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Burgess J, Kim HM, Porath BR, Van T, Osatuke K, Boden M, Sripada RK, Wong ES, Zivin K. The Importance of Autonomy and Performance Goals in Perceived Workload Among Behavioral Health Providers. Psychiatr Serv 2024:appips20230406. [PMID: 38532686 DOI: 10.1176/appi.ps.20230406] [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] [Indexed: 03/28/2024]
Abstract
OBJECTIVE The authors sought to assess workplace characteristics associated with perceived reasonable workload among behavioral health care providers in the Veterans Health Administration. METHODS The authors evaluated perceived reasonable workload and workplace characteristics from the 2019 All Employee Survey (AES; N=14,824) and 2019 Mental Health Provider Survey (MHPS; N=10,490) and facility-level staffing ratios from Mental Health Onboard Clinical Dashboard data. Nine AES and 15 MHPS workplace predictors of perceived reasonable workload, 11 AES and six MHPS demographic predictors, and facility-level staffing ratios were included in mixed-effects logistic regression models. RESULTS In total, 8,874 (59.9%) AES respondents and 5,915 (56.4%) MHPS respondents reported having a reasonable workload. The characteristics most strongly associated with perceived reasonable workload were having attainable performance goals (average marginal effect [AME]=0.10) in the AES and ability to schedule patients as frequently as indicated (AME=0.09) in the MHPS. Other AES characteristics significantly associated with reasonable workload included having appropriate resources, support for personal life, skill building, performance recognition, concerns being addressed, and no supervisor favoritism. MHPS characteristics included not having collateral duties that reduce care time, staffing levels not affecting care, support staff taking over some responsibilities, having spirit of teamwork, primary care-mental health integration, participation in performance discussions, well-coordinated mental health care, effective veteran programs, working at the top of licensure, and feeling involved in improving access. Facility-level staffing ratios were not significantly associated with perceived reasonable workload. CONCLUSIONS Leadership may consider focusing resources on initiatives that support behavioral health providers' autonomy to schedule patients as clinically indicated and develop attainable performance goals.
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Affiliation(s)
- Jennifer Burgess
- Center for Clinical Management Research, U.S. Department of Veterans Affairs (VA) Ann Arbor Health Care System, Ann Arbor (Burgess, Kim, Porath, Van, Sripada, Zivin); Departments of Biostatistics (Kim) and Psychiatry (Sripada, Zivin), University of Michigan, Ann Arbor; Veterans Health Administration, National Center for Organization Development, Cincinnati (Osatuke); Program Evaluation and Resource Center and VA Office of Mental Health Operations, VA Palo Alto Health Care System, Palo Alto, California (Boden); Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, and Department of Health Systems and Population Health, Magnuson Health Sciences Center, University of Washington School of Public Health, Seattle (Wong)
| | - Hyungjin Myra Kim
- Center for Clinical Management Research, U.S. Department of Veterans Affairs (VA) Ann Arbor Health Care System, Ann Arbor (Burgess, Kim, Porath, Van, Sripada, Zivin); Departments of Biostatistics (Kim) and Psychiatry (Sripada, Zivin), University of Michigan, Ann Arbor; Veterans Health Administration, National Center for Organization Development, Cincinnati (Osatuke); Program Evaluation and Resource Center and VA Office of Mental Health Operations, VA Palo Alto Health Care System, Palo Alto, California (Boden); Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, and Department of Health Systems and Population Health, Magnuson Health Sciences Center, University of Washington School of Public Health, Seattle (Wong)
| | - Brittany R Porath
- Center for Clinical Management Research, U.S. Department of Veterans Affairs (VA) Ann Arbor Health Care System, Ann Arbor (Burgess, Kim, Porath, Van, Sripada, Zivin); Departments of Biostatistics (Kim) and Psychiatry (Sripada, Zivin), University of Michigan, Ann Arbor; Veterans Health Administration, National Center for Organization Development, Cincinnati (Osatuke); Program Evaluation and Resource Center and VA Office of Mental Health Operations, VA Palo Alto Health Care System, Palo Alto, California (Boden); Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, and Department of Health Systems and Population Health, Magnuson Health Sciences Center, University of Washington School of Public Health, Seattle (Wong)
