Beliefs about mental health treatment, treatment initiation, and suicidal behaviors among veterans and service members at-risk for suicide and not in treatment

INTRODUCTION

Previous research has identified a variety of barriers to mental health care among military personnel and veterans, despite high rates of mental health symptoms. The current study is the first to examine beliefs about mental health treatment barriers among post-9/11 military personnel and veterans at elevated suicide risk not involved in treatment and whether these beliefs are associated with treatment initiation, engagement, or suicidal behaviors.

METHODS

Four hundred and twenty-two participants reported on beliefs about treatment during a cognitive behavioral treatment session and responded to follow-up questionnaires on mental health treatment initiation, engagement, and suicidal behaviors over 12 months. Beliefs identified in the therapy session were coded thematically, and rates of treatment initiation, engagement, and suicidal behavior were examined by belief category.

RESULTS

Nine belief themes emerged. Participants reporting logistical barriers and preferences about treatment type were least likely to initiate mental health treatment and participated in the fewest number of sessions, respectively. Participants endorsing beliefs about stigma or using other ways to cope were most likely to engage in suicidal behavior.

CONCLUSIONS

The current findings point to specific beliefs that may identify individuals who would benefit from systemic and individual interventions for mental health treatment engagement.

Pathways Linking Post-Traumatic Stress Disorder to Incident Ischemic Heart Disease in Women: Call to Action

Background

Post-traumatic stress disorder (PTSD) is associated with increased rates of incident ischemic heart disease (IHD) in women.

Objectives

The purpose of this study was to determine mechanisms of the PTSD-IHD association in women.

Methods

In this retrospective longitudinal cohort study, data were obtained from electronic health records of all U.S. women veterans who were enrolled in Veterans Health Administration care from January 1, 2000 to December 31, 2017. Propensity score matching was used to match women with PTSD to women without PTSD on age, number of prior Veterans Health Administration visits, and presence of various traditional and nontraditional cardiovascular risk factors at index visit. Cox regression was used to model time until incident IHD diagnosis (ie, coronary artery disease, angina, or myocardial infarction) as a function of PTSD and potential mediating risk factors. Diagnoses of IHD, PTSD, and risk factors were defined by International Classification of Diseases-9th or -10th Revision, and/or Current Procedural Terminology codes.

Results

PTSD was associated with elevated rates of developing each risk factor. Traditional risk factors (hypertension, hyperlipidemia, smoking, diabetes) accounted for 24.2% of the PTSD-IHD association, psychiatric risk factors (eg, depression, anxiety, substance use disorders) accounted for 33.8% of the association, and all 13 risk factors accounted for 48.5% of the association.

Conclusions

Traditional IHD risk factors explained a quarter of the PTSD-IHD association in women veterans, and over half of the risk of IHD associated with PTSD remained unexplained even when adjusting for a wide range of risk factors. To be actionable, factors underlying the remaining PTSD-IHD association warrant timely investigation.

Delivery of Exposure and Response Prevention Among Veterans with Obsessive-Compulsive Disorder

Veterans with obsessive-compulsive disorder (OCD) often face barriers to receiving evidence-based treatments such as exposure and response prevention (ERP). Through retrospective review of electronic medical records, this study examined the rates of ERP delivery in a national sample of 554 veterans newly diagnosed with OCD in the Veterans Health Administration between 2016 and 2017. Results indicated that only 4% of veterans (n = 22) received any ERP treatment; and, of those, 16 veterans received "true ERP." Veterans who received any ERP were younger than those who did not. ERP was primarily delivered by psychologists in urban facilities along the East and West coasts of the USA. The findings from this study emphasize the need to train more providers to effectively deliver ERP in addition to providing telehealth services to increase access to care for veterans in rural areas.

