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Ranney R, Maguen S, Woods A, Seal KH, Neylan TC, Bernardy N, Wiechers I, Ryder A, Cohen BE. Comparison of mental health outcomes of augmenting medications for patients with posttraumatic stress disorder: A national veterans affairs study. J Eval Clin Pract 2023; 29:191-202. [PMID: 35709244 DOI: 10.1111/jep.13726] [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: 03/15/2022] [Revised: 06/01/2022] [Accepted: 06/02/2022] [Indexed: 01/18/2023]
Abstract
RATIONALE Posttraumatic stress disorder (PTSD) is highly prevalent among veterans. Many veterans with PTSD respond well to serotonin reuptake inhibitors (SRIs). Nonresponders may be prescribed augmenting medications, which are not as well-studied in PTSD. AIMS AND OBJECTIVES We used Veterans Health Administration electronic records to compare mental health outcomes (PTSD symptoms and rates of mental health hospitalizations and psychiatric emergency room visits) in patients with PTSD who were prescribed four different groups of augmenting medications (atypical antipsychotics, mirtazapine, prazosin or tricyclic antidepressants) in addition to SRIs-from the year before to the year after the start of the augmenting medication. METHOD We included data from 169,982 patients with a diagnosis of PTSD (excluding patients with comorbid bipolar or psychotic disorders) seen in Veterans Affairs care from 2007 to 2015 who were taking an SRI and filled a new prescription for one of the four augmenting medications for at least 60 days. RESULTS Patients evidenced minimal (<2%) reduction in PTSD symptoms and a larger reduction in psychiatric hospitalizations and psychiatric emergency room visits after receiving augmenting medications; this effect was largely similar across the four medication groups. Initiating augmenting medications was preceded by increases in PTSD symptoms, psychiatric hospitalizations and psychiatric emergency room visits. After initiating an augmenting medication, PTSD symptoms/hospitalizations/emergency room visits returned to baseline levels (before the start of the augmenting medication), but generally did not improve beyond baseline. CONCLUSION Importantly, these effects could be explained by regression to the mean, additional interventions or confounding. These findings should be further explored with placebo controlled randomized clinical trials.
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Affiliation(s)
- Rachel Ranney
- Veterans Affairs San Francisco Health Care System, San Francisco, California, USA.,Department of Psychiatry and Behavioral Sciences, San Francisco School of Medicine, University of California, San Francisco, California, USA.,Sierra Pacific Mental Illness Research Education, and Clinical Center, San Francisco, California, USA
| | - Shira Maguen
- Veterans Affairs San Francisco Health Care System, San Francisco, California, USA.,Department of Psychiatry and Behavioral Sciences, San Francisco School of Medicine, University of California, San Francisco, California, USA
| | - Anne Woods
- Veterans Affairs San Francisco Health Care System, San Francisco, California, USA.,Northern California Institute for Research and Education, San Francisco, California, USA
| | - Karen H Seal
- Veterans Affairs San Francisco Health Care System, San Francisco, California, USA.,Department of Psychiatry and Behavioral Sciences, San Francisco School of Medicine, University of California, San Francisco, California, USA.,Department of Medicine, San Francisco School of Medicine, University of California, San Francisco, California, USA
| | - Thomas C Neylan
- Veterans Affairs San Francisco Health Care System, San Francisco, California, USA.,Department of Psychiatry and Behavioral Sciences, San Francisco School of Medicine, University of California, San Francisco, California, USA
| | - Nancy Bernardy
- Veterans Affairs White River Junction Health Care System, White River Junction, Vermont, USA
| | - Ilse Wiechers
- Department of Psychiatry and Behavioral Sciences, San Francisco School of Medicine, University of California, San Francisco, California, USA.,Department of Veterans Affairs, Northeast Program Evaluation Center, Office of Mental Health and Suicide Prevention, West Haven, Connecticut, USA.,Department of Psychiatry, Yale University School of Medicine, New Haven, New Haven, USA
| | - Annie Ryder
- Veterans Affairs San Francisco Health Care System, San Francisco, California, USA.,Department of Medicine, San Francisco School of Medicine, University of California, San Francisco, California, USA
| | - Beth E Cohen
- Veterans Affairs San Francisco Health Care System, San Francisco, California, USA.,Department of Medicine, San Francisco School of Medicine, University of California, San Francisco, California, USA
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2
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Shiner B, Huybrechts K, Gui J, Rozema L, Forehand J, Watts BV, Jiang T, Hoyt JE, Esteves J, Schnurr PP, Ray K, Gradus JL. Comparative Effectiveness of Direct-Acting Antivirals for Posttraumatic Stress Disorder in Veterans Affairs Patients With Hepatitis C Virus Infection. Am J Epidemiol 2022; 191:1614-1625. [PMID: 35689641 PMCID: PMC9989349 DOI: 10.1093/aje/kwac104] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 05/26/2022] [Accepted: 06/08/2022] [Indexed: 01/29/2023] Open
Abstract
We recently conducted an exploratory study that indicated that several direct-acting antivirals (DAAs), highly effective medications for hepatitis C virus (HCV) infection, were also associated with improvement in posttraumatic stress disorder (PTSD) among a national cohort of US Department of Veterans Affairs (VA) patients treated between October 1, 1999, and September 30, 2019. Limiting the same cohort to patients with PTSD and HCV, we compared the associations of individual DAAs with PTSD symptom improvement using propensity score weighting. After identifying patients who had available baseline and endpoint PTSD symptom data as measured with the PTSD Checklist (PCL), we compared changes over the 8-12 weeks of DAA treatment. The DAAs most prescribed in conjunction with PCL measurement were glecaprevir/pibrentasvir (GLE/PIB; n = 54), sofosbuvir/velpatasvir (SOF/VEL; n = 54), and ledipasvir/sofosbuvir (LDV/SOF; n = 145). GLE/PIB was superior to LDV/SOF, with a mean difference in improvement of 7.3 points on the PCL (95% confidence interval (CI): 1.1, 13.6). The mean differences in improvement on the PCL were smaller between GLE/PIB and SOF/VEL (3.0, 95% CI: -6.3, 12.2) and between SOF/VEL and LDV/SOF (4.4, 95% CI: -2.4, 11.2). While almost all patients were cured of HCV (92.5%) regardless of the agent received, PTSD outcomes were superior for those receiving GLE/PIB compared with those receiving LDV/SOF, indicating that GLE/PIB may merit further investigation as a potential PTSD treatment.