| | - Tony Van
- Center for Clinical Management Research, U.S. Department of Veterans Affairs (VA) Ann Arbor Health Care System, Ann Arbor (Burgess, Kim, Porath, Van, Sripada, Zivin); Departments of Biostatistics (Kim) and Psychiatry (Sripada, Zivin), University of Michigan, Ann Arbor; Veterans Health Administration, National Center for Organization Development, Cincinnati (Osatuke); Program Evaluation and Resource Center and VA Office of Mental Health Operations, VA Palo Alto Health Care System, Palo Alto, California (Boden); Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, and Department of Health Systems and Population Health, Magnuson Health Sciences Center, University of Washington School of Public Health, Seattle (Wong)
| | - Katerine Osatuke
- Center for Clinical Management Research, U.S. Department of Veterans Affairs (VA) Ann Arbor Health Care System, Ann Arbor (Burgess, Kim, Porath, Van, Sripada, Zivin); Departments of Biostatistics (Kim) and Psychiatry (Sripada, Zivin), University of Michigan, Ann Arbor; Veterans Health Administration, National Center for Organization Development, Cincinnati (Osatuke); Program Evaluation and Resource Center and VA Office of Mental Health Operations, VA Palo Alto Health Care System, Palo Alto, California (Boden); Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, and Department of Health Systems and Population Health, Magnuson Health Sciences Center, University of Washington School of Public Health, Seattle (Wong)
| | - Matthew Boden
- Center for Clinical Management Research, U.S. Department of Veterans Affairs (VA) Ann Arbor Health Care System, Ann Arbor (Burgess, Kim, Porath, Van, Sripada, Zivin); Departments of Biostatistics (Kim) and Psychiatry (Sripada, Zivin), University of Michigan, Ann Arbor; Veterans Health Administration, National Center for Organization Development, Cincinnati (Osatuke); Program Evaluation and Resource Center and VA Office of Mental Health Operations, VA Palo Alto Health Care System, Palo Alto, California (Boden); Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, and Department of Health Systems and Population Health, Magnuson Health Sciences Center, University of Washington School of Public Health, Seattle (Wong)
| | - Rebecca K Sripada
- Center for Clinical Management Research, U.S. Department of Veterans Affairs (VA) Ann Arbor Health Care System, Ann Arbor (Burgess, Kim, Porath, Van, Sripada, Zivin); Departments of Biostatistics (Kim) and Psychiatry (Sripada, Zivin), University of Michigan, Ann Arbor; Veterans Health Administration, National Center for Organization Development, Cincinnati (Osatuke); Program Evaluation and Resource Center and VA Office of Mental Health Operations, VA Palo Alto Health Care System, Palo Alto, California (Boden); Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, and Department of Health Systems and Population Health, Magnuson Health Sciences Center, University of Washington School of Public Health, Seattle (Wong)
| | - Edwin S Wong
- Center for Clinical Management Research, U.S. Department of Veterans Affairs (VA) Ann Arbor Health Care System, Ann Arbor (Burgess, Kim, Porath, Van, Sripada, Zivin); Departments of Biostatistics (Kim) and Psychiatry (Sripada, Zivin), University of Michigan, Ann Arbor; Veterans Health Administration, National Center for Organization Development, Cincinnati (Osatuke); Program Evaluation and Resource Center and VA Office of Mental Health Operations, VA Palo Alto Health Care System, Palo Alto, California (Boden); Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, and Department of Health Systems and Population Health, Magnuson Health Sciences Center, University of Washington School of Public Health, Seattle (Wong)
| | - Kara Zivin
- Center for Clinical Management Research, U.S. Department of Veterans Affairs (VA) Ann Arbor Health Care System, Ann Arbor (Burgess, Kim, Porath, Van, Sripada, Zivin); Departments of Biostatistics (Kim) and Psychiatry (Sripada, Zivin), University of Michigan, Ann Arbor; Veterans Health Administration, National Center for Organization Development, Cincinnati (Osatuke); Program Evaluation and Resource Center and VA Office of Mental Health Operations, VA Palo Alto Health Care System, Palo Alto, California (Boden); Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, and Department of Health Systems and Population Health, Magnuson Health Sciences Center, University of Washington School of Public Health, Seattle (Wong)
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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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Sripada RK, Walters HM. "I wish people could come together like we have," patient and provider perspectives on VA residential PTSD treatment. Psychol Serv 2023; 20:809-819. [PMID: 36136833 PMCID: PMC10249047 DOI: 10.1037/ser0000713] [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] [Indexed: 11/08/2022]
