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Shepherd-Banigan M, Shapiro A, Stechuchak KM, Glynn S, Calhoun P, Ackland PE, Bokhour B, Edelman D, Falkovic M, Weidenbacher HJ, Eldridge MR, Lanford T, Swinkels C, Dedert E, Wells S, Ruffin R, Van Houtven CH. Feasibility of a family-involved intervention to increase engagement in evidenced-based psychotherapies for posttraumatic stress disorder: A pilot study. PSYCHOLOGICAL TRAUMA : THEORY, RESEARCH, PRACTICE AND POLICY 2024:2024-44916-001. [PMID: 38236230 PMCID: PMC11255124 DOI: 10.1037/tra0001623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/19/2024]
Abstract
OBJECTIVE To assess the feasibility of a family-involved intervention, family support in mental health recovery (FAMILIAR), for veterans with posttraumatic stress disorder (PTSD) seeking psychotherapy at a single Veterans Administration Health System. METHOD This mixed-methods study reports qualitative and quantitative findings from a single-group pilot of 24 veterans and their support partners (SPs) about experiences with the intervention and interviews with eight VA mental health clinicians and leaders and the study interventionist to explore intervention feasibility. Findings across data sources were merged within domains of Bowen and colleagues' pilot study feasibility framework. RESULTS Out of 24 dyads, 16 veterans and 15 associated SPs completed the intervention. Participants viewed the intervention to be valuable and feasible. Veterans and SPs reported that they enrolled in the study to develop a shared understanding of PTSD and treatment. While participants identified few logistical barriers, finding a time for conjoint sessions could be a challenge. Veterans, SPs, and providers discussed benefits of the intervention, including that it facilitated conversation between the veteran and SP about PTSD and mental health care and helped to prepare the dyad for treatment. Providers noted potential challenges integrating family-involved interventions into clinical workflow in VA and suggested the need for additional training and standardized procedures for family-centered care. CONCLUSIONS Our study identified potential implementation facilitators (e.g., standard operating procedures about session documentation, confidentiality, and family ethics) and challenges (e.g., clinical workflow integration) that require further study to bring FAMILIAR into routine clinical care. (PsycInfo Database Record (c) 2024 APA, all rights reserved).
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Affiliation(s)
- Megan Shepherd-Banigan
- Durham VA Health Care System, 508 Fulton Street Durham, NC, 27705, USA
- Duke University, Department of Population Health Sciences, 215 Morris Street, Durham, NC, 27701
- Duke-Margolis Center for Health Policy, 100 Fuqua Drive, Box 90120, Durham, NC 27708
- Veterans Affairs Mid-Atlantic Region Mental Illness Research, Education, and Clinical Center, Durham, NC 27705
| | - Abigail Shapiro
- Durham VA Health Care System, 508 Fulton Street Durham, NC, 27705, USA
| | | | - Shirley Glynn
- West Los Angeles VA Medical Center, 11301 Wilshire Boulevard, Los Angeles, CA 90073-1003
- David Geffen School of Medicine, UCLA, Geffen Hall, 885 Tiverton Drive Los Angeles, CA 90095
| | - Patrick Calhoun
- Durham VA Health Care System, 508 Fulton Street Durham, NC, 27705, USA
- Veterans Affairs Mid-Atlantic Region Mental Illness Research, Education, and Clinical Center, Durham, NC 27705
- Department of Psychiatry & Behavioral Sciences, Duke University School of Medicine, 905 West Main Street, Durham, NC, 27701
| | - Princess E. Ackland
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, One Veterans Drive, Minneapolis, MN, 55417
- Department of Medicine, University of Minnesota, 420 Delaware St SE, Minneapolis, MN, 55455
| | - Barbara Bokhour
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, 200 Springs Road, Bedford, MA 01730-11
- UMass Chan Medical School, Population and Quantitative Health Sciences, 55 Lake Avenue North Worcester, MA 01655
| | - David Edelman
- Durham VA Health Care System, 508 Fulton Street Durham, NC, 27705, USA
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, 200 Morris Street, Durham, NC, 27701
| | - Margaret Falkovic
- Durham VA Health Care System, 508 Fulton Street Durham, NC, 27705, USA
- Duke University, Department of Population Health Sciences, 215 Morris Street, Durham, NC, 27701
| | | | | | - Tiera Lanford
- Durham VA Health Care System, 508 Fulton Street Durham, NC, 27705, USA