Factors Associated with Engaging in Evidence-Based Psychotherapy During the First Year of Posttraumatic Stress Disorder Treatment Between 2017 and 2019

To address the burden of posttraumatic stress disorder (PTSD), the Veterans Health Administration (VHA) implemented evidence-based psychotherapies (EBPs) for PTSD at all VHA medical centers. Prior investigations show EBP utilization has increased following the initial nationwide implementation. However, most patients still do not engage in EBPs and those who do often have substantial delays between diagnosis and treatment which is associated with poorer treatment outcomes. The goal of the current study is to identify patient and clinical factors associated with initiating EBP and completing a minimally adequate dose of treatment within the first year of a new PTSD diagnosis. Overall, 263,018 patients started PTSD treatment between 2017 and 2019 and 11.6% (n = 30,462) initiated EBP during their first year of treatment. Of those who initiated EBP, 32.9% (n = 10,030) received a minimally adequate dose. Older patients were less likely to initiate EBP, but more likely to receive an adequate dose when they did initiate. Black, Hispanic/Latino/a, and Pacific Islander patients' likelihood of initiating EBP was not significantly different than White patients, but these patients were less likely to receive an adequate dose. Patients with comorbid depressive disorders, bipolar disorder, psychotic disorders, or substance use disorders were less likely to initiate EBP, while patients reporting MST were more likely to initiate EBP. This study identifies several patient-level disparities that could be prioritized to increase EBP utilization. In our evaluation, most patients did not engage in EBP during their first year of PTSD treatment, which is consistent with previous evaluations of EBP utilization. Future research should focus on understanding the flow of patients from PTSD diagnosis to treatment to support effective PTSD care delivery.

Mining Clinical Data for Novel Posttraumatic Stress Disorder Medications

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.

Geographic Variation in Initiation of Evidence-based Psychotherapy Among Veterans With PTSD

Introduction

The United States Department of Veterans Affairs (VA) has invested in implementation of evidence-based psychotherapy (EBP) for post-traumatic stress disorder (PTSD) for over a decade, resulting in slow but steady uptake of these treatments nationally. However, no prior research has investigated the geographic variation in initiation of EBP. Our objectives were to determine whether there is geographic variation in the initiation of EBP for PTSD in the VA and to identify patient and clinic factors associated with EBP initiation.

Materials and Methods

We identified VA patients with PTSD who had not received EBP as of January 2016 (N = 946,667) using retrospective electronic medical records data and determined whether they initiated EBP by December 2017. We illustrated geographic variation in EBP initiation using national and regional maps. Using multivariate logistic regression, we determined patient, regional, and nearest VA facility predictors of initiating treatment. This study was approved by the Veterans Institutional Review Board of Northern New England.

Results

Nationally, 4.8% (n = 45,895) initiated EBP from 2016 to 2017, and there was geographic variation, ranging from none to almost 30% at the 3-digit ZIP code level. The strongest patient predictors of EBP initiation were the negative predictor of being older than 65 years (OR = 0.47; 95% CI, 0.45-0.49) and the positive predictor of reporting military-related sexual trauma (OR = 1.96; 95% CI, 1.90-2.03). The strongest regional predictors of EBP initiation were the negative predictor of living in the Northeast (OR = 0.89; 95% CI, 0.86-0.92) and the positive predictor of living in the Midwest (OR = 1.47; 95% CI, 1.44-1.51). The only nearest VA facility predictor of EBP initiation was the positive predictor of whether the facility was a VA Medical Center with a specialized PTSD clinic (OR = 1.23; 95% CI, 1.20-1.26).

Conclusion

Although less than 5% of VA patients with PTSD initiated EBP, there was regional variation. Patient factors, region of residence, and nearest VA facility characteristics were all associated with whether patients initiated EBP. Strengths of this study include the use of national longitudinal data, while weaknesses include the potential for misclassification of PTSD diagnoses as well as the potential for misidentification of EBP. Our work indicates geographic areas where access to EBP for PTSD may be poor and can help target work improving access. Future studies should also assess completion of EBP for PTSD and related symptomatic and functional outcomes across geographic areas.

Measurement Strategies for Evidence-Based Psychotherapy for Posttraumatic Stress Disorder Delivery: Trends and Associations with Patient-Reported Outcomes

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.

Measurement Strategies for Evidence-Based Antidepressants for Posttraumatic Stress Disorder Delivery: Trends and Associations with Patient-Reported Outcomes

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.