Abstract
Although most posttraumatic stress disorder (PTSD) care in the Veterans health administration (VHA) is provided on an outpatient basis, the VHA has 40 residential rehabilitation treatment programs (RRTPs) designed to treat Veterans who require more intensive and closely monitored care. Unfortunately, the clinical outcomes of these programs are modest, and previous attempts to identify key drivers of outcomes have uncovered few modifiable factors. The present study, informed by the model of resources, life events and changes in psychological state, was designed to identify factors associated with treatment response among RRTP patients and providers. Semistructured interviews were conducted with 24 patients and 12 providers at three regional RRTPs, using interview guides based on the theoretical model. Data were analyzed using rapid analysis. Results showed that patients and providers agreed on several factors critical to RRTP success. These factors included the provision of evidence-based psychotherapy (EBP), support and understanding from fellow patients, and skill and support from providers. Patients and providers also noted the importance of psychological flexibility, openness, and willingness to change. Patients who experienced less symptom improvement over the course of treatment were more likely to report poor therapeutic alliance. These findings underscore the importance of continued emphasis on EBP delivery but also suggest that RRTPs might find additional ways to capitalize on the residential milieu to encourage engagement in treatment and a focus on therapeutic change. (PsycInfo Database Record (c) 2023 APA, all rights reserved).
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Affiliation(s)
- Rebecca K. Sripada
- VA Center for Clinical Management Research, Ann Arbor, MI
- VA Ann Arbor Healthcare System, Ann Arbor, MI
- Department of Psychiatry, University of Michigan, Ann Arbor, MI
| | - Heather M. Walters
- VA Center for Clinical Management Research, Ann Arbor, MI
- VA Ann Arbor Healthcare System, Ann Arbor, MI
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Sripada RK, Peterson CL, Dziak JJ, Nahum-Shani I, Roberge EM, Martinson AA, Porter K, Grau P, Curtis D, McElroy S, Bryant S, Gracy I, Pryor C, Walters HM, Austin K, Ehlinger C, Sayer N, Wiltsey-Stirman S, Chard K. Using the multiphase optimization strategy to adapt cognitive processing therapy (CPT MOST): study protocol for a randomized controlled factorial experiment. Trials 2023; 24:676. [PMID: 37858262 PMCID: PMC10588087 DOI: 10.1186/s13063-023-07669-3] [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: 08/31/2023] [Accepted: 09/25/2023] [Indexed: 10/21/2023] Open
Abstract
BACKGROUND Approximately ten percent of US military veterans suffer from posttraumatic stress disorder (PTSD). Cognitive processing therapy (CPT) is a highly effective, evidence-based, first-line treatment for PTSD that has been widely adopted by the Department of Veterans Affairs (VA). CPT consists of discrete therapeutic components delivered across 12 sessions, but most veterans (up to 70%) never reach completion, and those who discontinue therapy receive only four sessions on average. Unfortunately, veterans who drop out prematurely may never receive the most effective components of CPT. Thus, there is an urgent need to use empirical approaches to identify the most effective components of CPT so CPT can be adapted into a briefer format. METHODS The multiphase optimization strategy (MOST) is an innovative, engineering-inspired framework that uses an optimization trial to assess the performance of individual intervention components within a multicomponent intervention such as CPT. Here we use a fractional factorial optimization trial to identify and retain the most effective intervention components to form a refined, abbreviated CPT intervention package. Specifically, we used a 16-condition fractional factorial experiment with 270 veterans (N = 270) at three VA Medical Centers to test the effectiveness of each of the five CPT components and each two-way interaction between components. This factorial design will identify which CPT components contribute meaningfully to a reduction in PTSD symptoms, as measured by PTSD symptom reduction on the Clinician-Administered PTSD Scale for DSM-5, across 6 months of follow-up. It will also identify mediators and moderators of component effectiveness. DISCUSSION There is an urgent need to adapt CPT into a briefer format using empirical approaches to identify its most effective components. A brief format of CPT may reduce attrition and improve efficiency, enabling providers to treat more patients with PTSD. The refined intervention package will be evaluated in a future large-scale, fully-powered effectiveness trial. Pending demonstration of effectiveness, the refined intervention can be disseminated through the VA CPT training program. TRIAL REGISTRATION ClinicalTrials.gov NCT05220137. Registration date: January 21, 2022.