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Affiliation(s)
- Brian Shiner
- Correspondence to Dr. Brian Shiner, VA Medical Center, 215 N. Main Street, White River Junction, VT 05009 (e-mail: )
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Shiner B, Levis M, Dufort VM, Patterson OV, Watts BV, DuVall SL, Russ CJ, Maguen S. Improvements to PTSD quality metrics with natural language processing. J Eval Clin Pract 2022; 28:520-530. [PMID: 34028937 DOI: 10.1111/jep.13587] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 05/05/2021] [Accepted: 05/10/2021] [Indexed: 01/07/2023]
Abstract
RATIONALE AIMS AND OBJECTIVES As quality measurement becomes increasingly reliant on the availability of structured electronic medical record (EMR) data, clinicians are asked to perform documentation using tools that facilitate data capture. These tools may not be available, feasible, or acceptable in all clinical scenarios. Alternative methods of assessment, including natural language processing (NLP) of clinical notes, may improve the completeness of quality measurement in real-world practice. Our objective was to measure the quality of care for a set of evidence-based practices using structured EMR data alone, and then supplement those measures with additional data derived from NLP. METHOD As a case example, we studied the quality of care for posttraumatic stress disorder (PTSD) in the United States Department of Veterans Affairs (VA) over a 20-year period. We measured two aspects of PTSD care, including delivery of evidence-based psychotherapy (EBP) and associated use of measurement-based care (MBC), using structured EMR data. We then recalculated these measures using additional data derived from NLP of clinical note text. RESULTS There were 2 098 389 VA patients with a diagnosis of PTSD between 2000 and 2019, 72% (n = 1 515 345) of whom had not previously received EBP for PTSD and were treated after a 2015 mandate to document EBP using templates that generate structured EMR data. Using structured EMR data, we determined that 3.2% (n = 48 004) of those patients met our EBP for PTSD quality standard between 2015 and 2019, and 48.1% (n = 23 088) received associated MBC. With the addition of NLP-derived data, estimates increased to 4.1% (n = 62 789) and 58.0% (n = 36 435), respectively. CONCLUSION Healthcare quality data can be significantly improved by supplementing structured EMR data with NLP-derived data. By using NLP, health systems may be able to fill the gaps in documentation when structured tools are not yet available or there are barriers to using them in clinical practice.
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Affiliation(s)
- Brian Shiner
- Veterans Affairs Medical Center, White River Junction, Vermont, USA.,Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA.,National Center for PTSD, White River Junction, Vermont, USA
| | - Maxwell Levis
- Veterans Affairs Medical Center, White River Junction, Vermont, USA.,Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
| | - Vincent M Dufort
- Veterans Affairs Medical Center, White River Junction, Vermont, USA
| | - Olga V Patterson
- VA Medical Center, Salt Lake City, Utah, USA.,University of Utah, Salt Lake City, Utah, USA
| | - Bradley V Watts
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA.,VA Office of Systems Redesign and Improvement, Washington, District of Columbia, USA
| | - Scott L DuVall
- VA Medical Center, Salt Lake City, Utah, USA.,University of Utah, Salt Lake City, Utah, USA
| | - Carey J Russ
- Veterans Affairs Medical Center, White River Junction, Vermont, USA
| | - Shira Maguen
- VA Medical Center, San Francisco, California, USA.,School of Medicine, University of California San Francisco, San Francisco, California, USA
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4
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Wingo TS, Gerasimov ES, Liu Y, Duong DM, Vattathil SM, Lori A, Gockley J, Breen MS, Maihofer AX, Nievergelt CM, Koenen KC, Levey DF, Gelernter J, Stein MB, Ressler KJ, Bennett DA, Levey AI, Seyfried NT, Wingo AP. Integrating human brain proteomes with genome-wide association data implicates novel proteins in post-traumatic stress disorder. Mol Psychiatry 2022; 27:3075-3084. [PMID: 35449297 PMCID: PMC9233006 DOI: 10.1038/s41380-022-01544-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 03/08/2022] [Accepted: 03/21/2022] [Indexed: 12/30/2022]
Abstract
Genome-wide association studies (GWAS) have identified several risk loci for post-traumatic stress disorder (PTSD); however, how they confer PTSD risk remains unclear. We aimed to identify genes that confer PTSD risk through their effects on brain protein abundance to provide new insights into PTSD pathogenesis. To that end, we integrated human brain proteomes with PTSD GWAS results to perform a proteome-wide association study (PWAS) of PTSD, followed by Mendelian randomization, using a discovery and confirmatory study design. Brain proteomes (N = 525) were profiled from the dorsolateral prefrontal cortex using mass spectrometry. The Million Veteran Program (MVP) PTSD GWAS (n = 186,689) was used for the discovery PWAS, and the Psychiatric Genomics Consortium PTSD GWAS (n = 174,659) was used for the confirmatory PWAS. To understand whether genes identified at the protein-level were also evident at the transcript-level, we performed a transcriptome-wide association study (TWAS) using human brain transcriptomes (N = 888) and the MVP PTSD GWAS results. We identified 11 genes that contribute to PTSD pathogenesis via their respective cis-regulated brain protein abundance. Seven of 11 genes (64%) replicated in the confirmatory PWAS and 4 of 11 also had their cis-regulated brain mRNA levels associated with PTSD. High confidence level was assigned to 9 of 11 genes after considering evidence from the confirmatory PWAS and TWAS. Most of the identified genes are expressed in other PTSD-relevant brain regions and several are preferentially expressed in excitatory neurons, astrocytes, and oligodendrocyte precursor cells. These genes are novel, promising targets for mechanistic and therapeutic studies to find new treatments for PTSD.
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Affiliation(s)
- Thomas S Wingo
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA
- Department of Human Genetics, Emory University School of Medicine, Atlanta, GA, USA
| | | | - Yue Liu
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA
| | - Duc M Duong
- Department of Biochemistry, Emory University School of Medicine, Atlanta, GA, USA
| | - Selina M Vattathil
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA
| | - Adriana Lori
- Department of Psychiatry, Emory University School of Medicine, Atlanta, GA, USA
| | | | - Michael S Breen
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Genetic and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Seaver Autism Center for Research and Treatment, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Adam X Maihofer
- Department of Psychiatry, University of California San Diego, La Jolla, CA, USA
- Veterans Affairs San Diego Health Care System, Center of Excellence for Stress and Mental Health, San Diego, CA, USA
| | - Caroline M Nievergelt
- Department of Psychiatry, University of California San Diego, La Jolla, CA, USA
- Veterans Affairs San Diego Health Care System, Center of Excellence for Stress and Mental Health, San Diego, CA, USA
| | - Karestan C Koenen
- Department of Epidemiology, Harvard School of Public Health, Boston, MA, USA
- Stanley Center for Psychiatric Research, Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Psychiatric Neurodevelopmental Genetics Unit, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Daniel F Levey
- Department of Psychiatry Yale, University School of Medicine, New Haven, CT, USA
| | - Joel Gelernter
- Department of Psychiatry Yale, University School of Medicine, New Haven, CT, USA
- Veterans Affairs Connecticut Health Center System, New Haven, CT, USA
| | - Murray B Stein
- Department of Psychiatry, University of California San Diego, La Jolla, CA, USA
- School of Public Health, University of California San Diego, La Jolla, CA, USA
| | | | - David A Bennett
- Rush Alzheimer's Disease Center, Rush University Medical Center, Chicago, IL, USA
| | - Allan I Levey
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA
| | - Nicholas T Seyfried
- Department of Biochemistry, Emory University School of Medicine, Atlanta, GA, USA
| | - Aliza P Wingo
- Department of Psychiatry, Emory University School of Medicine, Atlanta, GA, USA.
