith, Hoff, Harpaz-Rotem); Rocky Mountain Mental Illness Research, Education and Clinical Center for Veteran Suicide Prevention, Aurora, Colorado (Holliday); University of Colorado Anschutz Medical Campus, Aurora (Holliday); UCF RESTORES, University of Central Florida, Orlando (Rozek)
| | - Ryan Holliday
- U.S. Department of Veterans Affairs Northeast Program Evaluation Center, West Haven, Connecticut (Gross, Smith, Hoff, Harpaz-Rotem); Yale University School of Medicine, New Haven, Connecticut (Gross, Smith, Hoff, Harpaz-Rotem); Rocky Mountain Mental Illness Research, Education and Clinical Center for Veteran Suicide Prevention, Aurora, Colorado (Holliday); University of Colorado Anschutz Medical Campus, Aurora (Holliday); UCF RESTORES, University of Central Florida, Orlando (Rozek)
| | - David C Rozek
- U.S. Department of Veterans Affairs Northeast Program Evaluation Center, West Haven, Connecticut (Gross, Smith, Hoff, Harpaz-Rotem); Yale University School of Medicine, New Haven, Connecticut (Gross, Smith, Hoff, Harpaz-Rotem); Rocky Mountain Mental Illness Research, Education and Clinical Center for Veteran Suicide Prevention, Aurora, Colorado (Holliday); University of Colorado Anschutz Medical Campus, Aurora (Holliday); UCF RESTORES, University of Central Florida, Orlando (Rozek)
| | - Rani Hoff
- U.S. Department of Veterans Affairs Northeast Program Evaluation Center, West Haven, Connecticut (Gross, Smith, Hoff, Harpaz-Rotem); Yale University School of Medicine, New Haven, Connecticut (Gross, Smith, Hoff, Harpaz-Rotem); Rocky Mountain Mental Illness Research, Education and Clinical Center for Veteran Suicide Prevention, Aurora, Colorado (Holliday); University of Colorado Anschutz Medical Campus, Aurora (Holliday); UCF RESTORES, University of Central Florida, Orlando (Rozek)
| | - Ilan Harpaz-Rotem
- U.S. Department of Veterans Affairs Northeast Program Evaluation Center, West Haven, Connecticut (Gross, Smith, Hoff, Harpaz-Rotem); Yale University School of Medicine, New Haven, Connecticut (Gross, Smith, Hoff, Harpaz-Rotem); Rocky Mountain Mental Illness Research, Education and Clinical Center for Veteran Suicide Prevention, Aurora, Colorado (Holliday); University of Colorado Anschutz Medical Campus, Aurora (Holliday); UCF RESTORES, University of Central Florida, Orlando (Rozek)
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Bramoweth AD, Tighe CA, Berlin GS. Insomnia and Insomnia-Related Care in the Department of Veterans Affairs: An Electronic Health Record Analysis. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:8573. [PMID: 34444321 PMCID: PMC8394102 DOI: 10.3390/ijerph18168573] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 08/10/2021] [Accepted: 08/11/2021] [Indexed: 11/18/2022]
Abstract
The objective was to examine insomnia and insomnia-related care within a regional network of Department of Veterans Affairs (VA) facilities since the VA roll-out of cognitive behavioral therapy for insomnia (CBT-I) in 2011. A retrospective analysis of VA electronic health records (EHR) data from 2011 to 2019 was conducted. The annual and overall prevalence of four insomnia indicators was measured: diagnoses, medications, consultations for assessment/treatment, and participation in CBT-I. Also examined were sociodemographic and clinical differences among veterans with and without an insomnia indicator, as well as differences among the four individual insomnia indicators. The sample included 439,887 veterans, with 17% identified by one of the four indicators; medications was most common (15%), followed by diagnoses (6%), consults (1.5%), and CBT-I (0.6%). Trends over time included increasing yearly rates for diagnoses, consults, and CBT-I, and decreasing rates for medications. Significant differences were identified between the sociodemographic and clinical variables across indicators. An evaluation of a large sample of veterans identified that prescription sleep medications remain the best way to identify veterans with insomnia. Furthermore, insomnia continues to be under-diagnosed, per VA EHR data, which may have implications for treatment consistent with clinical practice guidelines and may negatively impact veteran health.
