A Resource Building Virtual Care Programme: improving symptoms and social functioning among female and male rural veterans

Sex and gender in psychotrauma research

Background: Posttraumatic stress disorder (PTSD) is two to three times more common in women than in men. To better understand this phenomenon, we need to know why men, women, and possibly individuals with other sex/gender identities respond differently to trauma. To stimulate sex and gender sensitive research, the European Journal of Psychotraumatology (EJPT) was the first journal to adopt a gender policy. In addition, a call for papers entitled Integrating and Evaluating Sex and Gender in Psychotrauma Research was announced.Objective: This special issue synthesizes the past five years of psychotrauma research with regard to sex/gender differences.Method: Seventy-seven articles were identified from EJPT archives, including five systematic reviews. These articles examined sex differences and/or gender differences in exposure to trauma, posttraumatic stress responses, or how sex and gender impacts (mental) health outcomes or treatment responses.Results: Findings from these studies outlined that: 1. sex and gender still need to be more clearly defined, also in relation to the context that codetermine trauma responses, like other 'diversity' variables; 2. in most studies, sex and gender are measured or reported as binary variables; 3. sex and gender are important variables when examining trauma exposure, responses to these events, symptoms trajectories, and mental and physical health outcomes across the life span; and 4. in PTSD treatment studies, including a meta-analysis and a systematic review, sex and gender were not significant predictors of treatment outcome.Conclusion: Future research must focus on sex and gender as important and distinct variables; they should include sex and gender in their statistical analyses plan to better clarify associations between these variables and (responses to) psychotrauma. To enhance reporting of comparable data across studies, we provide suggestions for future research, including how to assess sex and gender.

Rural Patients' Experiences with Synchronous Video Telehealth in the United States: A Scoping Review

Background: Telehealth can help increase rural health care access. To ensure this modality is accessible for rural patients, it is necessary to understand rural patients' experiences with telehealth. Objectives of this scoping review were to explore how rural patients' telehealth experiences have been measured, assess relevant research, and describe rural telehealth patient experiences. Methods: We searched five databases for articles published from 2016 through 2022. Primary research reports assessing rural adult patient experiences with synchronous video telehealth in the United States in any clinical area were included. Data collected pertained to study characteristics and patient experience assessment characteristics and outcomes. Quality of included studies was assessed using the Quality Assessment with Diverse Studies tool. Review findings were presented in a narrative synthesis. Results: There were 740 articles identified for screening, and 24 met review inclusion criteria. Most studies (70%, n = 16) assessed rural telehealth patient experience using questionnaires; studies employed interviews (n = 11) alone or in combination with surveys. The majority of surveys were study developed and not validated. Quantitative patient experience outcomes fell under categories of patient satisfaction, telehealth care characteristics, patient-provider rapport, technology elements, and access. Qualitative themes were most often presented as telehealth benefits or facilitators, and drawbacks or barriers. Conclusions: Available research indicates positive patient experiences with rural telehealth services. However, study weaknesses limit generalizability of findings. Future research should apply established definitions for participant rurality and clearly group samples by rurality. Efforts should be made to use validated telehealth patient experience measures.

Preliminary Investigation Into the Effectiveness of Group webSTAIR for Trauma-exposed Veterans in Primary Care

INTRODUCTION

A substantial number of trauma-exposed veterans seen in primary care report significant symptoms of PTSD and depression. While primary care mental health integration (PCMHI) providers have been successful in delivering brief mental health treatments in primary care, few studies have evaluated interventions that combine mobile health resources with PCMHI groups. This pilot study assessed the potential benefits of webSTAIR, a 10-module transdiagnostic treatment for trauma-exposed individuals, supported by 5 biweekly group sessions delivered via telehealth. The transdiagnostic and mobile health nature of the treatment, as well as the therapist and peer support provided through group sessions, may offer an innovative approach to increasing access to patient-centered and trauma-informed treatment in primary care settings.

MATERIALS AND METHODS

Thirty-nine male and female veterans with trauma-related symptoms (i.e., PTSD and/or depression) participated in group webSTAIR. Mixed effects analyses were conducted to assess changes in PTSD and depression at pre-, mid-, and post-treatment. Baseline symptom severity was assessed as a predictor of module completion and group attendance. The project was part of a VHA quality improvement project, and IRB approval was waived by the affiliated university.