- Veterans Affairs Atlanta Health Care System, Decatur, GA, USA.
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5
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Shiner B, Forehand JA, Rozema L, Kulldorff M, Watts BV, Trefethen M, Jiang T, Huybrechts KF, Schnurr PP, Vincenti M, Gui J, Gradus JL. Mining Clinical Data for Novel Posttraumatic Stress Disorder Medications. Biol Psychiatry 2022; 91:647-657. [PMID: 34952698 PMCID: PMC8918007 DOI: 10.1016/j.biopsych.2021.10.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 09/23/2021] [Accepted: 10/12/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND Despite the prevalence and negative impact of posttraumatic stress disorder (PTSD), there are few medications approved by the U.S. Food and Drug Administration for treatment, and approved medications do not work well enough. We leveraged large-scale electronic health record data to identify existing medications that may be repurposed as PTSD treatments. METHODS We constructed a mechanistic tree of all Food and Drug Administration-approved medications and used the tree-based scan statistic to identify medications associated with greater than expected levels of clinically meaningful improvement in PTSD symptoms using electronic health record data from the U.S. Department of Veterans Affairs. Our cohort included patients with a diagnosis of PTSD who had repeated symptom measurements using the PTSD Checklist over a 20-year period (N = 168,941). We calculated observed numbers based on patients taking each drug or mechanistically related class of drugs and the expected numbers based on the tree as a whole. RESULTS Medications typically used to treat PTSD, such as the Food and Drug Administration-approved agent sertraline, were associated with improvement in PTSD symptoms, but the effects were small. Several, but not all, direct-acting antivirals used in the treatment of hepatitis C virus demonstrated a strong association with PTSD improvement. The finding was robust to a sensitivity analysis excluding patients who received established PTSD treatments, including trauma-focused psychotherapy, concurrent with hepatitis treatment. CONCLUSIONS Our exploratory approach both demonstrated findings that are consistent with what is known about pharmacotherapy for PTSD and uncovered a novel class of medications that may improve PTSD symptoms.
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Affiliation(s)
- Brian Shiner
- White River Junction Veterans Affairs Medical Center, White River Junction, Vermont; Veterans Administration National Center for PTSD, White River Junction, Vermont; Geisel School of Medicine at Dartmouth, Hanover, New Hampshire.
| | | | - Luke Rozema
- Veterans Affairs Medical Center, White River Junction, Vermont
| | - Martin Kulldorff
- Harvard Medical School, Boston, Massachusetts,Brigham and Women’s Hospital, Boston, Massachusetts
| | - Bradley V. Watts
- Veterans Affairs Medical Center, White River Junction, Vermont,Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | | | - Tammy Jiang
- Boston University School of Public Health, Boston, Massachusetts
| | - Krista F. Huybrechts
- Harvard Medical School, Boston, Massachusetts,Brigham and Women’s Hospital, Boston, Massachusetts,Boston University School of Public Health, Boston, Massachusetts,Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Paula P. Schnurr
- National Center for Posttraumatic Stress Disorder, White River Junction, Vermont,Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Matthew Vincenti
- Veterans Affairs Medical Center, White River Junction, Vermont,Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Jiang Gui
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Jaimie L. Gradus
- Boston University School of Public Health, Boston, Massachusetts
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6
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Lie E, Yeo Y, Lee EJ, Shin W, Kim K, Han KA, Yang E, Choi TY, Bae M, Lee S, Um SM, Choi SY, Kim H, Ko J, Kim E. SALM4 negatively regulates NMDA receptor function and fear memory consolidation. Commun Biol 2021; 4:1138. [PMID: 34588597 PMCID: PMC8481232 DOI: 10.1038/s42003-021-02656-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 09/09/2021] [Indexed: 02/08/2023] Open
Abstract
Many synaptic adhesion molecules positively regulate synapse development and function, but relatively little is known about negative regulation. SALM4/Lrfn3 (synaptic adhesion-like molecule 4/leucine rich repeat and fibronectin type III domain containing 3) inhibits synapse development by suppressing other SALM family proteins, but whether SALM4 also inhibits synaptic function and specific behaviors remains unclear. Here we show that SALM4-knockout (Lrfn3-/-) male mice display enhanced contextual fear memory consolidation (7-day post-training) but not acquisition or 1-day retention, and exhibit normal cued fear, spatial, and object-recognition memory. The Lrfn3-/- hippocampus show increased currents of GluN2B-containing N-methyl-D-aspartate (NMDA) receptors (GluN2B-NMDARs), but not α-amino-3-hydroxy-5-methyl-4-isoxazole propionate (AMPA) receptors (AMPARs), which requires the presynaptic receptor tyrosine phosphatase PTPσ. Chronic treatment of Lrfn3-/- mice with fluoxetine, a selective serotonin reuptake inhibitor used to treat excessive fear memory that directly inhibits GluN2B-NMDARs, normalizes NMDAR function and contextual fear memory consolidation in Lrfn3-/- mice, although the GluN2B-specific NMDAR antagonist ifenprodil was not sufficient to reverse the enhanced fear memory consolidation. These results suggest that SALM4 suppresses excessive GluN2B-NMDAR (not AMPAR) function and fear memory consolidation (not acquisition).
