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Porter KE, Stein MB, Grau PP, Kim HM, Powell C, Hoge CW, Venners MR, Smith ER, Martis B, Simon NM, Liberzon I, Rauch SAM. Impact of PTSD treatment on postconcussive symptoms in veterans: A comparison of sertraline, prolonged exposure, and their combination. J Psychiatr Res 2024; 173:64-70. [PMID: 38503135 DOI: 10.1016/j.jpsychires.2024.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 02/29/2024] [Accepted: 03/07/2024] [Indexed: 03/21/2024]
Abstract
Many Veterans who served in Iraq and Afghanistan struggle with posttraumatic stress disorder (PTSD) and the effects of traumatic brain injuries (TBI). Some people with a history of TBI report a constellation of somatic, cognitive, and emotional complaints that are often referred to as postconcussive symptoms (PCS). Research suggests these symptoms may not be specific to TBI. This study examined the impact of PTSD treatment on PCS in combat Veterans seeking treatment for PTSD. As part of a larger randomized control trial, 198 Operation Iraqi Freedom, Operation Enduring Freedom, Operation New Dawn (OIF/OEF/OND) Veterans with PTSD received Prolonged Exposure Therapy, sertraline, or the combination. Potential deployment related TBI, PCS, PTSD and depression symptoms were assessed throughout treatment. Linear mixed models were used to predict PCS change over time across the full sample and treatment arms, and the association of change in PTSD and depression symptoms on PCS was also examined. Patterns of change for the full sample and the subsample of those who reported a head injury were examined. Results showed that PCS decreased with treatment. There were no significant differences across treatments. No significant differences were found in the pattern of symptom change based on TBI screening status. Shifts in PCS were predicted by change PTSD and depression. Results suggest that PCS reduced with PTSD treatment in this population and are related to shift in depression and PTSD severity, further supporting that reported PCS symptoms may be better understood as non-specific symptoms.
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Affiliation(s)
- Katherine E Porter
- Mental Health Service Line, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA; Department of Psychiatry, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA.
| | - Murray B Stein
- Department of Psychiatry, University of California San Diego, La Jolla, CA, USA; Mental Health Service Care VA San Diego Healthcare System, San Diego, CA, USA
| | - Peter P Grau
- Mental Health Service Line, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA; Department of Psychiatry, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA; VA Serious Mental Illness Treatment Resource and Evaluation Center (SMITREC), Ann Arbor, MI, USA
| | - H Myra Kim
- University of Michigan, Consulting for Statistics, Computing and Analytics Research, Ann Arbor, MI, USA
| | - Corey Powell
- University of Michigan, Consulting for Statistics, Computing and Analytics Research, Ann Arbor, MI, USA
| | - Charles W Hoge
- Walter Reed Army Institute of Research, Silver Spring, MD, USA
| | - Margaret R Venners
- National Center for PTSD, Dissemination and Training Division, VA Palo Alto Healthcare System, Menlo, Park, CA, USA; Research Service Line, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Erin R Smith
- Mental Health Service Line, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA; Department of Psychiatry, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Brian Martis
- Department of Psychiatry, University of California San Diego, La Jolla, CA, USA; Mental Health Service Care VA San Diego Healthcare System, San Diego, CA, USA
| | - Naomi M Simon
- Department of Psychiatry, New York University Grossman School of Medicine, New York, NY, USA
| | - Israel Liberzon
- Department of Psychiatry & Behavioral Science, Texas A&M Health, Bryan, TX, USA
| | - Sheila A M Rauch
- Research Service Line, Atlanta VA Medical Center, Decatur, GA, USA; Mental Health Service Line, Atlanta VA Medical Center, Decatur, GA, USA; Emory University School of Medicine, Atlanta, GA, USA
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Sripada RK, Grau PP, Porath BR, Burgess J, Van T, Kim HM, Boden MT, Zivin K. Role of Institutional Support for Evidence-Based Psychotherapy in Satisfaction and Burnout Among Veterans Affairs Therapists. Psychiatr Serv 2024; 75:206-213. [PMID: 37880969 DOI: 10.1176/appi.ps.20230086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2023]
Abstract
OBJECTIVE Burnout is widespread among psychotherapists and leads to negative mental and other health outcomes, absenteeism, and turnover. Job resources, including institutional support for evidence-based practices, can buffer against burnout and may improve satisfaction among therapists. The Veterans Health Administration (VHA) is the nation's largest integrated health system and employs 23,000 therapists, including psychologists, social workers, and counselors. The authors assessed associations between perceived institutional support for evidence-based treatment and satisfaction and burnout among VHA therapists. METHODS This analysis used data from the VHA's national 2018 Mental Health Provider Survey. Responding therapists (N=5,341) answered questions about the quality of mental health care and job satisfaction. Multilevel logistic regression models were used to predict burnout and satisfaction. The authors tested availability of evidence-based treatment and measurement-based care (MBC) as predictors; analyses were adjusted for therapist workload, demographic characteristics, and potential clustering by facility. RESULTS VHA therapists had less burnout and more job satisfaction when they perceived receiving institutional support for evidence-based psychotherapy (EBP) and MBC, irrespective of whether the analyses were adjusted for workload. Less difficulty in scheduling EBP was significantly associated with decreased likelihood of burnout (OR=0.83, p<0.001) and increased satisfaction (OR=1.09, p=0.008). Less difficulty ending psychotherapy was significantly associated with decreased likelihood of burnout (OR=0.89, p=0.002) and increased satisfaction (OR=1.12, p=0.004). CONCLUSIONS Support for evidence-based practices, including EBP and MBC, was closely linked to VHA therapists' satisfaction and burnout. Expanding support for therapists to provide evidence-based treatment may benefit therapists, patients, and the health care system.