RESULTS

Analyses revealed significant pre-to-post improvement in both PTSD and depression outcomes with a large effect size for PTSD (Hedges' gav = 0.88) and medium to large for depression (Hedges' gav = 0.73). Of participants who completed the baseline assessment, 90% began webSTAIR; of those, 71% completed the program. Baseline symptoms of PTSD and depression did not predict group attendance or module completion.

CONCLUSIONS

Good outcomes and a satisfactory retention rate suggest that group webSTAIR may provide easily accessible, high-quality, and effective treatment for patients presenting with trauma-related problems without increasing therapist or system burdens. The results suggest the value of conducting a randomized controlled trial to test the effectiveness of group webSTAIR relative to PCMHI usual care or other evidence-based, disorder-specific (e.g., PTSD) treatments for trauma-exposed individuals in PCMHI.

Patient Satisfaction With a Coach-Guided, Technology-Based Mental Health Treatment: Qualitative Interview Study and Theme Analysis

BACKGROUND

Technology-based mental health interventions address barriers rural veterans face in accessing care, including provider scarcity and distance from the hospital or clinic. webSTAIR is a 10-module, web-based treatment based on Skills Training in Affective and Interpersonal Regulation, designed to treat posttraumatic stress disorder and depression in individuals exposed to trauma. Previous work has demonstrated that webSTAIR is acceptable to participants and effective at reducing symptoms of posttraumatic stress disorder and depression when delivered synchronously or asynchronously (over 5 or 10 sessions).

OBJECTIVE

This study explored factors that lead to greater patient satisfaction with webSTAIR, a web-based, coach-guided intervention.

METHODS

We analyzed qualitative interview data to identify themes related to patient satisfaction with webSTAIR delivered with synchronous video-based coaching.

RESULTS

Four themes emerged from the data: (1) coaching provides accountability and support, (2) self-pacing offers value that meets individual needs, (3) participants like the comfort and convenience of the web-based format, and (4) technical issues were common but not insurmountable.

CONCLUSIONS

We conclude that participants valued the accountability, flexibility, and convenience of tech-based interventions with video-delivered coaching.

A prognostic index to predict symptom and functional outcomes of a coached, web-based intervention for trauma-exposed veterans

Researchers at the Department of Veterans Affairs (VA) have studied interventions for posttraumatic stress disorder and co-occurring conditions in both traditional and digital formats. One such empirically supported intervention is web skills training in affective and interpersonal regulation (webSTAIR), a coached, 10-module web program based on STAIR. To understand which patient characteristics were predictive of webSTAIR outcomes in a sample of trauma-exposed veterans (N = 189), we used machine learning (ML) to develop a prognostic index from among 18 baseline characteristics (i.e., demographic, military, trauma history, and clinical) to predict posttreatment posttraumatic stress disorder severity, depression severity, and psychosocial functioning impairment. We compared the ML models to a benchmark of linear regression models in which the only predictor was the baseline severity score of the outcome measure. The ML and "severity-only" models performed similarly, explaining 39%-45% of the variance in outcomes. This suggests that baseline symptom severity and functioning are strong indicators for webSTAIR outcomes in veterans, with higher severity indicating worse prognosis, and that the other variables examined did not contribute significant added predictive signal. Findings also highlight the importance of comparing ML models to an appropriate benchmark. Future research with larger samples could potentially detect smaller patient-level effects as well as effects driven by other types of variables (e.g., therapeutic process variables). As a transdiagnostic, digital intervention, webSTAIR can potentially serve a diverse veteran population with varying trauma histories and may be best conceptualized as a beneficial first step of a stepped care model for those with heightened symptoms or impairment. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Coaching with Internet-Based Mental Health Program: Patient and Coach Experiences

Introduction: The COVID-19 pandemic has laid bare the need for mental health treatment and the shortage of available providers. Internet-based, asynchronous mental health programs that incorporate coaching with a licensed provider address this widespread challenge. This study provides an in-depth exploration of both the patient and provider experience in webSTAIR, a coached, internet-based psychoeducational program, where coaching took place over video-telehealth. We focus on how patients and licensed mental health providers understood their coaching relationship in an internet-based mental health program. Materials and Methods: We interviewed a purposive sample of 60 patients who completed the coached, internet-based program and all 9 providers who provided coaching from 2017 to 2020. The project team and interviewers took notes during interviews. Patient interviews were studied using content and matrix analysis. Coach interviews were studied using thematic analysis. Results: Interviews across patients and coaches reveal the continued importance of relationship building and rapport and emphasized the central role of the coach in providing content clarification and application of skills. Discussion: For patients, coaches were critical for understanding and completing the internet-based program. As well, positive relationship with their coach further enhanced their experience in the program. Providers echoed the importance of relationship building and rapport for program success and saw their main role as helping patients to understand content and apply skills.