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Affiliation(s)
- Eunkyung Lie
- grid.410720.00000 0004 1784 4496Center for Synaptic Brain Dysfunctions, Institute for Basic Science (IBS), Daejeon, 34141 Korea ,grid.255168.d0000 0001 0671 5021Department of Chemistry, Dongguk University, Seoul, 04620 Korea
| | - Yeji Yeo
- grid.37172.300000 0001 2292 0500Department of Biological Sciences, Korea Advanced Institute for Science and Technology (KAIST), Daejeon, 34141 Korea
| | - Eun-Jae Lee
- grid.267370.70000 0004 0533 4667Department of Neurology, Asan Medical Center, University of Ulsan, College of Medicine, Seoul, 05505 Korea
| | - Wangyong Shin
- grid.410720.00000 0004 1784 4496Center for Synaptic Brain Dysfunctions, Institute for Basic Science (IBS), Daejeon, 34141 Korea
| | - Kyungdeok Kim
- grid.410720.00000 0004 1784 4496Center for Synaptic Brain Dysfunctions, Institute for Basic Science (IBS), Daejeon, 34141 Korea
| | - Kyung Ah Han
- grid.417736.00000 0004 0438 6721Department of Brain and Cognitive Sciences, Daegu Gyeongbuk Institute of Science and Technology (DGIST), Hyeonpoong-Eup, Dalseong-Gun, Daegu, 42988 Korea
| | - Esther Yang
- grid.222754.40000 0001 0840 2678Department of Anatomy and Division of Brain Korea 21, Biomedical Science, College of Medicine, Korea University, Seoul, 02841 Korea
| | - Tae-Yong Choi
- grid.31501.360000 0004 0470 5905Department of Physiology and Neuroscience, Dental Research Institute, Seoul National University School of Dentistry, Seoul, 03080 Korea
| | - Mihyun Bae
- grid.410720.00000 0004 1784 4496Center for Synaptic Brain Dysfunctions, Institute for Basic Science (IBS), Daejeon, 34141 Korea
| | - Suho Lee
- grid.410720.00000 0004 1784 4496Center for Synaptic Brain Dysfunctions, Institute for Basic Science (IBS), Daejeon, 34141 Korea
| | - Seung Min Um
- grid.37172.300000 0001 2292 0500Department of Biological Sciences, Korea Advanced Institute for Science and Technology (KAIST), Daejeon, 34141 Korea
| | - Se-Young Choi
- grid.31501.360000 0004 0470 5905Department of Physiology and Neuroscience, Dental Research Institute, Seoul National University School of Dentistry, Seoul, 03080 Korea
| | - Hyun Kim
- grid.222754.40000 0001 0840 2678Department of Anatomy and Division of Brain Korea 21, Biomedical Science, College of Medicine, Korea University, Seoul, 02841 Korea
| | - Jaewon Ko
- grid.417736.00000 0004 0438 6721Department of Brain and Cognitive Sciences, Daegu Gyeongbuk Institute of Science and Technology (DGIST), Hyeonpoong-Eup, Dalseong-Gun, Daegu, 42988 Korea
| | - Eunjoon Kim
- grid.410720.00000 0004 1784 4496Center for Synaptic Brain Dysfunctions, Institute for Basic Science (IBS), Daejeon, 34141 Korea ,grid.267370.70000 0004 0533 4667Department of Neurology, Asan Medical Center, University of Ulsan, College of Medicine, Seoul, 05505 Korea
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7
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Krystal JH, Chow B, Vessicchio J, Henrie AM, Neylan TC, Krystal AD, Marx BP, Xu K, Jindal RD, Davis LL, Schnurr PP, Stein MB, Thase ME, Ventura B, Huang GD, Shih MC. Design of the National Adaptive Trial for PTSD-related Insomnia (NAP Study), VA Cooperative Study Program (CSP) #2016. Contemp Clin Trials 2021; 109:106540. [PMID: 34416369 DOI: 10.1016/j.cct.2021.106540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 08/09/2021] [Accepted: 08/10/2021] [Indexed: 11/15/2022]
Abstract
There are currently no validated pharmacotherapies for posttraumatic stress disorder (PTSD)-related insomnia. The purpose of the National Adaptive Trial for PTSD-Related Insomnia (NAP Study) is to efficiently compare to placebo the effects of three insomnia medications with different mechanisms of action that are already prescribed widely to veterans diagnosed with PTSD within U.S. Department of Veterans Affairs (VA) Medical Centers. This study plans to enroll 1224 patients from 34 VA Medical Centers into a 12- week prospective, randomized placebo-controlled clinical trial comparing trazodone, eszopiclone, and gabapentin. The primary outcome measure is insomnia, assessed with the Insomnia Severity Index. A novel aspect of this study is its adaptive design. At the recruitment midpoint, an interim analysis will be conducted to inform a decision to close recruitment to any "futile" arms (i.e. arms where further recruitment is very unlikely to yield a significant result) while maintaining the overall study recruitment target. This step could result in the enrichment of the remaining study arms, enhancing statistical power for the remaining comparisons to placebo. This study will also explore clinical, actigraphic, and biochemical predictors of treatment response that may guide future biomarker development. Lastly, due to the COVID-19 pandemic, this study will allow the consenting process and follow-up visits to be conducted via video or phone contact if in-person meetings are not possible. Overall, this study aims to identify at least one effective pharmacotherapy for PTSD-related insomnia, and, perhaps, to generate definitive negative data to reduce the use of ineffective insomnia medications. NATIONAL CLINICAL TRIAL (NCT) IDENTIFIED NUMBER: NCT03668041.
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Affiliation(s)
- John H Krystal
- Clinical Neuroscience Division, National Center for PTSD, VA Connecticut Healthcare System, West Haven, CT, United States of America; Department of Psychiatry, Yale School of Medicine, New Haven, CT, United States of America; Departments of Neuroscience and Psychology, Yale University, New Haven, CT, United States of America.
| | - Bruce Chow
- Cooperative Studies Program Coordinating Center (CSPCC), VA Palo Alto Healthcare System, Palo Alto, CA, United States of America
| | - Jennifer Vessicchio
- Clinical Neuroscience Division, National Center for PTSD, VA Connecticut Healthcare System, West Haven, CT, United States of America; Department of Psychiatry, Yale School of Medicine, New Haven, CT, United States of America
| | - Adam M Henrie
- Cooperative Studies Program, Clinical Research Pharmacy Coordinating Center (CSPCRPCC), U.S. Department of Veterans Affairs, Albuquerque, NM, United States of America
| | - Thomas C Neylan
- Department of Psychiatry and UCSF Weill Institute for Neurosciences, School of Medicine, University of California, San Francisco, CA; VA San Francisco Healthcare System, San Francisco, CA, United States of America
| | - Andrew D Krystal
- Department of Psychiatry and UCSF Weill Institute for Neurosciences, School of Medicine, University of California, San Francisco, CA
| | - Brian P Marx
- Behavioral Sciences Division, National Center for PTSD, VA Boston Healthcare System, Boston, MA, Department of Psychiatry, Boston University School of Medicine, Boston, MA, United States of America
| | - Ke Xu
- Clinical Neuroscience Division, National Center for PTSD, VA Connecticut Healthcare System, West Haven, CT, United States of America; Department of Psychiatry, Yale School of Medicine, New Haven, CT, United States of America
| | - Ripu D Jindal
- Department of Psychiatry, Birmingham VA Medical Center, Departments of Neurology and Psychiatry, University of Alabama at Birmingham, Birmingham, AL, United States of America
| | - Lori L Davis
- Tuscaloosa VA Medical Center, Tuscaloosa, AL, United States of America; Department of Psychiatry, University of Alabama School of Medicine, Birmingham, AL, United States of America