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Affiliation(s)
- Rebecca K Sripada
- Center for Clinical Management Research, U.S. Department of Veterans Affairs (VA) Ann Arbor Healthcare System, Ann Arbor (Sripada, Grau, Porath, Burgess, Van, Kim, Zivin); Department of Psychiatry, Michigan Medicine (Sripada, Grau, Zivin), and Consulting for Statistics, Computing and Analytics Research (Kim), University of Michigan, Ann Arbor; Program Evaluation and Resource Center and VA Office of Mental Health Operations, VA Palo Alto Health Care System, Palo Alto, California (Boden)
| | - Peter P Grau
- Center for Clinical Management Research, U.S. Department of Veterans Affairs (VA) Ann Arbor Healthcare System, Ann Arbor (Sripada, Grau, Porath, Burgess, Van, Kim, Zivin); Department of Psychiatry, Michigan Medicine (Sripada, Grau, Zivin), and Consulting for Statistics, Computing and Analytics Research (Kim), University of Michigan, Ann Arbor; Program Evaluation and Resource Center and VA Office of Mental Health Operations, VA Palo Alto Health Care System, Palo Alto, California (Boden)
| | - Brittany R Porath
- Center for Clinical Management Research, U.S. Department of Veterans Affairs (VA) Ann Arbor Healthcare System, Ann Arbor (Sripada, Grau, Porath, Burgess, Van, Kim, Zivin); Department of Psychiatry, Michigan Medicine (Sripada, Grau, Zivin), and Consulting for Statistics, Computing and Analytics Research (Kim), University of Michigan, Ann Arbor; Program Evaluation and Resource Center and VA Office of Mental Health Operations, VA Palo Alto Health Care System, Palo Alto, California (Boden)
| | - Jennifer Burgess
- Center for Clinical Management Research, U.S. Department of Veterans Affairs (VA) Ann Arbor Healthcare System, Ann Arbor (Sripada, Grau, Porath, Burgess, Van, Kim, Zivin); Department of Psychiatry, Michigan Medicine (Sripada, Grau, Zivin), and Consulting for Statistics, Computing and Analytics Research (Kim), University of Michigan, Ann Arbor; Program Evaluation and Resource Center and VA Office of Mental Health Operations, VA Palo Alto Health Care System, Palo Alto, California (Boden)
| | - Tony Van
- Center for Clinical Management Research, U.S. Department of Veterans Affairs (VA) Ann Arbor Healthcare System, Ann Arbor (Sripada, Grau, Porath, Burgess, Van, Kim, Zivin); Department of Psychiatry, Michigan Medicine (Sripada, Grau, Zivin), and Consulting for Statistics, Computing and Analytics Research (Kim), University of Michigan, Ann Arbor; Program Evaluation and Resource Center and VA Office of Mental Health Operations, VA Palo Alto Health Care System, Palo Alto, California (Boden)
| | - H Myra Kim
- Center for Clinical Management Research, U.S. Department of Veterans Affairs (VA) Ann Arbor Healthcare System, Ann Arbor (Sripada, Grau, Porath, Burgess, Van, Kim, Zivin); Department of Psychiatry, Michigan Medicine (Sripada, Grau, Zivin), and Consulting for Statistics, Computing and Analytics Research (Kim), University of Michigan, Ann Arbor; Program Evaluation and Resource Center and VA Office of Mental Health Operations, VA Palo Alto Health Care System, Palo Alto, California (Boden)
| | - Matthew T Boden
- Center for Clinical Management Research, U.S. Department of Veterans Affairs (VA) Ann Arbor Healthcare System, Ann Arbor (Sripada, Grau, Porath, Burgess, Van, Kim, Zivin); Department of Psychiatry, Michigan Medicine (Sripada, Grau, Zivin), and Consulting for Statistics, Computing and Analytics Research (Kim), University of Michigan, Ann Arbor; Program Evaluation and Resource Center and VA Office of Mental Health Operations, VA Palo Alto Health Care System, Palo Alto, California (Boden)
| | - Kara Zivin
- Center for Clinical Management Research, U.S. Department of Veterans Affairs (VA) Ann Arbor Healthcare System, Ann Arbor (Sripada, Grau, Porath, Burgess, Van, Kim, Zivin); Department of Psychiatry, Michigan Medicine (Sripada, Grau, Zivin), and Consulting for Statistics, Computing and Analytics Research (Kim), University of Michigan, Ann Arbor; Program Evaluation and Resource Center and VA Office of Mental Health Operations, VA Palo Alto Health Care System, Palo Alto, California (Boden)
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Hein TC, Austin K, Grau PP, Keith JA, Claes NJ, Bowersox NW. Predictors of non-fatal suicide attempts among Veterans Health Administration (VHA) patients who experienced military sexual trauma. Suicide Life Threat Behav 2024. [PMID: 38421037 DOI: 10.1111/sltb.13038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 11/10/2023] [Accepted: 12/22/2023] [Indexed: 03/02/2024]
Abstract
OBJECTIVE Military sexual trauma (MST) has been identified as a risk factor for suicidal behavior. To inform suicide prevention efforts within the Veterans Health Administration (VHA), this study evaluates predictors of non-fatal suicide attempts (NFSAs) among VHA patients who experienced MST. METHODS For VHA patients in fiscal year (FY) 2019 who previously screened positive for a history of MST, documented NFSAs were assessed. Using multivariable logistic regression, demographic, clinical, and VHA care utilization predictors of NFSAs were assessed. RESULTS Of the 212,215 VHA patients who screened positive for MST prior to FY 2019 and for whom complete race, service connection, and rurality information was available, 1742 (0.8%) had a documented NFSA in FY 2019. In multivariable logistic regression analyses, total physical and mental health morbidities were not associated with NFSA risk. Predictors of a documented NFSA included specific mental health diagnoses [adjusted odds ratio (aOR) range: 1.28-1.94], receipt of psychotropic medication prescriptions (aOR range: 1.23-2.69) and having a prior year emergency department visit (aOR = 1.32) or inpatient psychiatric admission (aOR = 2.15). CONCLUSIONS Among VHA patients who experienced MST, specific mental health conditions may increase risk of NFSAs, even after adjustment for overall mental health morbidity. Additionally, indicators of severity of mental health difficulties such as receipt of psychotropic medication prescriptions and inpatient psychiatric admissions are also associated with increased risk above and beyond risk associated with diagnoses. Findings highlight targets for suicide prevention initiatives among this vulnerable group within VHA and may help identify patients who would benefit from additional support.