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Affiliation(s)
- Rebecca K Sripada
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Department of Psychiatry, University of Michigan, Ann Arbor, USA.
| | - Cassaundra L Peterson
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, USA
| | - John J Dziak
- Institute for Health Research and Policy, University of Illinois Chicago, Chicago, USA
| | - Inbal Nahum-Shani
- University of Michigan Institute for Social Research, Ann Arbor, USA
| | - Erika M Roberge
- VA Salt Lake City Health Care System, University of Utah School of Medicine, Salt Lake City, USA
| | | | | | - Peter Grau
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Department of Psychiatry, University of Michigan, Ann Arbor, USA
| | - Diana Curtis
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, USA
| | | | - Sarah Bryant
- VA Salt Lake City Health Care System, Salt Lake City, USA
| | - Isabel Gracy
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, USA
| | - Cosette Pryor
- VA Salt Lake City Health Care System, Salt Lake City, USA
| | - Heather M Walters
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, USA
| | - Karen Austin
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, USA
| | | | - Nina Sayer
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, USA
| | | | - Kathleen Chard
- Cincinnati VA Medical Center, University of Cincinnati, Cincinnati, USA
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Sayer NA, Nelson DB, Gradus JL, Sripada RK, Murdoch M, Teo AR, Orazem RJ, Cerel J. The Effects of Suicide Exposure on Mental Health Outcomes Among Post-9/11 Veterans: Protocol for an Explanatory, Sequential, Mixed Methods Study. JMIR Res Protoc 2023; 12:e51324. [PMID: 37751271 PMCID: PMC10565621 DOI: 10.2196/51324] [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: 08/03/2023] [Accepted: 08/11/2023] [Indexed: 09/27/2023] Open
Abstract
BACKGROUND The toll associated with suicide goes well beyond the individual who died. This study focuses on a risk factor for veteran suicide that has received little previous empirical attention-exposure to the suicide death of another person. OBJECTIVE The study's primary objective is to describe the mental health outcomes associated with suicide exposure among veterans who served on active duty after September 2001 ("post-9/11"). The secondary objective is to elucidate why some veterans develop persistent problems following suicide exposure, whereas others do not. METHODS This is an explanatory, sequential, mixed methods study of a nationally representative sample of post-9/11 veterans enrolled in Department of Veterans Affairs (VA) health care. Our sampling strategy was designed for adequate representation of female and American Indian and Alaska Native veterans to allow for examination of associations between suicide exposure and outcomes within these groups. Primary outcomes comprise mental health problems associated with trauma and loss (posttraumatic stress disorder and prolonged grief disorder) and suicide precursors (suicidal ideation, attempts, and planning). Data collection will be implemented in 3 waves. During wave 1, we will field a brief survey to a national probability sample to assess exposure history (suicide, other sudden death, or neither) and exposure characteristics (eg, closeness with the decedent) among 11,400 respondents. In wave 2, we will include 39.47% (4500/11,400) of the wave-1 respondents, stratified by exposure history (suicide, other sudden death, or neither), to assess health outcomes and other variables of interest. During wave 3, we will conduct interviews with a purposive subsample of 32 respondents exposed to suicide who differ in mental health outcomes. We will supplement the survey and interview data with VA administrative data identifying diagnoses, reported suicide attempts, and health care use. RESULTS The study began on July 1, 2022, and will end on June 30, 2026. This is the only national, population-based study of suicide exposure in veterans and the first one designed to study differences based on sex and race. Comparing those exposed to suicide with those exposed to sudden death for reasons other than suicide (eg, combat) and those unexposed to any sudden death may allow for the identification of the common and unique contribution of suicide exposure to outcomes and help seeking. CONCLUSIONS Integrating survey, qualitative, and VA administrative data to address significant knowledge gaps regarding the effects of suicide exposure in a national sample will lay the foundation for interventions to address the needs of individuals affected by a suicide death, including female and American Indian and Alaska Native veterans. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/51324.