| | - Paula P Schnurr
- Executive Division, National Center for PTSD, White River Junction, VT, Department of Psychiatry, Geisel School of Medicine at Dartmouth, Hanover, NH, United States of America
| | - Murray B Stein
- VA San Diego Healthcare System, San Diego, CA, Departments of Psychiatry, Family Medicine, and Public Health, University of California, San Diego, CA, United States of America
| | - Michael E Thase
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States of America
| | - Beverly Ventura
- Cooperative Studies Program Coordinating Center (CSPCC), VA Palo Alto Healthcare System, Palo Alto, CA, United States of America
| | - Grant D Huang
- Cooperative Studies Program, Office of Research and Development, U.S. Department of Veterans Affairs, Washington, DC, United States of America
| | - Mei-Chiung Shih
- Cooperative Studies Program Coordinating Center (CSPCC), VA Palo Alto Healthcare System, Palo Alto, CA, United States of America; Department of Biomedical Data Science, Stanford School of Medicine, Stanford, CA, United States of America
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8
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Hoerster KD, Tanksley L, Sulayman N, Bondzie J, Brier M, Damschroder L, Coggeshall S, Houseknecht D, Hunter-Merrill R, Monty G, Saelens BE, Sayre G, Simpson T, Wong E, Nelson K. Testing a tailored weight management program for veterans with PTSD: The MOVE! + UP randomized controlled trial. Contemp Clin Trials 2021; 107:106487. [PMID: 34144246 DOI: 10.1016/j.cct.2021.106487] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 06/10/2021] [Accepted: 06/11/2021] [Indexed: 10/21/2022]
Abstract
Post-traumatic stress disorder (PTSD), prevalent among Veterans, increases risk for having a high Body Mass Index. Although the Veterans Health Administration (VHA) offers an evidence-based behavioral weight management program called MOVE!, participants with PTSD lose less weight than those without mental health conditions, despite comparable participation. PTSD symptoms can interfere with one's ability to be physically active and maintain a healthy diet, the key targets in weight management programs. We developed and piloted a behavioral weight management program called MOVE! + UP that targets PTSD-related weight loss barriers. MOVE! + UP includes 16 group sessions with training in evidence-based weight management strategies, coupled with Cognitive Behavior Therapy (CBT) skills to address PTSD-specific barriers. The 16 sessions also include 30-min community walks to address PTSD-related barriers that may impede exercise. Two individual dietician sessions are provided. This hybrid type 1 randomized controlled trial (RCT) will compare MOVE! + UP to standard care-MOVE!-among 164 Veterans with BMI ≥ 25 who are receiving care for PTSD. We will randomize participants to MOVE! + UP or standard care and will compare absolute post-baseline change in weight at 6 (primary outcome) and 12 (secondary outcome) months, and PTSD symptom severity at 6 and 12 months (secondary outcome). Exploratory analyses will compare the treatment conditions on treatment targets measured at 6 months (e.g., physical activity, eating behavior, social support). Finally, we will estimate intervention costs, and identify MOVE! + UP implementation barriers and facilitators. If effective, MOVE! + UP could be an efficient way to simultaneously address physical and mental health for Veterans with PTSD.
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Affiliation(s)
- Katherine D Hoerster
- VA Puget Sound Healthcare System, Seattle Division, Mental Health Service; 1660 South Columbian Way (S-116), Seattle, WA 98108, United States; VA Puget Sound Healthcare System, Seattle Division, Health Services Research and Development, 1660 South Columbian Way (S-152), Seattle, WA 98108, United States; University of Washington, Department of Psychiatry and Behavioral Sciences, 100 NE 45(th) Street, Suite 300, Seattle, WA 98105; United States.
| | - Lamont Tanksley
- VA Puget Sound Healthcare System, Seattle Division, Mental Health Service; 1660 South Columbian Way (S-116), Seattle, WA 98108, United States.
| | - Nadiyah Sulayman
- VA Puget Sound Healthcare System, Seattle Division, Health Services Research and Development, 1660 South Columbian Way (S-152), Seattle, WA 98108, United States.
| | - Juliana Bondzie
- VA Puget Sound Healthcare System, Seattle Division, Health Services Research and Development, 1660 South Columbian Way (S-152), Seattle, WA 98108, United States.
| | - Moriah Brier
- VA Puget Sound Healthcare System, Anesthesiology Service, 1660 South Columbian Way, Seattle, WA 98108, United States.
| | - Laura Damschroder
- VA Ann Arbor Center for Clinical Management Research, 2800 Plymouth Rd. NCRC Bldg 16 (152), Ann Arbor, MI 48105, USA.
| | - Scott Coggeshall
- VA Puget Sound Healthcare System, Seattle Division, Health Services Research and Development, 1660 South Columbian Way (S-152), Seattle, WA 98108, United States.
| | - Dakota Houseknecht
- VA Puget Sound Healthcare System, Seattle Division, Health Services Research and Development, 1660 South Columbian Way (S-152), Seattle, WA 98108, United States.
| | - Rachel Hunter-Merrill
- VA Puget Sound Healthcare System, Seattle Division, Health Services Research and Development, 1660 South Columbian Way (S-152), Seattle, WA 98108, United States.
| | - Gillian Monty
- VA Puget Sound Healthcare System, Seattle Division, Health Services Research and Development, 1660 South Columbian Way (S-152), Seattle, WA 98108, United States.
| | - Brian E Saelens
- Seattle Children's Research Institute, 1920 Terry Avenue, Seattle, WA 98101, United States of America; University of Washington, Department of Pediatrics, 1959 NE Pacific Street, Seattle, WA 98195, United States of America.
| | - George Sayre
- VA Puget Sound Healthcare System, Seattle Division, Health Services Research and Development, 1660 South Columbian Way (S-152), Seattle, WA 98108, United States; VA Puget Sound Health Care System, Center of Excellence in Substance Addiction Treatment and Education (CESATE), 1660 South Columbian Way, Seattle, WA 98108, United States; University of Washington, School of Public Health, Department of Health Services, United States.
| | - Tracy Simpson
- VA Puget Sound Healthcare System, Seattle Division, Mental Health Service; 1660 South Columbian Way (S-116), Seattle, WA 98108, United States; VA Puget Sound Health Care System, Center of Excellence in Substance Addiction Treatment and Education (CESATE), 1660 South Columbian Way, Seattle, WA 98108, United States; University of Washington, School of Public Health, Department of Health Services, United States.
| | - Edwin Wong
- VA Puget Sound Healthcare System, Seattle Division, Health Services Research and Development, 1660 South Columbian Way (S-152), Seattle, WA 98108, United States.
| | - Karin Nelson
- VA Puget Sound Healthcare System, Seattle Division, Health Services Research and Development, 1660 South Columbian Way (S-152), Seattle, WA 98108, United States; VA Puget Sound Health Care System, Center of Excellence in Substance Addiction Treatment and Education (CESATE), 1660 South Columbian Way, Seattle, WA 98108, United States; University of Washington, School of Public Health, Department of Health Services, United States; University of Washington, Department of Medicine, 1959 NE Pacific St, Seattle, WA 98195, United States.