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Affiliation(s)
- Tyler C Hein
- Department of Veterans Affairs, Serious Mental Illness Treatment Resource and Evaluation Center (SMITREC), Office of Mental Health and Suicide Prevention (11MHSP), Ann Arbor, Michigan, USA
- TRAILS, a Project of Tides Center, Ann Arbor, Michigan, USA
| | - Karen Austin
- Department of Veterans Affairs, Serious Mental Illness Treatment Resource and Evaluation Center (SMITREC), Office of Mental Health and Suicide Prevention (11MHSP), Ann Arbor, Michigan, USA
| | - Peter P Grau
- Department of Veterans Affairs, Serious Mental Illness Treatment Resource and Evaluation Center (SMITREC), Office of Mental Health and Suicide Prevention (11MHSP), Ann Arbor, Michigan, USA
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan, USA
- VA Center for Clinical Management Research (CCMR), Ann Arbor, Michigan, USA
| | - Jessica A Keith
- Department of Veterans Affairs, Military Sexual Trauma Support Team, Office of Mental Health and Suicide Prevention (11MHSP), Washington, DC, USA
- College of Medicine, University of Central Florida, Orlando, Florida, USA
| | - Nathan J Claes
- Department of Veterans Affairs, Military Sexual Trauma Support Team, Office of Mental Health and Suicide Prevention (11MHSP), Washington, DC, USA
| | - Nicholas W Bowersox
- Department of Veterans Affairs, Serious Mental Illness Treatment Resource and Evaluation Center (SMITREC), Office of Mental Health and Suicide Prevention (11MHSP), Ann Arbor, Michigan, USA
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan, USA
- VA Center for Clinical Management Research (CCMR), Ann Arbor, Michigan, USA
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Grau PP, Browne J, Nelson SM, Austin K, Keith JA, Claes NJ, Kawentel LM, Bowersox NW. Engagement in posttraumatic stress disorder treatment for veterans who experienced military sexual trauma and are diagnosed with serious mental illness. Psychol Serv 2024:2024-53069-001. [PMID: 38358699 DOI: 10.1037/ser0000845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2024]
Abstract
It is important to ensure that veterans who have experienced military sexual trauma (MST) and have posttraumatic stress disorder (PTSD) have access to trauma-focused treatment. For veterans with serious mental illness (SMI), prior work documents decreased likelihood to receive trauma-focused care. This study focused on evaluating the engagement of Veterans Health Administration (VHA) patients diagnosed with PTSD and who have experienced MST in PTSD specialty care, as well as how this differs for veterans with SMI. Using VHA administrative data, all VHA patients who screened positive for MST prior to fiscal year 2019 (FY2019) were identified (N = 84,503). Based on information from FY2019, measures of psychiatric diagnosis status and VHA treatment participation were generated for all cohort members. Logistic regressions assessed whether there were differences in the likelihood to initiate PTSD care (1+ VHA PTSD specialty clinic encounter) or receive guideline-concordant levels of PTSD specialty care (8+ VHA PTSD specialty clinic encounter) during FY2019. Several other patient characteristics associated with decreased likelihood to receive VHA PTSD specialty servies were identified, including White race and older age. Patient SMI status was not significantly associated with likelihood to initiate or receive guideline-concordant levels of PTSD specialty care. Overall, PTSD treatment initiation was low (11% of veterans with SMI initiated PTSD specialty treatment, as opposed to 10% of veterans without SMI). Additional work is merited to identify ways that VHA is able to overcome barriers to trauma care participation experienced by persons who have experienced MST and been diagnosed with PTSD. (PsycInfo Database Record (c) 2024 APA, all rights reserved).
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Affiliation(s)
- Peter P Grau
- Department of Veterans Affairs, Serious Mental Illness Treatment Resource and Evaluation Center, Office of Mental Health and Suicide Prevention, VA Ann Arbor Healthcare System
| | - Julia Browne
- Durham VA Health Care System Geriatric Research Education and Clinical Center
| | - Sharon M Nelson
- Department of Veterans Affairs, Serious Mental Illness Treatment Resource and Evaluation Center, Office of Mental Health and Suicide Prevention, VA Ann Arbor Healthcare System
| | - Karen Austin
- Department of Veterans Affairs, Serious Mental Illness Treatment Resource and Evaluation Center, Office of Mental Health and Suicide Prevention, VA Ann Arbor Healthcare System
| | - Jessica A Keith
- Department of Veterans Affairs, Military Sexual Trauma Support Team, Office of Mental Health and Suicide Prevention
| | - Nathan J Claes
- Department of Veterans Affairs, Military Sexual Trauma Support Team, Office of Mental Health and Suicide Prevention
| | - Linda M Kawentel
- Quality Enhancement Research Initiative Center for Evaluation and Implementation Resources
| | - Nicholas W Bowersox
- Department of Veterans Affairs, Serious Mental Illness Treatment Resource and Evaluation Center, Office of Mental Health and Suicide Prevention, VA Ann Arbor Healthcare System
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Fernando M, Tu JW, Grau PP, Koch EI, Blevins EJ, Jefferson S, Sexton MB. Differential Associations Between Posttraumatic Cognitions, Posttraumatic Stress Disorder Symptoms, and Race Among Black and White Veterans Seeking Treatment for Assaultive Military Sexual Trauma. J Interpers Violence 2024; 39:631-650. [PMID: 37714821 DOI: 10.1177/08862605231197773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/17/2023]
Abstract
Past research supports the role of negative posttraumatic cognitions (NPCs) in the development and maintenance of posttraumatic stress disorder (PTSD). The relationship between NPCs and PTSD may be uniquely impacted by racial status and experiences of military sexual trauma (MST), both of which may have a unique impact on one's understanding of self, others, and the world. We explored racial differences in the association between NPCs and PTSD symptom clusters in a sample of veterans endorsing MST (N = 139; 74.8% White, 25.2% Black). A path model was created and analyzed both with the full sample and separately by racial group. In the full sample, NPCs about the self and world were significantly associated with intrusion, negative alterations in cognitions and mood (NACM), and arousal, but not avoidance. Self-blame was not a significant predictor of negative alterations in cognition in mood. This model was consistent in the White veteran model, whereas only negative cognitions about the self were associated with NACM in the Black veteran path model. NPCs about the self and world appear important to non-avoidance PTSD symptomatology related to MST and thus should be targeted in treatment. For Black veterans endorsing distress related to NACM symptoms, negative beliefs about the self should be specifically considered for intervention.