Study protocol for a hybrid 1 effectiveness-implementation trial of Brief Skills Training in Affective and Interpersonal Regulation (Brief STAIR) and web-administered STAIR (webSTAIR) for posttraumatic stress disorder in integrated primary care

BACKGROUND

Posttraumatic stress disorder (PTSD) disproportionally affects low-income, racial and ethnic minoritized communities, where prevalence is high, yet access to evidence-based treatments (EBTs) is low. As such, there is a need to identify effective, feasible, and scalable interventions for PTSD. Stepped care approaches that include brief, low-intensity treatments are one approach to improving access yet have not been developed for adults with PTSD. Our study aims to test the effectiveness of a step one PTSD treatment in primary care while gathering information on implementation to maximize sustainability in the setting.

METHODS

This study will be conducted in integrated primary care in the largest safety net hospital in New England using a hybrid type 1 effectiveness-implementation design. Eligible trial participants are adult primary care patients who meet full or subthreshold criteria for PTSD. Interventions include Brief clinician-administered Skills Training in Affective and Interpersonal Regulation (Brief STAIR) versus web-administered STAIR (webSTAIR) during a 15-week active treatment period. Participants complete assessments at baseline (pre-treatment), 15 weeks (post-treatment), and 9 months (follow-up) post-randomization. We will assess feasibility and acceptability post-trial using surveys and interviews with patients, study therapists, and other key informants, and will assess the preliminary effectiveness of interventions in terms of PTSD symptom change and functioning.

CONCLUSION

This study will provide evidence for the feasibility, acceptability, and preliminary effectiveness of brief, low-intensity interventions in safety net integrated primary care, with the aim of including these interventions in a future stepped care approach to PTSD treatment.

CLINICAL TRIAL NUMBER

NCT04937504.

Whole Health coaching to rural Veterans through telehealth: Advantages, gaps, and opportunities

Background

The Veterans Health Administration (VHA) is one of the largest providers of telehealth in the United States and continues to lead the way in transforming healthcare services. VHA has been implementing its Whole Health (WH) initiative since 2018, a proactive practice empowering patients to take charge of their health and well-being. A key facilitator of the WH initiative is the WH coach who partners with Veterans to achieve their health-related goals. A gap exists in the literature regarding the understanding of WH coaches’ use of telehealth to engage rural-residing Veterans. COVID-19 unexpectedly interrupted in-person VHA delivery of care, including WH coaching which primarily relied on in-person delivery and focused less on telehealth. During the pandemic, WH coaches had to adapt and integrate different modalities to engage their Veteran patients. We examined WH coaches’ approaches to extending coaching to rural Veterans via technology, emphasizing the advantages of telehealth, existing gaps in telehealth delivery, and opportunities for telehealth as a coaching modality.

Methods

This project was implemented as part of a larger mixed methods evaluation regarding WH coaching for rural Veterans; this manuscript presents the findings from the qualitative data from the larger study. The qualitative dataset is comprised of data collected using three different qualitative methods: four focus groups (n = 11; 3–4 participants per group), in-depth individual interviews (n = 9), and open-ended responses from a national web-based survey (n = 140). Focus group, in-depth interview, and open-ended survey data were collected sequentially and separately analyzed following each wave of data collection. Findings from the three analyses were then collaboratively merged, compared, reorganized, and refined by the evaluation team to create final themes.

Results

Three final themes that emerged from the merged data were: (1) Advantages of Telehealth; (2) Telehealth Gaps for Rural Veterans, and (3) Strategies for Bridging Telehealth Gaps. Themes explicate telehealth advantages, gaps, and opportunities for rural Veteran WH coaching.