Feasibility of a 3-week intensive treatment program for service members and veterans with PTSD

OBJECTIVE

The purpose of the present study was to detail the patient flow and establish the feasibility of a brief 3-week intensive treatment program (ITP) for veterans with posttraumatic stress disorder (PTSD).

METHOD

The present study examined data from 648 veterans referred to a non-Veterans Affairs ITP for PTSD from January 2016 to February 2018 to determine the flow of patients into and through the ITP and evaluate individuals' satisfaction with treatment.

RESULTS

On average, 25.9 individuals contacted the ITP each month expressing interest in the program. A large proportion of individuals who completed an intake evaluation were accepted (72.2%) into the ITP. Of those accepted, 70.6% ultimately attended the ITP, and the vast majority of veterans who attended the ITP completed treatment (91.6%). Logistic regression results suggested that among veterans who were accepted to the program, those who were legally separated or divorced had significantly greater odds of attending the program compared to single veterans. Veterans were highly satisfied with the 3-week ITP and rated cognitive processing therapy components as the most helpful part of the program.

CONCLUSIONS

The present study demonstrates that ITP formats for PTSD are of interest and acceptable to veterans, and this format allows individuals to receive high doses of evidence-based treatments in a short amount of time. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Longitudinal association of PTSD symptoms and self-reported physical functioning among Veterans

BACKGROUND

Few longitudinal studies have investigated the potentially dynamic relationship between Posttraumatic Stress Disorder (PTSD) and physical functioning, and the number of follow-up timepoints have been limited. We evaluated whether PTSD symptoms predicted future physical functioning and vice versa using five assessments over four years.

METHODS

Data was used from a longitudinal cohort of 695 participants recruited from Veteran Affairs medical outpatient clinics who experienced a traumatic event. PTSD symptom severity was assessed annually with the PTSD Checklist (PCL). Physical functioning was measured with the 10-item subscale of the SF-36. An autoregressive cross-lagged panel model was used to determine the temporal associations between PTSD and physical functioning, adjusting for age, sex, ethnicity, education and employment. Comorbidities and health behaviors were added to assess their roles in the relationship.

RESULTS

Greater PTSD symptom severity predicted worse physical functioning the following year (average β = -0.10, P <0.001), where a 10-point increase in PCL score predicted a 0.3-point decline in physical function score over one year. Similarly, better physical functioning also predicted reduced PTSD severity the following year, but to a smaller magnitude (average β = -0.04, P = .003). The pattern of effects was similar after controlling for comorbidities and health behaviors.

LIMITATIONS

Both primary variables relied on self-report, and generalizability may be limited by the mostly male Veteran sample.

CONCLUSIONS

Our results support a bidirectional, but unequal, relationship between PTSD and physical functioning over time. They also highlight the importance of long-term control of PTSD symptoms in preventing functional decline.

Disabilities Status, Health Insurance, and Medical Hardship among Veterans

This study aims to examine the health care hardships among veterans and the effects from the measures of disability statuses and health insurance coverage. Patterns and variations for different subgroups are categorized and analyzed. Using the 2014 National Health Interview Survey (NHIS), this study included 2,686 veterans who were active duty in U.S. military in Persian Gulf War in the 1990s and Gulf War-era II since September 2001 or later. The dependent variable, medical hardship, was measured with four dichotomous indicators: problems paying medical bills, currently having medical bills that were being paid over time, currently having medical bills that were unable to be paid at all, and having medical care delayed due to cost. The independent variables were disability status and health care coverage. Covariates included demographics (age, gender, race), socioeconomic status (education, poverty status), along with marital status and self-reported health status. Logistic regressions were employed to predict the likelihood of experiencing health care hardships. Statistical results indicated that health disparities were prevalent in terms of health care hardships. Disabled veterans were more likely to report medical hardships compared to their counterparts with no disability. Having no health insurance coverage further deteriorated the severity of medical hardship. Veterans who self-reported poor health lived in poverty were less educated, and had higher likelihood of experiencing health care hardship. The policy implications can be lined with disabled veterans' programs in terms of outreach activities, community services, and integrated care.