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Affiliation(s)
- Michelle Fernando
- VA Ann Arbor Healthcare System, MI, USA
- VA Boston National Center for PTSD, USA
- Eastern Michigan University, Ypsilanti, USA
- Boston University Chobanian & Avedisian School of Medicine, USA
| | - Joseph W Tu
- VA Ann Arbor Healthcare System, MI, USA
- Eastern Michigan University, Ypsilanti, USA
| | - Peter P Grau
- VA Ann Arbor Healthcare System, MI, USA
- Michigan Medicine, USA
| | | | - Emily J Blevins
- VA Ann Arbor Healthcare System, MI, USA
- Michigan Medicine, USA
| | | | - Minden B Sexton
- VA Ann Arbor Healthcare System, MI, USA
- Michigan Medicine, USA
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Bowersox NW, Browne J, Grau PP, Merrill SL, Haderlein TP, Llorente MD, Washington DL. COVID-19 mortality among veterans with serious mental illness in the veterans health administration. J Psychiatr Res 2023; 163:222-229. [PMID: 37230006 PMCID: PMC10171776 DOI: 10.1016/j.jpsychires.2023.05.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 03/31/2023] [Accepted: 05/01/2023] [Indexed: 05/27/2023]
Abstract
OBJECTIVE Persons with serious mental illness (SMI: schizophrenia-spectrum disorders, bipolar disorder) experience increased risk of mortality after contracting COVID-19 based on the results of several international evaluations. However, information about COVID-19 mortality risk among patients with SMI in the Veterans Health Administration (VHA) has been limited, precluding identification of protective factors. The current evaluation was conducted to assess COVID-19 mortality risk among VHA patients with SMI and to evaluate potential protective factors in mitigating mortality risk following a positive COVID-19 diagnosis. METHODS National VHA administrative data was used to identify all patients (N = 52,916) who received a positive COVID-19 test result between March 1, 2020, and September 30, 2020. Mortality risk was assessed by SMI status via bivariate comparisons and multivariate regression analyses. RESULTS In unadjusted analyses, VHA patients with SMI overall and patients with bipolar disorder in particular did not experience increased mortality risk in the 30 days following a positive COVID test, although patients with schizophrenia had increased risk. Within adjusted analyses, patients with schizophrenia remained at increased mortality risk (OR = 1.38), but at reduced levels relative to previous evaluations in other healthcare settings. CONCLUSIONS Within VHA, patients with schizophrenia, but not those with bipolar disorder, experience increased mortality risk in the 30 days following a positive COVID-19 test. Large integrated healthcare settings such as VHA may offer services which may protect against COVID-19 mortality for vulnerable groups such as persons with SMI. Additional work is needed to identify practices which may reduce the risk of COVID-19 mortality among persons with SMI.
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Affiliation(s)
- Nicholas W Bowersox
- Serious Mental Illness Treatment Resource and Evaluation Center, Office of Mental Health and Suicide Prevention, Department of Veterans Affairs Central Office, Washington DC, USA; Department of Psychiatry, University of Michigan Medical School, Ann Arbor, MI, USA.
| | - Julia Browne
- Research Service, VA Providence Healthcare System, Providence, RI, USA; Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, RI, USA
| | - Peter P Grau
- Serious Mental Illness Treatment Resource and Evaluation Center, Office of Mental Health and Suicide Prevention, Department of Veterans Affairs Central Office, Washington DC, USA; Department of Psychiatry, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Stephanie L Merrill
- Serious Mental Illness Treatment Resource and Evaluation Center, Office of Mental Health and Suicide Prevention, Department of Veterans Affairs Central Office, Washington DC, USA
| | - Taona P Haderlein
- Veterans Health Administration Health Services Research and Development Center for the Study of Healthcare Innovation, Implementation, and Policy, Los Angeles, CA, USA; Veterans Emergency Management Evaluation Center, Department of Veterans Affairs, North Hills, CA, USA
| | - Maria D Llorente
- Patient Care Services, Department of Veterans Affairs, Washington DC, USA; Department of Psychiatry, Georgetown University School of Medicine, Washington DC, USA
| | - Donna L Washington
- Veterans Health Administration Health Services Research and Development Center for the Study of Healthcare Innovation, Implementation, and Policy, Los Angeles, CA, USA; Division of General Internal Medicine and Health Services Research, Department of Medicine, University of California Los Angeles Geffen School of Medicine, Los Angeles, CA, USA
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Sripada RK, Smith K, Walters HM, Ganoczy D, Kim HM, Grau PP, Nahum-Shani I, Possemato K, Kuhn E, Zivin K, Pfeiffer PN, Bohnert KM, Cigrang JA, Avallone KM, Rauch SAM. Testing adaptive interventions to improve PTSD treatment outcomes in Federally Qualified Health Centers: Protocol for a randomized clinical trial. Contemp Clin Trials 2023; 129:107182. [PMID: 37044157 PMCID: PMC10349653 DOI: 10.1016/j.cct.2023.107182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 04/02/2023] [Accepted: 04/08/2023] [Indexed: 04/14/2023]
Abstract
BACKGROUND Posttraumatic stress disorder (PTSD) disproportionately affects low-income individuals and is untreated in 70% of those affected. One third of low-income Americans are treated in Federally Qualified Health Centers (FQHCs), which do not have the capacity to provide all patients with first-line treatments such as Prolonged Exposure (PE). To address this problem, FQHCs could use low-intensity interventions (e.g., Clinician-Supported PTSD Coach: CS PTSD Coach) and medium-intensity interventions (e.g., PE for Primary Care: PE-PC) to treat PTSD with fewer resources. However, some patients will still require high-intensity treatments (e.g., full-length PE) for sustained clinical benefit. Thus, there is a critical need to develop stepped-care models for PTSD in FQHCs. METHOD We are conducting a Sequential, Multiple Assignment, Randomized Trial (SMART) with 430 adults with PTSD in FQHCs. Participants are initially randomized to CS PTSD Coach or PE-PC. After four sessions, early responders step down to lower frequency interaction within their assigned initial treatment strategy. Slow responders are re-randomized to either continue their initial treatment strategy or step up to Full PE for an additional eight weeks. The specific aims are to test the effectiveness of initiating treatment with PE-PC versus CS PTSD Coach in reducing PTSD symptoms and to test the effectiveness of second-stage strategies (continue versus step-up to Full PE) for slow responders. CONCLUSIONS This project will provide critical evidence to inform the development of an effective stepped-care model for PTSD. Testing scalable, sustainable sequences of PTSD treatments delivered in low-resource community health centers will improve clinical practice for PTSD.