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9
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Shiner B, Westgate CL, Gui J, Cornelius S, Maguen SE, Watts BV, Schnurr PP. Measurement Strategies for Evidence-Based Psychotherapy for Posttraumatic Stress Disorder Delivery: Trends and Associations with Patient-Reported Outcomes. ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2021; 47:451-467. [PMID: 31853686 DOI: 10.1007/s10488-019-01004-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
We sought to develop a quality standard for the delivery of psychotherapy for posttraumatic stress disorder (PTSD) that is both consistent with the underlying evidence supporting psychotherapy as a treatment for PTSD and associated with the best levels of symptom improvement. We quantified psychotherapy receipt during the initial year of PTSD treatment in a 10-year national cohort of Department of Veterans Affairs (VA) users who completed patient-reported outcome measurement as part of routine practice. We added progressively stringent measurement requirements. The most stringent requirement was associated with superior outcomes. Quality of psychotherapy for PTSD in the VA improved over time.
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Affiliation(s)
- Brian Shiner
- White River Junction VA Medical Center, 215 North Main Street, White River Junction, VT, USA.
- Geisel School of Medicine at Dartmouth, Hanover, NH, USA.
- National Center for PTSD Executive Division, White River Junction, VT, USA.
| | | | - Jiang Gui
- Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - Sarah Cornelius
- White River Junction VA Medical Center, 215 North Main Street, White River Junction, VT, USA
| | - Shira E Maguen
- San Francisco VA Medical Center, San Francisco, CA, USA
- University of California, San Francisco, CA, USA
| | - Bradley V Watts
- Geisel School of Medicine at Dartmouth, Hanover, NH, USA
- VA Office of Systems Redesign and Improvement, Washington, DC, USA
| | - Paula P Schnurr
- Geisel School of Medicine at Dartmouth, Hanover, NH, USA
- National Center for PTSD Executive Division, White River Junction, VT, USA
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10
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Spangler PT, West JC, Dempsey CL, Possemato K, Bartolanzo D, Aliaga P, Zarate C, Vythilingam M, Benedek DM. Randomized Controlled Trial of Riluzole Augmentation for Posttraumatic Stress Disorder: Efficacy of a Glutamatergic Modulator for Antidepressant-Resistant Symptoms. J Clin Psychiatry 2020; 81:20m13233. [PMID: 33113596 PMCID: PMC7673650 DOI: 10.4088/jcp.20m13233] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Accepted: 05/18/2020] [Indexed: 01/07/2023]
Abstract
OBJECTIVE Current pharmacologic treatments for posttraumatic stress disorder (PTSD) have shown limited efficacy, prompting a call to investigate new classes of medications. The current study investigated the efficacy of glutamate modulation with riluzole augmentation for combat-related PTSD symptoms resistant to treatment with selective serotonin reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors (SNRIs). METHODS A randomized, double-blind, placebo-controlled, parallel trial was conducted at Walter Reed National Military Medical Center and Syracuse VA Medical Center between December 2013 and November 2017. Veterans and active duty service members with combat-related PTSD (per the Clinician Administered PTSD Scale [CAPS]) who were not responsive to SSRI or SNRI pharmacotherapy were randomized to 8-week augmentation with a starting dose of 100 mg/d of riluzole (n = 36) or placebo (n = 38) and assessed weekly for PTSD symptoms, anxiety, depression, disability, and side effects. RESULTS Intent-to-treat analyses (N = 74) of the primary outcome (CAPS for DSM-IV) showed no significant between-group difference in change in overall PTSD symptoms (F = 0.64, P = .422), with a small effect size (d = 0.25). There was clinically significant within-group improvement in overall PTSD symptoms in both groups, with a greater mean (SD) decrease in CAPS score in the riluzole group (-21.1 [18.9]) than in the placebo group (-16.7 [17.2]). Exploratory analyses of PTSD symptom clusters showed significantly greater improvement on hyperarousal symptoms in the riluzole group as measured by the PTSD Checklist-Specific-Subscale D (d = 0.48) and near-significant findings on the CAPS Subscale D. Riluzole augmentation was not superior to placebo on change in depression, anxiety, or disability severity. CONCLUSIONS Although preliminary, the exploratory findings of this study offer some evidence that riluzole augmentation of an SSRI or SNRI may selectively improve PTSD hyperarousal symptoms without changes in overall PTSD symptoms, depression, anxiety, or disability. Additional investigation of the mechanism of the efficacy of riluzole for hyperarousal symptoms is warranted. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT02155829.
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Affiliation(s)
- Patricia T. Spangler
- Center for the Study of Traumatic Stress, Department of Psychiatry, Uniformed Services University, Bethesda, MD
| | - James C. West
- Department of Psychiatry, Uniformed Services University, Bethesda, MD
| | - Catherine L. Dempsey
- Center for the Study of Traumatic Stress, Department of Psychiatry, Uniformed Services University, Bethesda, MD
| | - Kyle Possemato
- Veterans Administration Center for Integrated Healthcare, Syracuse, NY
| | - Danielle Bartolanzo
- Center for the Study of Traumatic Stress, Department of Psychiatry, Uniformed Services University, Bethesda, MD
| | - Pablo Aliaga
- Center for the Study of Traumatic Stress, Department of Psychiatry, Uniformed Services University, Bethesda, MD
| | - Carlos Zarate
- Experimental Therapeutics & Pathophysiology Branch, National Institute of Mental Health, Bethesda, MD
| | | | - David M. Benedek
- Department of Psychiatry, Uniformed Services University, Bethesda, MD
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11
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Shiner BR, Leonard CE, Gui J, Cornelius S, Schnurr PP, Hoyt JE, Young-Xu Y, Watts BV. Comparing Medications for DSM-5 PTSD in Routine VA Practice. J Clin Psychiatry 2020; 81:20m13244. [PMID: 33049805 PMCID: PMC7669235 DOI: 10.4088/jcp.20m13244] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Accepted: 05/18/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Fluoxetine, paroxetine, sertraline, topiramate, and venlafaxine have previously shown efficacy for posttraumatic stress disorder (PTSD). One prior study using US Department of Veterans Affairs (VA) medical records data to compare these agents found no differences in symptom reduction in clinical practice. The current study addresses several weaknesses in that study, including limited standardization of treatment duration, inability to account for prior treatment receipt, use of an outdated symptomatic assessment for PTSD, and lack of functional outcome. METHODS A total of 834 VA outpatients were identified with DSM-5 clinical diagnoses of PTSD between October 2016 and March 2018 who initiated one of the medications and met prespecified criteria for treatment duration and dose, combined with baseline and endpoint DSM-5 PTSD Checklist (PCL-5) measurements. Twelve-week acute-phase changes in PCL-5 score and remission of PTSD symptoms were compared among patients receiving the different medications, as was use of acute psychiatric services in the subsequent 6-month continuation phase. RESULTS In the acute phase, patients improved by a mean of 6.8-10.1 points on the PCL-5 and 0.0%-10.9% achieved remission of PTSD symptoms. Those taking venlafaxine were significantly more likely to achieve remission (P = .008 vs fluoxetine and P < .0001 vs paroxetine, sertraline, and topiramate). In the continuation phase, there were no differences in acute psychiatric care use between medications. Those who continued their medication were less likely to use acute psychiatric services (HR = 0.55; P = .03). CONCLUSIONS There may be an advantage to venlafaxine over other agents in achieving acute-phase remission for DSM-5 PTSD in routine clinical practice, but this finding requires further study. Regardless of the agent chosen, medication cessation during the continuation phase is associated with a higher risk of acute psychiatric care use.