Behavioral Health Treatment Receipt Among a Community Sample of Young Adult Veterans

Young adult veterans are at risk for behavioral health problems such as depression, posttraumatic stress disorder (PTSD), and substance misuse. Despite this, studies of veterans within the Veterans Affairs Healthcare System (VA) indicate that about half of those warranting treatment receive it in any form, with few receiving an adequate dose of care. For this study, the behavioral health screening status and behavioral health usage (including care outside of VA settings) among a community sample of 812 young adult veterans recruited from the Internet is described. Although approximately 70% of the sample screened positive for behavioral health problems, only one fifth to three fifths of those screening positive reported any mental health or substance use treatment in the past year, with one third or less receiving a dose of minimally adequate psychotherapy or psychotropic care. Findings expand on prior work and suggest that more effort is necessary to engage young veterans in behavioral health services.

Psychotropic Medication Prescribing in Iraq/Afghanistan Veterans and Vietnam Era Veterans With Posttraumatic Stress Disorder

A new generation of veterans from Iraq/Afghanistan wars is seeking psychotropic pharmacotherapy for posttraumatic stress disorder (PTSD) from the Veterans Health Administration, but little is known about differences in prescribing practices between this group and Vietnam era veterans with the same diagnosis. The Veterans Health Administration administrative data for fiscal year 2012 were used to compare prescribing for 155,631 Iraq/Afghanistan veterans and for 327,634 Vietnam era veterans diagnosed with PTSD. The proportion of veterans who were prescribed psychotropic medications (altogether and within five of seven medication classes) were not substantially different between veteran groups. Iraq/Afghanistan veterans were more frequently prescribed prazosin (p < 0.0001, relative risk = 1.51). However, the number of prescriptions for anxiolytics/sedatives/hypnotics as well as prazosin and opiates filled by this younger group was lower by a small magnitude (Cohen's d < 0.2). Iraq/Afghanistan veterans have good access to psychopharmacological treatment for PTSD but fill somewhat fewer prescriptions than Vietnam era veterans.

Anticonvulsant Medication Use in Veterans With Posttraumatic Stress Disorder

OBJECTIVE

Anticonvulsants have been studied for many indications, including posttraumatic stress disorder (PTSD). The limited efficacy research on anticonvulsants for PTSD is mixed. However, anticonvulsants are prescribed widely to veterans with PTSD. Our objective was to measure trends and factors associated with anticonvulsant prescriptions among veterans with PTSD.

METHODS

We obtained administrative and pharmacy data for veterans who initiated PTSD treatment in the US Department of Veterans Affairs (VA) between 2004 and 2013 (N = 731,520). We identified those who received anticonvulsants during the year following their initial clinical PTSD diagnosis and examined common indications for anticonvulsant use, patient characteristics, and service use characteristics. Using logistic regression, we determined the predictors of anticonvulsant initiation among those without an indication.

RESULTS

Although 24.9% of patients in the cohort received an anticonvulsant during their initial year of PTSD treatment, 94.6% had an indication unrelated to PTSD and 51.2% initiated anticonvulsant use before their PTSD diagnosis. While there was growth in anticonvulsant initiation over the 10-year period, this was explained both by growth in indications unrelated to PTSD and by increased use of anticonvulsants for these indications. The rate of anticonvulsant initiation without an indication was stable at approximately 5% throughout the period, with patient and service use characteristics driving the selection of individual agents.

CONCLUSIONS

A large and increasing proportion of veterans with PTSD receives anticonvulsant prescriptions. However, this may be appropriate use driven by increased prevalence of comorbid conditions that may be an indication for anticonvulsant use, including pain and headache disorders.

Evidence-based Treatments for Military-related Posttraumatic Stress Disorder in a Veterans Affairs Setting

Posttraumatic stress disorder (PTSD) can have a significant negative impact on the physical, emotional, and mental health of individuals. This article discusses the prevalence, risk factors, and diagnostic criteria for PTSD. Given the high incidence of PTSD in the Veteran population, much attention has been given to assessment and treatment issues. Treatment options for PTSD, including the 2 most effective treatments, prolonged exposure and cognitive processing therapy, are discussed. Special issues concerning the treatment of Veterans are also reviewed.