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Affiliation(s)
- Rebecca K Sripada
- Department of Psychiatry, Michigan Medicine, Ann Arbor, MI, United States of America; Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, United States of America.
| | - Kayla Smith
- Department of Psychiatry, Michigan Medicine, Ann Arbor, MI, United States of America
| | - Heather M Walters
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, United States of America
| | - Dara Ganoczy
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, United States of America
| | - H Myra Kim
- Department of Psychiatry, Michigan Medicine, Ann Arbor, MI, United States of America; Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, United States of America; Consulting for Statistics, Computing and Analytics Research, University of Michigan, Ann Arbor, MI, United States of America
| | - Peter P Grau
- Department of Psychiatry, Michigan Medicine, Ann Arbor, MI, United States of America; Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, United States of America
| | - Inbal Nahum-Shani
- Data-Science for Dynamic Decision-making Center, Institute for Social Research, University of Michigan, Ann Arbor, MI, United States of America
| | - Kyle Possemato
- VA Center for Integrated Healthcare, Syracuse, NY, United States of America
| | - Eric Kuhn
- National Center for PTSD, Dissemination and Training Division, VA Palo Alto Health Care System, Palo Alto, CA, United States of America; Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, United States of America
| | - Kara Zivin
- Department of Psychiatry, Michigan Medicine, Ann Arbor, MI, United States of America; Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, United States of America
| | - Paul N Pfeiffer
- Department of Psychiatry, Michigan Medicine, Ann Arbor, MI, United States of America; Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, United States of America
| | - Kipling M Bohnert
- Department of Epidemiology and Biostatistics, College of Human Medicine, Michigan State University, East Lansing, MI, United States of America
| | - Jeffrey A Cigrang
- School of Professional Psychology, College of Health Education and Human Services, Wright State University, Fairborn, OH, United States of America
| | - Kimberly M Avallone
- Department of Psychiatry, Michigan Medicine, Ann Arbor, MI, United States of America
| | - Sheila A M Rauch
- VA Atlanta Healthcare System, Decatur, GA, United States of America; Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, United States of America
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Matloub Lepak J, Zhang X, Grau PP, Wetterneck CT. Does change in trauma-related shame predict change in PTSD symptomatology? Psychol Trauma 2023:2023-63371-001. [PMID: 37053404 DOI: 10.1037/tra0001454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/15/2023]
Abstract
OBJECTIVE Trauma-related shame (TR-shame) is associated with Posttraumatic Stress Disorder (PTSD) symptoms. However, research findings are inconsistent regarding the role of TR-shame in PTSD treatment. The purpose of this study was to examine if change in TR-shame predicted change in PTSD symptoms in treatment. METHOD A sample of 462 adults who received PTSD treatment at a Partial Hospitalization Program completed questionnaires measuring TR-shame (i.e., Trauma-Related Shame Inventory; TRSI) and PTSD symptoms (PTSD Checklist for DSM-5; PCL-5). Latent growth curve models were estimated to examine if the rate of change in TRSI predicted the rate of change in PCL-5 by using structural equation modeling. Furthermore, a latent regression model was estimated to predict the intercept and slope of the PCL-5. RESULTS Model fits for the PCL-5 and the TRSI linear models were acceptable and both linear slopes were significant. On average, PCL-5 scores reduced 22.18 points from admission to discharge, while TRSI scores reduced 21.9 points from admission to discharge. The results of latent curve regression model suggested that the TRSI linear slope and intercept predicted the PCL-5 linear slope and intercept, respectively. Additionally, post-hoc analyses suggested that the variance in PCL-5 factors at discharge that were explained by TRSI intercept and linear slope ranged from 18.6% to 34.9%. CONCLUSIONS The results of this study indicated that the rate of change in TR-shame predicted the rate of change in PTSD symptoms. Given the negative impact of TR-shame on PTSD symptoms, TR-shame should be a target in treatment for PTSD. (PsycInfo Database Record (c) 2023 APA, all rights reserved).
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Affiliation(s)
| | - Xiaonan Zhang
- Department of Counselor Education and Counseling Psychology
| | - Peter P Grau
- VA Serious Mental Illness Treatment Resource and Evaluation Center (SMITREC)
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Grau PP, Sripada RK, Ganoczy D, Weinstein JH, Pfeiffer PN. Outcomes of Acceptance and Commitment Therapy for depression and predictors of treatment response in Veterans Health Administration patients. J Affect Disord 2023; 323:826-833. [PMID: 36529407 DOI: 10.1016/j.jad.2022.12.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 12/06/2022] [Accepted: 12/07/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND Acceptance and Commitment Therapy for depression (ACT-D) is a promising depression treatment which has not been evaluated on a large scale within VA. This study aimed to evaluate ACT-D's effectiveness in a national, treatment-seeking sample of Veterans. METHODS The sample comprised 831 Veterans who received a primary depression diagnosis and received at least two sessions of ACT-D during fiscal years 2015-2020. We used GLM to measure predictors of symptom change, treatment response (50 % reduction in PHQ-9 and AAQ-II scores), subthreshold depression symptoms (PHQ-9 < 10; AAQ-II < 27), and treatment completion. RESULTS Veterans experienced an average reduction of 3.39 points on the PHQ-9 (Cohen's d = 0.56) and 3.76 points on the AAQ-II (Cohen's d = 0.43). On the PHQ-9, 40 % achieved subthreshold depression symptoms. On the AAQ-II, 36 % of Veterans achieved subthreshold psychological inflexibility scores. Service-connected disability rating for depression and higher levels of medical comorbidity were both related to lower levels of overall depression symptom change and treatment response. Substance use disorder and bipolar/psychosis diagnoses were associated with greater reductions in psychological inflexibility. LIMITATIONS This is an observational study without a control group, so we were unable to compare the effectiveness of ACT-D to other usual care for depression. We were also unable to assess variables that can influence treatment success, such as therapist fidelity and patient engagement. CONCLUSIONS ACT-D achieved similar improvements in depression as reported in controlled trials. Adaptations to ACT-D may be needed to improve outcomes for Veterans with depression and comorbid PTSD.