| | - Cindy Swinkels
- Durham VA Health Care System, 508 Fulton Street Durham, NC, 27705, USA
- Veterans Affairs Mid-Atlantic Region Mental Illness Research, Education, and Clinical Center, Durham, NC 27705
| | - Eric Dedert
- Durham VA Health Care System, 508 Fulton Street Durham, NC, 27705, USA
- Veterans Affairs Mid-Atlantic Region Mental Illness Research, Education, and Clinical Center, Durham, NC 27705
- Department of Psychiatry & Behavioral Sciences, Duke University School of Medicine, 905 West Main Street, Durham, NC, 27701
| | - Stephanie Wells
- Durham VA Health Care System, 508 Fulton Street Durham, NC, 27705, USA
- Veterans Affairs Mid-Atlantic Region Mental Illness Research, Education, and Clinical Center, Durham, NC 27705
| | - Rachel Ruffin
- Durham VA Health Care System, 508 Fulton Street Durham, NC, 27705, USA
| | - Courtney H. Van Houtven
- Durham VA Health Care System, 508 Fulton Street Durham, NC, 27705, USA
- Duke University, Department of Population Health Sciences, 215 Morris Street, Durham, NC, 27701
- Duke-Margolis Center for Health Policy, 100 Fuqua Drive, Box 90120, Durham, NC 27708
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Dodge J, Sullivan K, Grau PP, Chen C, Sripada R, Pfeiffer PN. Retention in Individual Trauma-Focused Treatment Following Family-Based Treatment Among US Veterans. JAMA Netw Open 2023; 6:e2349098. [PMID: 38127345 PMCID: PMC10739069 DOI: 10.1001/jamanetworkopen.2023.49098] [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: 09/07/2023] [Accepted: 11/09/2023] [Indexed: 12/23/2023] Open
Abstract
Importance Despite the availability of several empirically supported trauma-focused interventions, retention in posttraumatic stress disorder (PTSD) psychotherapy is poor. Preliminary efficacy data shows that brief, family-based interventions may improve treatment retention in a veteran's individual PTSD treatment, although whether this occurs in routine clinical practice is not established. Objective To characterize receipt of family therapy among veterans diagnosed with PTSD and evaluate whether participation in family therapy is associated with an increased likelihood of completing individual trauma-focused treatment. Design, Setting, and Participants This retrospective cohort study used the Veterans Health Administration (VHA) Informatics and Computing Infrastructure to extract electronic health record data of participants. All participants were US veterans diagnosed with PTSD between October 1, 2015, and December 31, 2019, who attended at least 1 individual trauma-focused treatment session. Statistical analysis was performed from May to August 2023. Exposures Receipt of any family psychotherapy and subtype of family-based psychotherapy. Main Outcomes and Measures Minimally adequate individual trauma-focused treatment completion (ie, 8 or more sessions of trauma-focused treatment in a 6-month period). Results Among a total of 1 516 887 US veterans with VHA patient data included in the study, 58 653 (3.9%) received any family therapy; 334 645 (23.5%) were Black, 1 006 168 (70.5%) were White, and 86 176 (6.0%) were other race; 1 322 592 (87.2%) were male; 1 201 902 (79.9%) lived in urban areas; and the mean (SD) age at first individual psychotherapy appointment was 52.7 (15.9) years. Among the 58 653 veterans (3.9%) who received any family therapy, 36 913 (62.9%) received undefined family therapy only, 15 528 (26.5%) received trauma-informed cognitive-behavioral conjoint therapy (CBCT) only, 5210 (8.9%) received integrative behavioral couples therapy (IBCT) only, and 282 (0.5%) received behavioral family therapy (BFT) only. Compared with receiving no family therapy, the odds of completing individual PTSD treatment were 7% higher for veterans who also received CBCT (OR, 1.07 [95% CI, 1.01-1.13]) and 68% higher for veterans received undefined family therapy (OR, 1.68 [95% CI, 1.63-1.74]). However, compared with receiving no family therapy care, veterans had 26% lower odds of completing individual PTSD treatment if they were also receiving IBCT (OR, 0.74 [95% CI, 0.66-0.82]). Conclusions and Relevance In this cohort study of US veterans, family-based psychotherapies were found to differ substantially in their associations with individual PTSD psychotherapy retention. These findings highlight potential benefits of concurrently providing family-based therapy with individual PTSD treatment but also the need for careful clinical attention to the balance between family-based therapies and individual PTSD treatment.