Conclusion

Findings highlight that video telehealth alone is not sufficient for meeting the needs of rural Veterans. Digital technologies hold promise for equalizing health access gaps; however, both human factors and broadband infrastructure constraints continue to require WH coaches to use a mix of modalities in working with rural Veterans. To overcome challenges and bridge gaps, WH coaches should be ready to adopt a blended approach that integrates virtual, in-person, and lower-tech options.

Exploring the Role of Social Connection in Interventions With Military Veterans Diagnosed With Post-traumatic Stress Disorder: Systematic Narrative Review

Background

It has been identified that military veterans have distinct experiences of loneliness and social isolation and, when comparing this community to other client groups with a PTSD diagnosis, veterans respond less favorably to treatment. However, the link between PTSD and loneliness for veterans remains insufficiently researched and it is unclear if there are effective interventions tackling this distinct experience of loneliness.

Aims

This systematic narrative review aimed to synthesize existing evidence incorporating elements of social connection, social isolation, and loneliness within interventions for military veterans with a diagnosis of PTSD, consequently aiming to examine the impact of such interventions upon this community.

Methods

Six databases were searched, utilizing relevant search criteria, with no date restrictions. Articles were included if they involved intervention or treatment for military veterans with PTSD and considered elements of social connection, social isolation, and/or loneliness. The initial search returned 202 papers. After exclusions, removal of duplications, and a reference/citation search, 28 papers remained and were included in this review.

Results

From the 28 studies, 11 directly addressed social isolation and two studies directly addressed loneliness. Six themes were generated: (i) rethinking the diagnosis of PTSD, (ii) holistic interventions, (iii) peer support, (iv) social reintegration, (v) empowerment through purpose and community, and (vi) building trust.

Conclusions

A direct focus upon social reintegration and engagement, psychosocial functioning, building trust, peer support, group cohesiveness and empowerment through a sense of purpose and learning new skills may mitigate experiential loneliness and social isolation for veterans with PTSD. Future research and practice should further explore the needs of the PTSD-diagnosed veteran community, seek to explore and identify potential common routes toward the development of PTSD within this community and consider bespoke interventions for tackling loneliness.

Comparing the Ratio of Therapist Support to Internet Sessions in a Blended Therapy Delivered to Trauma-Exposed Veterans: Quasi-experimental Comparison Study

BACKGROUND

Blended models of therapy, which incorporate elements of both internet and face-to-face methods, have been shown to be effective, but therapists and patients have expressed concerns that fewer face-to-face therapy sessions than self-guided internet sessions may be associated with lower therapeutic alliance, lower program completion rates, and poorer outcomes.

OBJECTIVE

A multisite quasi-experimental comparison study with a noninferiority design implemented in routine clinical care was used to assess webSTAIR, a 10-module blended therapy derived from STAIR (skills training in affective and interpersonal regulation) for trauma-exposed individuals delivered with 10 weekly therapist sessions (termed Coach10) compared to 5 biweekly sessions (Coach5). It was hypothesized that Coach5 would be as good as Coach10 in a range of outcomes.

METHODS

A total of 202 veterans were enrolled in the study with 101 assigned to Coach5 and 101 to Coach10. Posttraumatic stress disorder (PTSD) symptoms, depression, emotion regulation, interpersonal problems, and social functioning measures were collected pre-, mid-, and posttreatment, and at a 3-month follow-up. Noninferiority analyses were conducted on symptom outcome measures. Comparisons were made of continuous and categorical measures regarding participant and therapist activities.

RESULTS

Participants reported moderate to severe levels of baseline PTSD, depression, or both. Significant reductions were obtained in all symptom measures posttreatment and at the 3-month follow up. Coach5 was not inferior to Coach10 in any outcome. Therapeutic alliance was at an equivalently high level across the 2 treatment conditions; completion rates and web usage were similar. Total session time was substantially less for the Coach5 therapists than the Coach10 therapists. Both programs were associated with a low, but equal number of therapist activities related to scheduling and crisis or motivational sessions.

CONCLUSIONS

A blended model delivered with 5 sessions of therapist support was noninferior to 10 sessions in individuals with moderate to severe symptoms. Future studies identifying patient characteristics as moderators of outcomes with high versus low doses of therapist support will help create flexible, technology-based intervention programming.