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Affiliation(s)
- Peter P Grau
- VA Serious Mental Illness Treatment Resource and Evaluation Center (SMITREC), 2800 Plymouth Road, Bldg 16, Ann Arbor, MI 48109, United States; VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI 48105, United States; Department of Psychiatry, University of Michigan Medical School, United States; Veterans Affairs Center for Clinical Management Research, Health Services Research and Development, Ann Arbor, MI, United States.
| | - Rebecca K Sripada
- VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI 48105, United States; Department of Psychiatry, University of Michigan Medical School, United States; Veterans Affairs Center for Clinical Management Research, Health Services Research and Development, Ann Arbor, MI, United States
| | - Dara Ganoczy
- Veterans Affairs Center for Clinical Management Research, Health Services Research and Development, Ann Arbor, MI, United States
| | - Jonathan H Weinstein
- VA Northport Medical Center, 79 Middleville Road, Northport, NY 11768, United States
| | - Paul N Pfeiffer
- VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI 48105, United States; Department of Psychiatry, University of Michigan Medical School, United States; Veterans Affairs Center for Clinical Management Research, Health Services Research and Development, Ann Arbor, MI, United States
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11
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Grau PP, Sripada RK, Pietrzak RH, Ganoczy D, Harpaz-Rotem I. Treatment response trajectories in residential PTSD programs for veterans: A national cohort investigation. J Anxiety Disord 2022; 92:102645. [PMID: 36334317 DOI: 10.1016/j.janxdis.2022.102645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 10/05/2022] [Accepted: 10/28/2022] [Indexed: 11/06/2022]
Abstract
Although improving residential PTSD care is a priority for the Department of Veterans Affairs, previous evaluations have been limited by a lack of systematic data collection across more than two timepoints. This study used recently available data to assess symptom trajectories in a large, national sample of veterans who engaged in residential PTSD treatment. Group-based trajectory analysis PROC TRAJ was used to identify PTSD residential treatment response in a national cohort of veterans (n = 10,832) and the subset of veterans (n = 6515) receiving evidence-based psychotherapy (EBP). PTSD symptoms were assessed at intake, discharge, and 4-month follow-up. Predictors of trajectory membership were estimated using multinomial models. For the full cohort, a three-group trajectory model provided the best fit with the following identified groups: "Severe/Stable" (51.8%), "Moderate/Rebound" (40.1%), and "Mild/Rebound" (8.1%). For the EBP sub-cohort, a three-group trajectory model was selected with the following groups: "Severe/Stable" (58.5%), "Moderate/Rebound" (34.1%), and "Mild/Rebound" (7.4%). Across all trajectories, psychological distress, pain severity, substance use, Iraq/Afghanistan combat era, non-White race, and treatment dropout were associated with poorer treatment response. In the EBP sub-cohort, homelessness and unemployment at the time of admission were also associated with poorer treatment outcomes to varying degrees. This study demonstrates that residential treatment for PTSD is associated with heterogeneous treatment trajectories which highlight the need to continue to explore and improve residential PTSD treatment outcomes. Our results underscore the importance of obtaining follow-up data and identifying ways to maintain therapeutic gains following discharge.
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Affiliation(s)
- Peter P Grau
- VA Serious Mental Illness Treatment Resource and Evaluation Center (SMITREC), 2800 Plymouth Road, Bldg 16, Ann Arbor, MI 48109, United States; VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI 48105, United States; Department of Psychiatry, University of Michigan Medical School, United States.
| | - Rebecca K Sripada
- VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI 48105, United States; Department of Psychiatry, University of Michigan Medical School, United States; Veterans Affairs Center for Clinical Management Research, Health Services Research and Development, Ann Arbor, MI, United States
| | - Robert H Pietrzak
- Veterans Affairs National Center for PTSD, Veteran Affairs Connecticut Healthcare System, West Haven, CT, United States; Yale University, Department of Psychiatry, New Haven, CT, United States
| | - Dara Ganoczy
- Veterans Affairs Center for Clinical Management Research, Health Services Research and Development, Ann Arbor, MI, United States
| | - Ilan Harpaz-Rotem
- Veterans Affairs National Center for PTSD, Veteran Affairs Connecticut Healthcare System, West Haven, CT, United States; Yale University, Department of Psychiatry, New Haven, CT, United States; Veterans Affairs Northeast Program Evaluation Center, West Haven, CT, United States
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12
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Grau PP, Bohnert KM, Ganoczy D, Sripada RK. Who improves in trauma-focused treatment: A cluster analysis of treatment response in VA patients undergoing PE and CPT. J Affect Disord 2022; 318:159-166. [PMID: 36070830 DOI: 10.1016/j.jad.2022.08.126] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 05/20/2022] [Accepted: 08/28/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND Although most veterans with posttraumatic stress disorder (PTSD) benefit from evidence-based treatments, questions persist concerning the profiles of those at risk for poor outcomes. To help address these gaps, this study analyzed a large clinical cohort of veterans receiving prolonged exposure (PE) or cognitive processing therapy (CPT). METHODS Cluster analysis using Ward's method with Euclidian distances identified clinically meaningful subgroups of veterans in a national cohort (n = 20,848) using variables maintained in the electronic medical record. The clusters were then compared via one-way analysis of variance and Tukey's HSD on indicators of treatment progress including PTSD symptom change, clinical recovery, clinically significant change, remission, and treatment completion. RESULTS Effect size differences on clinical outcome measures for PE and CPT were negligible. Less than half of veterans achieved at least a 15-point reduction in PCL-5 score and half completed treatment. We identified 10 distinct clusters. Higher rates of PTSD service-connected disability were linked to poorer outcomes across multiple clusters, especially when combined with Post-Vietnam service era. Non-White race was also linked with poorer clinical outcomes. Factors associated with better outcomes included a greater proportion of female veterans, especially when combined with recent service era, and longer PTSD diagnosis duration. CONCLUSIONS This study suggests the need to improve PTSD treatment outcomes for non-White and male veterans, examine treatment response in Post-Vietnam era veterans, and consider ways in which the service connection process could hinder treatment response. The results from this study also indicate the benefits of integrating elements of clinical complexity into an analytic approach.