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Affiliation(s)
- Brian R. Shiner
- National Center for PTSD and Veterans Affairs Medical Center, White River Junction, VT;,Departments of Psychiatry and The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, NH
| | | | - Jiang Gui
- Veterans Affairs Medical Center, White River Junction, VT;,Departments of Biomedical Data Science, Community & Family Medicine, and The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, NH
| | | | - Paula P. Schnurr
- National Center for PTSD, White River Junction, VT; Department of Psychiatry, Geisel School of Medicine at Dartmouth, Hanover, NH
| | | | - Yinong Young-Xu
- Clinical Epidemiology Program and National Center for Patient Safety, White River Junction VT;,Departments of Epidemiology and Psychiatry, Geisel School of Medicine at Dartmouth, Hanover, NH
| | - Bradley V. Watts
- Office of Systems Redesign and Veterans Affairs Medical Center, White River Junction, VT,,Department of Psychiatry, Geisel School of Medicine at Dartmouth, Hanover, NH
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12
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Shiner B, Leonard C, Gui J, Cornelius S, Gradus JL, Schnurr PP, Watts BV. Measurement Strategies for Evidence-Based Antidepressants for Posttraumatic Stress Disorder Delivery: Trends and Associations with Patient-Reported Outcomes. ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2020; 48:70-87. [PMID: 32394096 DOI: 10.1007/s10488-020-01047-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
We sought to develop a quality standard for the prescription of antidepressants for posttraumatic stress disorder (PTSD) that is both consistent with the underlying evidence supporting antidepressants as a treatment for PTSD and associated with the best levels of symptom improvement. We quantified antidepressant initiation during the first year of PTSD treatment in a 10-year national cohort of Department of Veterans Affairs (VA) users, and compared outcomes in a subgroup who completed patient-reported outcome measurement (PROM) as part of routine practice. We added progressively stringent measurement requirements. Prescribing quality for PTSD in the VA was stable over time. Use of PROM was rare in the case of antidepressant treatment, limiting our assessment of outcomes.
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Affiliation(s)
- Brian Shiner
- White River Junction VA Medical Center, 215 North Main Street, White River Junction, VT, 05009, USA. .,Geisel School of Medicine at Dartmouth, Hanover, NH, USA. .,National Center for PTSD Executive Division, White River Junction, VT, USA.
| | - Christine Leonard
- White River Junction VA Medical Center, 215 North Main Street, White River Junction, VT, 05009, USA
| | - Jiang Gui
- Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - Sarah Cornelius
- White River Junction VA Medical Center, 215 North Main Street, White River Junction, VT, 05009, USA
| | | | - Paula P Schnurr
- Geisel School of Medicine at Dartmouth, Hanover, NH, USA.,National Center for PTSD Executive Division, White River Junction, VT, USA
| | - Bradley V Watts
- Geisel School of Medicine at Dartmouth, Hanover, NH, USA.,VA Office of Systems Redesign and Improvement, Washington, DC, USA
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13
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Affiliation(s)
- William M McDonald
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta
| | - Sanne J H van Rooij
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta
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14
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Shiner B, Gui J, Westgate CL, Schnurr PP, Watts BV, Cornelius SL, Maguen S. Using patient-reported outcomes to understand the effectiveness of guideline-concordant care for post-traumatic stress disorder in clinical practice. J Eval Clin Pract 2019; 25:689-699. [PMID: 31115137 PMCID: PMC6615989 DOI: 10.1111/jep.13158] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Revised: 03/26/2019] [Accepted: 04/05/2019] [Indexed: 11/30/2022]
Abstract
RATIONALE Identifying predictors of improvement amongst patients receiving routine treatment for post-traumatic stress disorder (PTSD) could provide information about factors that influence the clinical effectiveness of guideline-concordant care. This study builds on prior work by accounting for delivery of specific evidence-based treatments (EBTs) for PTSD while identifying potential predictors of clinical improvement using patient-reported outcomes measurement. METHOD Our sample consisted of 2 643 US Department of Veterans Affairs (VA) outpatients who initiated treatment for PTSD between 2008 and 2013 and received at least four PTSD checklist (PCL) measurements over 12 weeks. We obtained PCL data as well as demographic, diagnostic, and health services use information from the VA corporate data warehouse. We used latent trajectory analysis to identify classes of patients based on PCL scores, then determined demographic, diagnostic, and treatment predictors of membership in each class. RESULTS Patients who met our PCL-based inclusion criteria were far more likely than those who did not receive EBTs. We identified two latent trajectories of PTSD symptoms. Patients in the substantial improvement group (25.9%) had a mean decrease in PCL score of 16.24, whereas patients in the modest improvement group improved by a mean of 8.09 points. However, there were few differences between the groups, and our model to predict group membership was only slightly better than chance (area under the curve [AUC] = 0.55). Of the 64 covariates we tested, the only robust individual predictor of improvement was gender, with men having lower odds of being in the substantial improvement group compared with women (odds ratio [OR] 0.76; 95% confidence interval [CI] 0.58-0.96). CONCLUSION VA patients with PTSD can realize significant improvement in routine clinical practice. Although available medical records-based variables were generally insufficient to predict improvement trajectory, this study did indicate that men have lower odds of substantial improvement than women.
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Affiliation(s)
- Brian Shiner
- Research Division, White River Junction VA Medical Center, White River Junction, Vermont
- Department of Psychiatry, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
- Executive Division, National Center for PTSD, Hartford, Vermont
| | - Jiang Gui
- Department of Psychiatry, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | | | - Paula P Schnurr
- Department of Psychiatry, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
- Executive Division, National Center for PTSD, Hartford, Vermont
| | - Bradley V Watts
- Department of Psychiatry, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
- Field Office, National Center for Patient Safety, Ann Arbor, Michigan
| | - Sarah L Cornelius
- Research Division, White River Junction VA Medical Center, White River Junction, Vermont
| | - Shira Maguen
- Posttraumatic Stress Disorder Clinical Team, San Francisco VA Medical Center, San Francisco, California
- School of Medicine, University of California San Francisco, San Francisco, California
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15
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Ni K, Chu H, Zeng L, Li N, Zhao Y. Barriers and facilitators to data quality of electronic health records used for clinical research in China: a qualitative study. BMJ Open 2019; 9:e029314. [PMID: 31270120 PMCID: PMC6609143 DOI: 10.1136/bmjopen-2019-029314] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
OBJECTIVES There is an increasing trend in the use of electronic health records (EHRs) for clinical research. However, more knowledge is needed on how to assure and improve data quality. This study aimed to explore healthcare professionals' experiences and perceptions of barriers and facilitators of data quality of EHR-based studies in the Chinese context. SETTING Four tertiary hospitals in Beijing, China. PARTICIPANTS Nineteen healthcare professionals with experience in using EHR data for clinical research participated in the study. METHODS A qualitative study based on face-to-face semistructured interviews was conducted from March to July 2018. The interviews were audiorecorded and transcribed verbatim. Data analysis was performed using the inductive thematic analysis approach. RESULTS The main themes included factors related to healthcare systems, clinical documentation, EHR systems and researchers. The perceived barriers to data quality included heavy workload, staff rotations, lack of detailed information for specific research, variations in terminology, limited retrieval capabilities, large amounts of unstructured data, challenges with patient identification and matching, problems with data extraction and unfamiliar with data quality assessment. To improve data quality, suggestions from participants included: better staff training, providing monetary incentives, performing daily data verification, improving software functionality and coding structures as well as enhancing multidisciplinary cooperation. CONCLUSIONS These results provide a basis to begin to address current barriers and ultimately to improve validity and generalisability of research findings in China.