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Affiliation(s)
- Nina A Sayer
- Center for Care Delivery and Outcomes Research, Minneapolis VA Healthcare System, Minneapolis, MN, United States
- Department of Psychiatry and Behavioral Sciences, University of Minnesota, Minneapolis, MN, United States
- Department of Medicine, University of Minnesota, Minneapolis, MN, United States
| | - David B Nelson
- Center for Care Delivery and Outcomes Research, Minneapolis VA Healthcare System, Minneapolis, MN, United States
- Department of Medicine, University of Minnesota, Minneapolis, MN, United States
| | - Jaimie L Gradus
- Department of Epidemiology, School of Public Health, Boston University, Boston, MA, United States
| | - Rebecca K Sripada
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, United States
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, United States
| | - Maureen Murdoch
- Center for Care Delivery and Outcomes Research, Minneapolis VA Healthcare System, Minneapolis, MN, United States
- Department of Medicine, University of Minnesota, Minneapolis, MN, United States
- Section of General Internal Medicine, Minneapolis VA Health Care System, Minneapolis, MN, United States
| | - Alan R Teo
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, OR, United States
- Department of Psychiatry, Oregon Health & Science University, Portland, OR, United States
| | - Robert J Orazem
- Center for Care Delivery and Outcomes Research, Minneapolis VA Healthcare System, Minneapolis, MN, United States
| | - Julie Cerel
- College of Social Work, University of Kentucky, Lexington, KY, United States
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Zivin K, Van T, Osatuke K, Boden M, Pfeiffer PN, Sripada RK, Abraham KM, Burgess J, Kim HM. Behavioral Health Provider Burnout and Mental Health Care in the Veterans Health Administration. J Gen Intern Med 2023; 38:2254-2261. [PMID: 37227659 PMCID: PMC10211276 DOI: 10.1007/s11606-023-08235-y] [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] [Received: 09/13/2022] [Accepted: 05/09/2023] [Indexed: 05/26/2023]
Abstract
BACKGROUND Although many studies assess predictors of provider burnout, few analyses provide high-quality, consistent evidence on the impact of provider burnout on patient outcomes exist, particularly among behavioral health providers (BHPs). OBJECTIVE To assess the impact of burnout among psychiatrists, psychologists, and social workers on access-related quality measures in the Veterans Health Administration (VHA). DESIGN This study used burnout in VA All Employee Survey (AES) and Mental Health Provider Survey (MHPS) data to predict metrics assessed by the Strategic Analytics for Improvement and Learning Value, Mental Health Domain (MH-SAIL), VHA's quality monitoring system. The study used prior year (2014-2018) facility-level burnout proportion among BHPs to predict subsequent year (2015-2019) facility-level MH-SAIL domain scores. Analyses used multiple regression models, adjusting for facility characteristics, including BHP staffing and productivity. PARTICIPANTS Psychologists, psychiatrists, and social workers who responded to the AES and MHPS at 127 VHA facilities. MAIN MEASURES Four compositive outcomes included two objective measures (population coverage, continuity of care), one subjective measure (experience of care), and one composite measure of the former three measures (mental health domain quality). KEY RESULTS Adjusted analyses showed prior year burnout generally had no impact on population coverage, continuity of care, and patient experiences of care but had a negative impact on provider experiences of care consistently across 5 years (p < 0.001). Pooled across years, a 5% higher facility-level burnout in AES and MHPS had a 0.05 and 0.09 standard deviation worse facility experiences of care from the prior year, respectively. CONCLUSIONS Burnout had a significant negative impact on provider-reported experiential outcome measures. This analysis showed that burnout had a negative effect on subjective but not on objective quality measures of Veteran access to care, which could inform future policies and interventions regarding provider burnout.