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Affiliation(s)
- Peter P Grau
- VA Serious Mental Illness Treatment Resource and Evaluation Center (SMITREC), 2800 Plymouth Road, Bldg 16, Ann Arbor, MI 48109, United States; VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI 48105, United States; Department of Psychiatry, University of Michigan Medical School, United States.
| | - Kipling M Bohnert
- Department of Epidemiology and Biostatistics, Michigan State University, United States
| | - Dara Ganoczy
- Veterans Affairs Center for Clinical Management Research, Health Services Research and Development, Ann Arbor, MI, United States
| | - Rebecca K Sripada
- VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI 48105, United States; Department of Psychiatry, University of Michigan Medical School, United States; Veterans Affairs Center for Clinical Management Research, Health Services Research and Development, Ann Arbor, MI, United States
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Grau PP, Valentine LM, Vuper TC, Rogers TA, Wong JD, Sexton MB. Military sexual trauma in context: Ethnoracial differences in ecological resources among treatment-seeking veterans. J Trauma Stress 2022; 35:1535-1545. [PMID: 35819929 DOI: 10.1002/jts.22859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 05/19/2022] [Accepted: 05/20/2022] [Indexed: 11/05/2022]
Abstract
Veterans who have experienced military sexual trauma (MST) are at increased risk for a host of negative outcomes, including posttraumatic stress disorder, depressive disorders, and substance use disorders. Previous studies have shown racial differences in MST exposure, namely that Black veterans experience MST more frequently than White veterans. One way to help clinicians and researchers understand the impact of these ethnoracial differences in MST exposure is through an applied theory of ecological resources, which has demonstrated ecological factors (e.g., aspects of identity, beliefs, and environmental stressors) contribute to veteran well-being in the aftermath of MST. The present study aimed to examine ethnoracial differences in ecological resources (i.e., available social support, spiritual coping, past-year interpersonal violence, financial sufficiency, and stable living environment). Participants (N = 505) were U.S. veterans who sought care at a Veterans Healthcare Administration clinic in the midwestern United States for mental health issues related to MST. Results demonstrated Black veterans were more likely than White veterans to report being financially insecure, U = 18,091.50, z = -2.04, p = .042, r = .10. Black veterans were also more likely to report spiritual beliefs that assisted with coping, Cramer's V = .19, but less likely to report having a social support system, Cramer's V = .16. These findings highlight the importance of assessing and addressing disparities illuminated by ethnoracial differences in ecological resources and barriers in veterans seeking care for MST.
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Affiliation(s)
- Peter P Grau
- VA Serious Mental Illness Treatment Resource and Evaluation Center (SMITREC), Ann Arbor, Michigan, USA.,VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA.,Department of Psychiatry, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Lisa M Valentine
- VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA.,Department of Psychiatry, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Tessa C Vuper
- VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA.,Department of Psychiatry, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Travis A Rogers
- VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA.,Department of Psychiatry, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Jennifer D Wong
- New Mexico Veterans Affairs Healthcare System, Albuquerque, New Mexico, USA
| | - Minden B Sexton
- VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA.,Department of Psychiatry, University of Michigan Medical School, Ann Arbor, Michigan, USA
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Grekin R, Bohnert KM, Grau PP, Ganoczy D, Sripada RK. Rates and predictors of psychotherapy receipt among U.S. veterans with comorbid posttraumatic stress disorder and substance use disorders. Drug Alcohol Depend Rep 2021; 1:100010. [PMID: 36843911 PMCID: PMC9948867 DOI: 10.1016/j.dadr.2021.100010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 11/22/2021] [Accepted: 11/22/2021] [Indexed: 11/17/2022]
Abstract
Introduction Veterans with comorbid posttraumatic stress disorder (PTSD) and substance use disorder (SUD) have complex needs and often do not receive adequate mental health treatment. The purpose of this study was to examine rates and predictors of PTSD-only, SUD-only, or PTSD and SUD psychotherapy receipt among newly diagnosed Veterans with PTSD and SUD. Design and setting An administrative dataset including Veterans Health Administration (VHA) users. Participants The sample comprised 32,779 United States Veterans with a new PTSD and a new SUD diagnosis in fiscal year 2015. Measurement Multinomial logistic regression was used to identify predictors of receipt of any and adequate psychotherapy for PTSD, SUD, or PTSD and SUD across settings. Binomial logistic regression was used to identify predictors of PTSD psychotherapy among those who received any psychotherapy. Findings A total of 13,824 (42.17%) Veterans in this sample received any PTSD- or SUD-related therapy in the year following diagnosis. Low rates of veterans received an adequate dose of PTSD-related psychotherapy (6.58%), SUD-related psychotherapy (7.72%), or both PTSD and SUD-related psychotherapy (<1%) In adjusted models, older age, service-connected disability, and psychiatric comorbidities were associated with decreased odds of treatment. Specific types of SUDs, including alcohol, cocaine, and opioid use disorders, along with receipt of diagnosis in a PTSD or SUD clinic, were associated with increased odds of treatment. Conclusions Low rates of PTSD and SUD related psychotherapy highlight a need to better engage and retain Veterans with these disorders in care. Predictors of decreased treatment utilization, such as older age, service connection, and bipolar and major depressive disorders, may inform efforts by the VHA to further target and engage Veterans with indicated treatments.
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Affiliation(s)
- Rebecca Grekin
- VA Serious Mental Illness Treatment Resource and Evaluation Center (SMITREC), 2800 Plymouth Road, Bldg 16, Ann Arbor, MI 48109, United States
- Great Lakes Perinatal Wellness, Ann Arbor, MI 48105, United States
- Department of Psychological and Brain Sciences, University of Iowa, United States
| | - Kipling M. Bohnert
- Department of Epidemiology and Biostatistics, Michigan State University, United States
| | - Peter P. Grau
- VA Serious Mental Illness Treatment Resource and Evaluation Center (SMITREC), 2800 Plymouth Road, Bldg 16, Ann Arbor, MI 48109, United States
- VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI 48105, United States
- Department of Psychiatry, University of Michigan Medical School, United States
| | - Dara Ganoczy
- Veterans Affairs Center for Clinical Management Research, Health Services Research and Development, Ann Arbor Michigan, United States
| | - Rebecca K. Sripada
- VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI 48105, United States
- Department of Psychiatry, University of Michigan Medical School, United States
- Veterans Affairs Center for Clinical Management Research, Health Services Research and Development, Ann Arbor Michigan, United States
- Corresponding author at: Serious Mental Illness Treatment Resource and Evaluation Center, 2800 Plymouth Road, 016, Ann Arbor, MI 48109, United States.