Redesign of a brief PTSD treatment in safety net integrated primary care: Supporting implementation in the context of the COVID-19 pandemic

OBJECTIVE

We conducted a formative evaluation to understand the impact of the COVID-19 pandemic on the safety net integrated primary care setting and to identify (and respond to) new implementation barriers prior to a hybrid type I effectiveness-implementation trial of a posttraumatic stress disorder (PTSD) treatment.

METHOD

We used surveys and qualitative interviews with employee stakeholders (N = 27) to (1) understand pandemic-related factors that may influence implementation, including changes in patient needs, provider experiences, and the practice, and (2) assess the need for augmentation to study design, implementation plan, or intervention.

RESULTS

Conventional content analysis and survey findings suggest that patient acuity and volume increased provider burden, leading to high burnout. Although the shift to telehealth improved behavioral health access, issues with technology access and literacy were common. Changes to the study design and implementation plan, based on findings, included the provision of multi-modality treatments (in person, telehealth, web-administered), technology and administrative support, and other strategies for reducing provider burnout.

CONCLUSIONS

This study describes how an ongoing research study adapted to major changes to the implementation setting during the pandemic. Changes to study design and implementation plan were responsive to the shift to telehealth and therapist burden (and burnout) concerns.

Increasing access to care for trauma-exposed rural veterans: A mixed methods outcome evaluation of a web-based skills training program with telehealth-delivered coaching

PURPOSE

While rural veterans with trauma exposure report high rates of posttraumatic stress disorder (PTSD), depression, and functional impairment, utilization of health services is low. This pilot study used mixed qualitative and quantitative methods to evaluate the potential benefits of a transdiagnostic web-based skills training program paired with telehealth-delivered coaching to address a range of symptoms and functional difficulties. The study directed substantial outreach efforts to women veterans who had experienced military sexual trauma given their growing representation in the Veterans Healthcare Administration (VHA) and identified need for services.

METHODS

Participants were 32 trauma-exposed veterans enrolled in rural-serving VHA facilities who screened positive for either PTSD or depression. Symptoms of PTSD, depression, emotion regulation, and interpersonal problems were assessed at baseline, midpoint, posttreatment, and 3-month follow-up. Veterans completed exit interviews to identify benefits and limitations of the program.

RESULTS

Intent-to-treat analyses revealed significant symptom reduction for all outcomes, with large to moderate effect sizes at 3-month follow-up. Outcomes did not differ by gender or military sexual trauma status. Veterans' rating of the therapeutic alliance was high and interview responses indicated that the presence of the coach was critical to success in the program.

CONCLUSION

This remotely delivered transdiagnostic intervention provided significant benefits across a range of symptoms and functional outcomes and was viewed positively by veterans. The results indicate that further research (ie, a randomized controlled trial) is warranted. Attention to the role of the coach as a means by which to increase engagement and retention in technology-delivered interventions is warranted.

The international trauma questionnaire (ITQ) measures reliable and clinically significant treatment-related change in PTSD and complex PTSD

Background: The International Trauma Questionnaire (ITQ) is a validated measure that assesses ICD-11 posttraumatic stress disorder (PTSD) and complex PTSD (CPTSD). An important task is to determine whether the ITQ is an appropriate evaluative measure for clinical trials. Objective: To assess the psychometric properties of the ITQ in the context of treatment and determine if the ITQ measures reliable and clinically significant change over the course of a psychosocial intervention. Method: Analyses were based on data from an online skills training programme delivered to 254 U.S. Veterans. Reliability and validity of the ITQ scores were assessed at baseline. Changes in symptom scores and probable diagnostic rates were compared at pre-, mid- and post-treatment. A reliable change index (RCI) score was computed to classify participants as improved, unchanged, or worsened. The PCL-5 was used as a comparison measure. Results: Baseline concurrent and factorial validity was similar to previous studies. Internal consistency at each assessment was excellent and comparable to the PCL-5. Decline in symptoms from pre-to-post-treatment was significant for PTSD and CPTSD symptom profiles. Rate of probable disorder (PTSD or CPTSD) declined significantly from pre-treatment to post-treatment. Pre-to-post treatment declines exceeded the critical RCI values for the ITQ. Clinically significant changes were observed where most participants improved, some stayed the same, and few worsened. The performance of the ITQ was consistent with the PCL-5 regarding sensitivity to change. Conclusion: This study provides the first demonstration that the ITQ measures reliable and clinically significant treatment-related change of ICD-11 PTSD and CPTSD symptoms.