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Affiliation(s)
- Kara Zivin
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA.
- Department of Psychiatry, Michigan Medicine, Ann Arbor, MI, USA.
| | - Tony Van
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Katerine Osatuke
- VHA National Center for Organization Development, Cincinnati, OH, USA
| | - Matt Boden
- Program Evaluation and Resource Center and VA Office of Mental Health Operations, VA Palo Alto Health Care System, Palo Alto, CA, USA
| | - Paul N Pfeiffer
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
- Department of Psychiatry, Michigan Medicine, Ann Arbor, MI, USA
| | - Rebecca K Sripada
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
- Department of Psychiatry, Michigan Medicine, Ann Arbor, MI, USA
| | - Kristen M Abraham
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
- Department of Psychology, University of Detroit Mercy, Detroit, MI, USA
| | - Jennifer Burgess
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
- Department of Psychiatry, Michigan Medicine, Ann Arbor, MI, USA
| | - Hyungjin Myra Kim
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
- Consulting for Statistics, Computing and Analytics Research, University of Michigan, Ann Arbor, MI, 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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8
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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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9
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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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10
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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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11
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Sripada RK, Rodriguez JL, Wright TP, Hyland JA, Walters HM, Ganoczy D, Haft SM, Smith ER, Porter KE, Driesenga SA, DeJong TM, Rauch SAM. Feasibility and Acceptability of Group-Facilitated Prolonged Exposure Therapy for PTSD in VA Residential Rehabilitation Treatment Programs. Behav Ther 2022; 53:714-724. [PMID: 35697433 DOI: 10.1016/j.beth.2022.02.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 10/04/2021] [Revised: 02/11/2022] [Accepted: 02/15/2022] [Indexed: 11/02/2022]
Abstract
Prolonged Exposure therapy (PE) is a first-line treatment for posttraumatic stress disorder (PTSD); however, few VA patients receive this treatment. One of the barriers to PE receipt is that it is only available in an individual (one-on-one) format, whereas many VA mental health clinics provide the majority of their psychotherapy services in group format. In particular, PTSD residential rehabilitation treatment programs (RRTPs) offer most programming in group format. Consequently, strategies are needed to improve the scalability of PE by adapting it to fit the delivery setting. The current study was designed to pilot test a group-facilitated format of PE in RRTPs. Thirty-nine Veterans who were engaged in care in the PTSD RRTP at a Midwestern VA were recruited to participate in a Group-facilitated PE protocol. Participants engaged in twelve 90-minute sessions of Group PE over the course of 6 weeks, plus six 60-minute individual sessions for imaginal exposure. Group treatment followed the PE model and consisted of psychoeducation, treatment rationale, and in vivo exposure to reduce trauma-related avoidance and thereby improve PTSD symptoms. PTSD symptoms were measured via the PTSD Checklist for DSM-5 (PCL-5) and depression symptoms were measured via the Patient Health Questionnaire (PHQ-9) at baseline, endpoint (6 weeks), and at 2-month follow-up. Thirty-nine individuals initiated Group-facilitated PE and 34 completed treatment. The average number of group sessions attended was 11 out of 12. Acceptability ratings were high. Mean change (improvement) in the intent-to-treat sample at 2-month follow-up was 20.0 points on the PCL-5 (CI 18.1, 21.9; Cohen's d = 1.1) and 4.8 points on the PHQ-9 (CI 4.1, 5.5, d = .8). These results suggest that adapted evidence-based interventions for PTSD can improve treatment access and efficiency for the RRTP setting. A group-based approach has the potential to improve the scalability of PTSD treatment by reducing required resources. A fully powered trial is now needed to test the effectiveness of Group-facilitated PE in the RRTP setting.