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Affiliation(s)
- Adam D. Bramoweth
- VISN 4 Mental Illness Research, Education and Clinical Center, VA Pittsburgh Healthcare System, Research Office Building (151RU/MIRECC), University Drive, Pittsburgh, PA 15240, USA;
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Research Office Building (151C), University Drive, Pittsburgh, PA 15240, USA
| | - Caitlan A. Tighe
- VISN 4 Mental Illness Research, Education and Clinical Center, VA Pittsburgh Healthcare System, Research Office Building (151RU/MIRECC), University Drive, Pittsburgh, PA 15240, USA;
| | - Gregory S. Berlin
- VA Connecticut Healthcare System, 950 Campbell Avenue (116B), West Haven, CT 06516, USA;
- Department of Psychiatry, Yale University School of Medicine, 300 George Street, New Haven, CT 06511, USA
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Holder N, Shiner B, Li Y, Madden E, Neylan TC, Seal KH, Lujan C, Patterson OV, DuVall SL, Maguen S. Cognitive Processing Therapy for Veterans with Posttraumatic Stress Disorder: What is the Median Effective Dose? J Affect Disord 2020; 273:425-433. [PMID: 32560937 DOI: 10.1016/j.jad.2020.04.030] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Revised: 02/27/2020] [Accepted: 04/21/2020] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Cognitive Processing Therapy (CPT) has been disseminated in the Veterans Health Administration (VHA) to treat posttraumatic stress disorder (PTSD). Identifying the median effective dose (MED) of CPT, the number of sessions at which the probability of experiencing clinically meaningful improvement (CMI) is 50%, can assist with treatment. METHOD From a cohort of Iraq and Afghanistan war veterans who received PTSD psychotherapy in VHA between 2001-2017, veterans who received CPT with available PTSD symptom outcomes (PTSD Checklist; PCL) were identified using natural language processing (n=26,189). Cox proportional hazards regression was used to examine how number of CPT sessions, together with covariates, influenced CMI (10-point PCL reduction). Kaplan-Meier curves were plotted to determine MED. RESULTS At eight sessions, there was a 50% probability of experiencing CMI. The Cox proportional hazard regression indicated a greater likelihood of CMI in fewer sessions for veterans who received individual-only CPT versus any group CPT (HR:1.31, 95%CI:1.23-1.39). Kaplan-Meier curves indicated a 50% probability of experiencing CMI at seven sessions for veterans who received individual-only CPT versus ten sessions for veterans receiving any group CPT. LIMITATIONS PCL data was not available for all veterans who received CPT or at each potential assessment point. Not all veterans continued in CPT until CMI was observed. CONCLUSIONS The MED of CPT was eight sessions. Fewer sessions were needed to reach MED for veterans who received individual versus group CPT. These results may help those who treat, research, and are recovering from PTSD through accurately anchoring treatment expectations and providing a marker of initial treatment response.
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Affiliation(s)
- Nicholas Holder
- San Francisco Veterans Affairs Health Care System; Sierra Pacific Mental Illness Research, Education, and Clinical Center; University of California San Francisco School of Medicine.
| | - Brian Shiner
- White River Junction Veterans Affairs Medical Center; Geisel School of Medicine at Dartmouth; National Center for Posttraumatic Stress Disorder, Executive Division
| | - Yongmei Li
- San Francisco Veterans Affairs Health Care System
| | - Erin Madden
- San Francisco Veterans Affairs Health Care System
| | - Thomas C Neylan
- San Francisco Veterans Affairs Health Care System; Sierra Pacific Mental Illness Research, Education, and Clinical Center; University of California San Francisco School of Medicine
| | - Karen H Seal
- San Francisco Veterans Affairs Health Care System; University of California San Francisco School of Medicine
| | - Callan Lujan
- San Francisco Veterans Affairs Health Care System
| | - Olga V Patterson
- Department of Veterans Affairs Salt Lake City Health Care System; University of Utah School of Medicine
| | - Scott L DuVall
- Department of Veterans Affairs Salt Lake City Health Care System; University of Utah School of Medicine
| | - Shira Maguen
- San Francisco Veterans Affairs Health Care System; Sierra Pacific Mental Illness Research, Education, and Clinical Center; University of California San Francisco School of Medicine
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Manyam SB, Davis TL, Mitchell CD. Trauma Group Therapy with African American Children and Adolescents: A 30-plus Year Content Analysis. JOURNAL FOR SPECIALISTS IN GROUP WORK 2019. [DOI: 10.1080/01933922.2019.1699619] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Holliday RP, Holder ND, Williamson MLC, Surís A. Therapeutic response to Cognitive Processing Therapy in White and Black female veterans with military sexual trauma-related PTSD. Cogn Behav Ther 2017; 46:432-446. [PMID: 28485687 DOI: 10.1080/16506073.2017.1312511] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Cognitive Processing Therapy (CPT) is an evidence-based treatment (EBT) for posttraumatic stress disorder (PTSD) which has been validated for female veterans with military-related PTSD. Existing trials have enrolled predominantly White veterans with some studies documenting higher rates of early termination from EBTs among Black females when compared to White females. Data from a previously published randomized clinical trial were used to evaluate the effectiveness of CPT for Black female veterans with military sexual trauma (MST)-related PTSD. Reductions in PTSD symptom severity, number of sessions attended, and early termination rates were compared between Black (n = 20) and White (n = 16) female veterans. A hierarchical linear modeling approach was used, with PTSD symptom severity over the course of treatment and follow-up entered as a level-1 variable and race (Black or White) entered as a level-2 predictor. Piecewise growth curves analyses revealed that both Black and White female veterans experienced significant reductions in PTSD symptom severity over the course of treatment and gains were maintained up to 6 months post-treatment. Race was not found to be a significant predictor of change in the slope of PTSD symptom severity over the course of CPT treatment. Additionally, number of sessions attended and rates of early termination did not significantly differ based on race. Results suggest that CPT was a well-tolerated and effective psychotherapeutic treatment for this sample regardless of racial self-identification.
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Affiliation(s)
- Ryan P Holliday
- a Veterans Affairs North Texas Health Care System , Dallas , TX 75216 , USA.,b University of Texas Southwestern Medical Center , Dallas , TX 75390 , USA
| | - Nicholas D Holder
- a Veterans Affairs North Texas Health Care System , Dallas , TX 75216 , USA.,b University of Texas Southwestern Medical Center , Dallas , TX 75390 , USA
| | | | - Alina Surís
- a Veterans Affairs North Texas Health Care System , Dallas , TX 75216 , USA.,b University of Texas Southwestern Medical Center , Dallas , TX 75390 , USA
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