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15
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Grau PP, Kusch MM, Williams MT, Loyo KT, Zhang X, Warner RC, Wetterneck CT. A review of the inclusion of ethnoracial groups in empirically supported posttraumatic stress disorder treatment research. Psychol Trauma 2021; 14:55-65. [PMID: 34498899 DOI: 10.1037/tra0001108] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Empirically supported treatments (ESTs) have been criticized for lack of ethnoracial representation, which may limit the generalizability of findings for non-White patients. This study assessed ethnoracial representation in United States-based randomized controlled trials (RCTs) for three evidence-based treatments for posttraumatic stress disorder (PTSD)-Prolonged Exposure (PE), Cognitive Processing Therapy (CPT), and Eye-Movement Desensitization and Reprocessing (EMDR). METHOD Representation was measured by explicit inclusion of people of color in published PTSD RCTs. Follow-up emails were sent to corresponding authors if full demographic information was not included in the reviewed manuscripts. Information concerning participant remuneration was collected for descriptive purposes. RESULTS All three treatment modalities reported White participants as the majority in their sample. PE and CPT trials reported similar levels of ethnoracial diversity, while EMDR efficacy studies reported the least ethnoracial diversity. Across the reviewed studies, with few exceptions, we found low numbers of non-White participants in the majority of reviewed studies, which was compounded by poor or unclear methods of reporting ethnoracial information. CONCLUSIONS This study demonstrates that the ESTs for PTSD are not adequately representative of the majority of non-White participants. Future RCTs should place a stronger emphasis on broad ethnoracial diversity in study participants to improve generalizability of findings. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
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Affiliation(s)
- Peter P Grau
- Department of Counselor Education and Counseling Psychology
| | | | | | - Karina T Loyo
- Department of Counselor Education and Counseling Psychology
| | - Xiaonan Zhang
- Department of Counselor Education and Counseling Psychology
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16
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Grau PP, Larsen SE, Lancaster SL, Garnier-Villarreal M, Wetterneck CT. Change in Event Centrality and Posttraumatic Stress Disorder Symptoms During Intensive Treatment. J Trauma Stress 2021; 34:116-123. [PMID: 32521088 DOI: 10.1002/jts.22541] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 04/02/2020] [Accepted: 04/06/2020] [Indexed: 11/06/2022]
Abstract
Event centrality, defined as the extent to which a traumatic event becomes a core component of a person's identity (Berntsen & Rubin, 2006), is both a correlate and predictor of posttraumatic stress disorder (PTSD) symptoms, over and above event severity. These findings suggest that decreasing the perceived centrality of a traumatic event to one's identity might result in decreases in PTSD symptom severity. To date, few studies have examined how centrality is affected by PTSD treatment. The present study tested the hypotheses that change in centrality would be associated with both change in PTSD symptom severity and discharge PTSD symptom severity in an exposure-based PTSD partial hospitalization program (N = 132; 86.0% White; 85.2% female; M age = 36 years). At discharge (i.e., after approximately 6 weeks of treatment), both PTSD symptoms and centrality had significantly decreased, ds = .70 and .98, respectively, with large effect sizes. Decreases in Centrality of Events Scale (CES) scores at posttreatment, baseline CES scores, and baseline PTSD Checklist for DSM-5 (PCL-5) scores were associated with change (i.e., decrease) in PCL-5 scores, p < .001, as well as with posttreatment PCL-5 scores, p < .001. Decreases in CES scores over time, baseline CES scores, and baseline PCL-5 scores explained 31% of the variance in PCL-5 change and 34% of the variance in posttreatment PCL-5 scores. The results indicate the potential importance of decreasing the centrality of a traumatic event in PTSD treatment and recovery.
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Affiliation(s)
- Peter P Grau
- Department of Counselor Education and Counseling Psychology, Marquette University, Milwaukee, Wisconsin, USA
| | - Sadie E Larsen
- Department of Psychiatry and Behavioral Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA.,Milwaukee VA Medical Center, Milwaukee, Wisconsin, USA
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Grau PP, McDonald JE, Clark MN, Wetterneck CT. The relationship between three ACT core processes of change, PTSD, and depressive symptoms. Journal of Contextual Behavioral Science 2020. [DOI: 10.1016/j.jcbs.2020.04.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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McDonald JE, Grau PP. Challenges and growth through bereavement during graduate training. Journal of Psychotherapy Integration 2019. [DOI: 10.1037/int0000142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Johnson BT, Grau PP, Saunders SM. Psychiatric Medications and Stigmatizing Attitudes in College Students. Journal of College Student Psychotherapy 2019. [DOI: 10.1080/87568225.2019.1600092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Affiliation(s)
- Laura Bein
- Advocate Health Care, Marquette University, Milwaukee, Wisconsin
| | - Peter P. Grau
- Department of Counseling Psychology, Marquette University, Milwaukee, Wisconsin
| | | | - Terri A. deRoon-Cassini
- Department of Surgery, Division of Trauma & Critical Care, Medical College of Wisconsin, Milwaukee, Wisconsin
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Abstract
The activity of the endoribonuclease VI from Artemia is sensitive to several purine nucleotides. The enzyme is non-competitively inhibited by diguanosine tetraphosphate (Ki = 75 microM), a nucleotide abundant in Artemia encysted gastrulae and located in the same particulate fraction as the gastrular ribonuclease. Diguanosine triphosphate and diadenosine tetraphosphate are less efficient inhibitors (Ki congruent to 200 microM). The ribonuclease is non-competitively inhibited by 5'-AMP (Ki = 10 microM) and 5'-GMP (Ki = 50 microM) but is insensitive to the corresponding 5'-phosphates of cytosine and uridine. Other purine mononucleotides inhibit the enzyme activity less efficiently. The modulation of the enzyme activity by these nucleotides is discussed in relation with the changes in ribonuclease activity during early development of Artemia.
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Affiliation(s)
- P P Grau
- Instituto de Investigaciones Biomédicas del CSIC, Facultad de Medicina, UAM, Madrid, Spain
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