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Affiliation(s)
- Jessica Dodge
- Health Services Research and Development/Center for Clinical Management Research, Ann Arbor Veterans Affairs Hospital (152), Ann Arbor, Michigan
| | | | - Peter P. Grau
- Health Services Research and Development/Center for Clinical Management Research, Ann Arbor Veterans Affairs Hospital (152), Ann Arbor, Michigan
- Department of Psychiatry, University of Michigan Medical School, Ann Arbor
| | - Charity Chen
- Health Services Research and Development/Center for Clinical Management Research, Ann Arbor Veterans Affairs Hospital (152), Ann Arbor, Michigan
| | - Rebecca Sripada
- Health Services Research and Development/Center for Clinical Management Research, Ann Arbor Veterans Affairs Hospital (152), Ann Arbor, Michigan
- Department of Psychiatry, University of Michigan Medical School, Ann Arbor
| | - Paul N. Pfeiffer
- Health Services Research and Development/Center for Clinical Management Research, Ann Arbor Veterans Affairs Hospital (152), Ann Arbor, Michigan
- Department of Psychiatry, University of Michigan Medical School, Ann Arbor
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Shepherd-Banigan M, Shapiro A, Sheahan KL, Ackland PE, Meis LA, Thompson-Hollands J, Edelman D, Calhoun PS, Weidenbacher H, Van Houtven CH. Mental health therapy for veterans with PTSD as a family affair: A qualitative inquiry into how family support and social norms influence veteran engagement in care. Psychol Serv 2023; 20:839-848. [PMID: 36780280 PMCID: PMC10423295 DOI: 10.1037/ser0000742] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/14/2023]
Abstract
Social support is important for posttraumatic stress disorder (PTSD) recovery and emerging literature indicate that social support could increase engagement in PTSD therapy. However, there is a need to understand how and why family involvement can increase treatment engagement to inform strategies used in clinical practice. This study explores how individuals with PTSD and family members of individuals with PTSD experience therapy and how social interactions help or hinder therapy engagement. We interviewed 18 U.S. military veterans who had been referred for psychotherapy for PTSD in the Veterans Health Administration and 13 family members and used rapid content analysis to identify themes. We found that engaging in therapy was a family-level decision that participants expected to improve family life. Veterans were motivated to seek treatment to protect their relationships with loved ones. Family members generally encouraged veterans to seek treatment. Specifically, family members who viewed PTSD as a treatable illness versus a static aspect of the veteran's personality expressed positive attitudes about the effectiveness of therapy for reducing symptoms. Veterans whose social networks included individuals with prior military or trauma-related experiences reported that their loved ones possessed more understanding of PTSD and described positive subjective norms around therapy. Family members are often embedded in the therapy process because PTSD has a profound impact on the family. Positive subjective norms for therapy are created by family encouragement and may influence veteran perceptions about the value of treatment. Family members should be engaged early in mental health therapy and to the extent desired by the patient and family member. (PsycInfo Database Record (c) 2023 APA, all rights reserved).