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Affiliation(s)
- Rebecca K Sripada
- Veterans Affairs Center for Clinical Management Research, Ann Arbor; Veterans Affairs Ann Arbor Health Care System; University of Michigan.
| | | | | | | | | | - Dara Ganoczy
- Veterans Affairs Center for Clinical Management Research, Ann Arbor
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12
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Sripada RK, Walters HM, Ganoczy D, Avallone KM, Cigrang JA, Rauch SAM. Feasibility and Acceptability of Prolonged Exposure in Primary Care (PE-PC) for Posttraumatic Stress Disorder in Federally Qualified Health Centers: A Pilot Study. Adm Policy Ment Health 2022; 49:722-734. [PMID: 35445362 PMCID: PMC9020756 DOI: 10.1007/s10488-022-01195-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/23/2022] [Indexed: 12/05/2022]
Abstract
Posttraumatic stress disorder (PTSD) is a debilitating psychiatric disorder that affects 6% of U.S. adults, yet is treated in only 30% of affected individuals and even fewer low-income individuals. One third of the nation’s low-income individuals are treated in Federally Qualified Health Centers (FQHCs). Most of these facilities lack capacity to provide their patients with first-line, evidence-based treatments for PTSD such as Prolonged Exposure (PE). To address this problem, PE has been adapted for use in a primary care setting and demonstrated efficacy in a brief model for military service members (PE in Primary Care: PE-PC). The effectiveness of this treatment in civilian, low-resource settings such as FQHCs is unknown. This pilot study tested the feasibility and acceptability of PE-PC in 30 Michigan FQHC patients. High rates of therapy participation suggest that the intervention was feasible and acceptable. Semi-structured interview data from 10 patients and 5 FQHC providers indicated that the intervention was helpful and filled a critical need for effective PTSD treatment in the FQHC setting. Interviews also elucidated barriers such as transportation, provider training, and time commitment for patients and providers. These findings set the stage for a full-scale randomized controlled trial to test the effectiveness of PE-PC on PTSD symptoms in this low-resource, high-need setting. Trial registry ClinicalTrials.gov Identifier: NCT03711266. October 18, 2018.
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Affiliation(s)
- Rebecca K Sripada
- Veterans Affairs Center for Clinical Management Research, Veterans Affairs Ann Arbor Health Care System, Ann Arbor, MI, USA. .,Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA.