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Affiliation(s)
- Kaiwen Ni
- Research Center of Clinical Epidemiology, Peking University Third Hospital, Beijing, China
| | - Hongling Chu
- Research Center of Clinical Epidemiology, Peking University Third Hospital, Beijing, China
| | - Lin Zeng
- Research Center of Clinical Epidemiology, Peking University Third Hospital, Beijing, China
| | - Nan Li
- Research Center of Clinical Epidemiology, Peking University Third Hospital, Beijing, China
| | - Yiming Zhao
- Research Center of Clinical Epidemiology, Peking University Third Hospital, Beijing, China
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16
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Kozel FA, Van Trees K, Larson V, Phillips S, Hashimie J, Gadbois B, Johnson S, Gallinati J, Barrett B, Toyinbo P, Weisman M, Centorino M, Gibson CA, Catalano G. One hertz versus ten hertz repetitive TMS treatment of PTSD: A randomized clinical trial. Psychiatry Res 2019; 273:153-162. [PMID: 30641346 DOI: 10.1016/j.psychres.2019.01.004] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Revised: 12/19/2018] [Accepted: 01/01/2019] [Indexed: 02/06/2023]
Abstract
The purpose of this trial was to test whether right prefrontal cortex 1 Hz versus 10 Hz rTMS provides a significantly greater improvement in PTSD symptoms and/or function. Veterans 18 to 50 years of age suffering from PTSD were randomized to right prefrontal 1 Hz rTMS [2400 pulses/session] versus right prefrontal 10 Hz rTMS [2400 pulses/session]. The treatments were performed 5 days a week for 6 weeks with a 3-week taper using the NeuroStar system. There were one month and three months post treatment follow-up evaluations. Forty-four participants were enrolled with 17 being randomized to 1 Hz rTMS and 18 to 10 Hz rTMS. Both groups had significant improvement in PTSD and depression scores from baseline to the end of acute treatment. The 10 Hz group but not the 1 Hz group demonstrated significant improvement in function. Although both groups demonstrated significant improvement in PTSD and depression symptoms, a significant advantage for either the 1 Hz or 10 Hz frequency group on any of the scales acquired was not demonstrated. Further work is required with larger samples sizes to test whether low or high frequency is superior or if individual differences would indicate the more effective frequency.
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Affiliation(s)
- F Andrew Kozel
- Mental Health and Behavioral Sciences, James A. Haley Veterans' Administration Hospital and Clinics, Tampa, FL, USA; HSR&D Center of Innovation on Disability and Rehabilitation Research (CINDRR), James A. Haley Veterans' Administration Hospital and Clinics, Tampa, FL, USA; Department of Psychiatry and Behavioral Sciences, University of South Florida, Tampa, FL, USA.
| | - Kimberly Van Trees
- Nursing Services, James A. Haley Veterans' Administration Hospital and Clinics, Tampa, FL, USA
| | - Valerie Larson
- HSR&D Center of Innovation on Disability and Rehabilitation Research (CINDRR), James A. Haley Veterans' Administration Hospital and Clinics, Tampa, FL, USA
| | - Sean Phillips
- Mental Health and Behavioral Sciences, James A. Haley Veterans' Administration Hospital and Clinics, Tampa, FL, USA; Department of Psychiatry and Behavioral Sciences, University of South Florida, Tampa, FL, USA
| | - Jaffrey Hashimie
- Mental Health and Behavioral Sciences, James A. Haley Veterans' Administration Hospital and Clinics, Tampa, FL, USA; Department of Psychiatry and Behavioral Sciences, University of South Florida, Tampa, FL, USA
| | - Brian Gadbois
- Mental Health and Behavioral Sciences, James A. Haley Veterans' Administration Hospital and Clinics, Tampa, FL, USA; Department of Psychiatry and Behavioral Sciences, University of South Florida, Tampa, FL, USA
| | - Suzanne Johnson
- Mental Health and Behavioral Sciences, James A. Haley Veterans' Administration Hospital and Clinics, Tampa, FL, USA
| | - Jessica Gallinati
- Mental Health and Behavioral Sciences, James A. Haley Veterans' Administration Hospital and Clinics, Tampa, FL, USA
| | - Blake Barrett
- HSR&D Center of Innovation on Disability and Rehabilitation Research (CINDRR), James A. Haley Veterans' Administration Hospital and Clinics, Tampa, FL, USA; VISN 8 Patient Safety Center of Inquiry, James A. Haley Veterans' Administration Hospital and Clinics, Tampa, FL, USA
| | - Peter Toyinbo
- HSR&D Center of Innovation on Disability and Rehabilitation Research (CINDRR), James A. Haley Veterans' Administration Hospital and Clinics, Tampa, FL, USA; Department of Epidemiology and Biostatistics, College of Public Health, University of South Florida, Tampa, FL, USA
| | - Mark Weisman
- Mental Health and Behavioral Sciences, James A. Haley Veterans' Administration Hospital and Clinics, Tampa, FL, USA; Department of Psychiatry and Behavioral Sciences, University of South Florida, Tampa, FL, USA
| | - Michael Centorino
- Mental Health and Behavioral Sciences, James A. Haley Veterans' Administration Hospital and Clinics, Tampa, FL, USA; Department of Psychiatry and Behavioral Sciences, University of South Florida, Tampa, FL, USA
| | - Carri-Ann Gibson
- Mental Health and Behavioral Sciences, James A. Haley Veterans' Administration Hospital and Clinics, Tampa, FL, USA; Department of Psychiatry and Behavioral Sciences, University of South Florida, Tampa, FL, USA
| | - Glenn Catalano
- Mental Health and Behavioral Sciences, James A. Haley Veterans' Administration Hospital and Clinics, Tampa, FL, USA; Department of Psychiatry and Behavioral Sciences, University of South Florida, Tampa, FL, USA
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