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Affiliation(s)
- Megan Shepherd-Banigan
- Durham VA Health Care System, 508 Fulton Street Durham, NC, 27705, USA
- Duke University, Department of Population Health Sciences, 215 Morris Street, Durham, NC, 27701, USA
- Duke-Margolis Center for Health Policy, 100 Fuqua Drive, Box 90120 Durham, NC 27708, USA
| | - Abigail Shapiro
- Durham VA Health Care System, 508 Fulton Street Durham, NC, 27705, USA
| | - Kate L. Sheahan
- Durham VA Health Care System, 508 Fulton Street Durham, NC, 27705, USA
| | - Princess E. Ackland
- Women’s Health Sciences Division, National Center for PTSD, VA Boston Healthcare System, 150 South Huntington Avenue, Boston, MA, 02130
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, One Veterans Drive, Minneapolis, MN, 55417, USA
| | - Laura A. Meis
- Women’s Health Sciences Division, National Center for PTSD, VA Boston Healthcare System, 150 South Huntington Avenue, Boston, MA, 02130
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, One Veterans Drive, Minneapolis, MN, 55417, USA
- Department of Medicine, University of Minnesota Medical School, One Veterans Drive, Minneapolis, MN, 55417, USA
| | - Johanna Thompson-Hollands
- Behavioral Sciences Division, National Center for PTSD, VA Boston Healthcare System, 150 South Huntington Avenue, Boston, MA, 02130
- Boston University School of Medicine, Department of Psychiatry, 720 Harrison Ave, Boston, MA 02118
| | - David Edelman
- Durham VA Health Care System, 508 Fulton Street Durham, NC, 27705, USA
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, 200 Morris Street, Durham, NC, 27701, USA
| | - Patrick S. Calhoun
- Durham VA Health Care System, 508 Fulton Street Durham, NC, 27705, USA
- Department of Psychiatry & Behavioral Sciences, Duke University School of Medicine, 905 W Main St, Durham, NC, 27701, USA
| | | | - Courtney H. Van Houtven
- Durham VA Health Care System, 508 Fulton Street Durham, NC, 27705, USA
- Duke University, Department of Population Health Sciences, 215 Morris Street, Durham, NC, 27701, USA
- Duke-Margolis Center for Health Policy, 100 Fuqua Drive, Box 90120 Durham, NC 27708, USA
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Galovski TE, Rossi FS, Fox AB, Vogt D, Duke CC, Nillni YI. Relationship of perceived neighborhood danger with depression and PTSD among veterans: The moderating role of social support and neighborhood cohesion. AMERICAN JOURNAL OF COMMUNITY PSYCHOLOGY 2023; 71:395-409. [PMID: 36661400 DOI: 10.1002/ajcp.12655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 12/16/2022] [Accepted: 12/20/2022] [Indexed: 06/06/2023]
Abstract
Little is known about the impact of perceived neighborhood danger on military veterans' mental health, a population potentially at higher risk for this experience, or whether interpersonal social support and neighborhood cohesion can help buffer against poor mental health. This study examined: (1) the impact of perceived neighborhood danger on depression and posttraumatic stress disorder (PTSD) among veterans; (2) whether interpersonal social support and neighborhood cohesion can mitigate these effects; and (3) how prior trauma history may interact with these factors. Six moderation models were examined using data from 3049 veterans enrolled in the Longitudinal Investigation of Gender, Health, and Trauma study, a mail-based survey that oversampled for veterans in high crime neighborhoods. Most notably, results indicated that perceived neighborhood danger was associated with increased depression and PTSD (all p < .001). Interpersonal social support or neighborhood cohesion mitigated the effect of perceived neighborhood danger on veterans' depression, but, only for those without prior trauma (all p < .011). For trauma-exposed veterans, interpersonal social support was more effective in mitigating the effect of perceived neighborhood danger on depression than neighborhood cohesion (p = .006). Findings help inform interventions to improve the mental health of veterans living in high crime neighborhoods.
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Affiliation(s)
- Tara E Galovski
- Women's Health Sciences Division, National Center for PTSD, VA Boston Healthcare System, Boston, Massachusetts, USA
- Department of Psychiatry, Chobanian and Avedesian School of Medicine at Boston University, Boston, Massachusetts, USA
| | - Fernanda S Rossi
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California, USA
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California, USA
| | - Annie B Fox
- Women's Health Sciences Division, National Center for PTSD, VA Boston Healthcare System, Boston, Massachusetts, USA
- School of Healthcare Leadership, MGH Institute of Health Professions, Boston, Massachusetts, USA
| | - Dawne Vogt
- Women's Health Sciences Division, National Center for PTSD, VA Boston Healthcare System, Boston, Massachusetts, USA
- Department of Psychiatry, Chobanian and Avedesian School of Medicine at Boston University, Boston, Massachusetts, USA
| | | | - Yael I Nillni
- Women's Health Sciences Division, National Center for PTSD, VA Boston Healthcare System, Boston, Massachusetts, USA
- Department of Psychiatry, Chobanian and Avedesian School of Medicine at Boston University, Boston, Massachusetts, USA
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Shepherd-Banigan M, Wells SY, Falkovic M, Ackland PE, Swinkels C, Dedert E, Ruffin R, Van Houtven CH, Calhoun PS, Edelman D, Weidenbacher HJ, Shapiro A, Glynn S. Adapting a family-involved intervention to increase initiation and completion of evidenced-based psychotherapy for posttraumatic stress disorder. SSM - MENTAL HEALTH 2022; 2:100114. [PMID: 35979411 PMCID: PMC9376943 DOI: 10.1016/j.ssmmh.2022.100114] [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: 11/24/2022] Open
Abstract
Posttraumatic stress disorder (PTSD) is disabling condition among United States Veterans. Training programs for evidenced-based therapies have been rolled out nationally in the Veterans Health Administration (VHA), but provider adoption of these treatments is limited and rates of Veteran dropout are high. Increasing support for mental health therapy within the Veteran's social network would improve treatment engagement. We discuss the adaptation of Recovery-Oriented Decisions for Relatives' Support (REORDER)-a family-based intervention for individuals with serious mental illness- to create Family Support in Mental Health Recovery (FAMILIAR), an intervention that seeks to strengthen support partners' abilities to help Veterans engage in therapy. Our goal was to apply modifications to meet the needs of Veterans with PTSD and their support partners. We used input from Veterans, support partners, clinicians and VA system leaders to inform the modifications. Then, a multi-disciplinary intervention development team met to determine which modifications would be applied and how. We used the domains from the Framework for Adaptations and Modification (FRAME) to systematically track and describe modifications. Adaptations made to REORDER included changes in content, structure, and delivery format. The resulting intervention, FAMILIAR, was a 3-4 session intervention beginning prior to EBP initiation and continuing through sessions 3, 4 or 5 of the EBP. Sessions were designed for maximum flexibility and could be offered either in-person or virtually, and sessions involve interactions between the interventionist with the Veteran and support partner alone and together. We learned the importance of including diverse stakeholder perspectives to develop a comprehensive understanding of the needs of the target population and the health system. While feasibility and effectiveness testing is needed, we applied a proactive adaptation approach that we anticipate will make FAMILIAR successful in addressing patient, clinical, and system considerations of a family approach to increase Veteran engagement in PTSD treatment.
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Affiliation(s)
- Megan Shepherd-Banigan
- Durham VA Health Care System, 508 Fulton Street Durham, NC, 27705, USA
- Duke University, Department of Population Health Sciences, 215 Morris Street, Durham, NC, 27701, USA
- Duke-Margolis Center for Health Policy, 100 Fuqua Drive, Box 90120 Durham, NC 27708, USA
| | | | - Margaret Falkovic
- Durham VA Health Care System, 508 Fulton Street Durham, NC, 27705, USA
- Duke University, Department of Population Health Sciences, 215 Morris Street, Durham, NC, 27701, USA
| | - Princess E. Ackland
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, One Veterans Drive, Minneapolis, MN, 55417, USA
- Department of Medicine, University of Minnesota, One Veterans Drive, Minneapolis, MN, 55417, USA
| | - Cindy Swinkels
- Durham VA Health Care System, 508 Fulton Street Durham, NC, 27705, USA
| | - Eric Dedert
- Durham VA Health Care System, 508 Fulton Street Durham, NC, 27705, USA
- Department of Psychiatry & Behavioral Sciences, Duke University School of Medicine, 905 West Main Street, Durham, NC, 27701, USA
| | - Rachel Ruffin
- Durham VA Health Care System, 508 Fulton Street Durham, NC, 27705, USA
| | - Courtney H. Van Houtven
- Durham VA Health Care System, 508 Fulton Street Durham, NC, 27705, USA
- Duke University, Department of Population Health Sciences, 215 Morris Street, Durham, NC, 27701, USA
- Duke-Margolis Center for Health Policy, 100 Fuqua Drive, Box 90120 Durham, NC 27708, USA
| | - Patrick S. Calhoun
- Durham VA Health Care System, 508 Fulton Street Durham, NC, 27705, USA
- Department of Psychiatry & Behavioral Sciences, Duke University School of Medicine, 905 West Main Street, Durham, NC, 27701, USA
| | - David Edelman
- Durham VA Health Care System, 508 Fulton Street Durham, NC, 27705, USA
- Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, 200 Morris Street, Durham, NC, 27701, USA
| | | | - Abigail Shapiro
- Durham VA Health Care System, 508 Fulton Street Durham, NC, 27705, USA
| | - Shirley Glynn
- Semel Institute of Neuroscience and Human Behavior, Greater LA VA Health Care System/UCLA, B151 11301 Whiltshire Boulevard, Los Angeles, CA, 90073 USA
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