| | - Heather M Walters
- Veterans Affairs Center for Clinical Management Research, Veterans Affairs Ann Arbor Health Care System, Ann Arbor, MI, USA
| | - Dara Ganoczy
- Veterans Affairs Center for Clinical Management Research, Veterans Affairs Ann Arbor Health Care System, Ann Arbor, MI, USA
| | | | | | - Sheila A M Rauch
- Department of Psychiatry and Behavioral Sciences, Emory University, Atlanta, GA, USA.,Atlanta VA Medical Center, Atlanta, GA, USA
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13
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Rodriguez JL, Hale AC, Marston HN, Sage-Germain CE, Wright TP, Driesenga SA, Martin SM, Sripada RK. The Association Between Service Connection and Treatment Outcome in Veterans Undergoing Residential PTSD Treatment. Psychiatr Q 2022; 93:285-296. [PMID: 34532825 DOI: 10.1007/s11126-021-09940-9] [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] [Accepted: 08/05/2021] [Indexed: 11/26/2022]
Abstract
The Department of Veterans Affairs has invested significant time and resources into the treatment of posttraumatic stress disorder (PTSD). Despite concerted efforts, a significant portion of patients do not respond optimally to trauma-focused treatment. One of the factors that has been hypothesized to be associated with treatment response is participation in the Veterans Benefits Administration service-connected disability process. This factor may be particularly relevant in the residential treatment setting, where most participants are engaged in the compensation seeking process. We conducted a retrospective chart review of 105 veterans who completed Cognitive Processing Therapy (CPT) in a residential rehabilitation program. ANCOVAs that adjusted for baseline PTSD severity compared symptom change between those who were and were non-compensation seeking at the time of treatment. Compensation seeking status was associated with significantly less symptom improvement over the course of CPT after adjusting for baseline PTSD severity (F(1, 102) = 4.29, p < .001, η2 = .03). Sensitivity analyses did not detect a similar effect during a prior coping skills phase of treatment. During CPT, clinically significant change was met by 66.7% of non-compensation seeking veterans (M = -15, SD = 14.56) and by 40.1% of the compensation seeking group (M = -7.1, SD = 12.24). Compensation-seeking may be associated with reduced response to trauma-focused treatment in certain settings. Future research is needed to better understand the mechanisms underlying this effect.
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Affiliation(s)
- Jessica L Rodriguez
- Psychology Service, Battle Creek VA Medical Center, 5500 Armstrong Road, Battle Creek, MI, 49037, USA.
| | - Andrew C Hale
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System/Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
| | - Holloway N Marston
- Psychology Service, Battle Creek VA Medical Center, 5500 Armstrong Road, Battle Creek, MI, 49037, USA
| | - Chelsea E Sage-Germain
- Psychology Service, Battle Creek VA Medical Center, 5500 Armstrong Road, Battle Creek, MI, 49037, USA
| | - Theodore P Wright
- Psychology Service, Battle Creek VA Medical Center, 5500 Armstrong Road, Battle Creek, MI, 49037, USA
| | - Scott A Driesenga
- Psychology Service, Battle Creek VA Medical Center, 5500 Armstrong Road, Battle Creek, MI, 49037, USA
| | - Shannon M Martin
- Department of Psychology, Converse College, Spartanburg, SC, USA
| | - Rebecca K Sripada
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System/Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
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14
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Zivin K, Chang MUM, Van T, Osatuke K, Boden M, Sripada RK, Abraham KM, Pfeiffer PN, Kim HM. Relationships between work-environment characteristics and behavioral health provider burnout in the Veterans Health Administration. Health Serv Res 2022; 57 Suppl 1:83-94. [PMID: 35230714 PMCID: PMC9108225 DOI: 10.1111/1475-6773.13964] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 02/03/2022] [Accepted: 02/04/2022] [Indexed: 11/28/2022] Open
Abstract
Objective To identify work–environment characteristics associated with Veterans Health Administration (VHA) behavioral health provider (BHP) burnout among psychiatrists, psychologists, and social workers. Data Sources The 2015–2018 data from Annual All Employee Survey (AES); Mental Health Provider Survey (MHPS); N = 57,397 respondents; facility‐level Mental Health Onboard Clinical (MHOC) staffing and productivity data, N = 140 facilities. Study Design For AES and MHPS separately, we used mixed‐effects logistic regression to predict BHP burnout using surveys from year pairs (2015–2016, 2016–2017, 2017–2018; six models). Within each year‐pair, we used the earlier year of data to train models and tested the model in the later year, with burnout (emotional exhaustion and/or depersonalization) as the outcome for each survey. We used potentially modifiable work–environment characteristics as predictors, controlling for employee demographic characteristics as covariates, and employment facility as random intercepts. Data Collection/Extraction Methods We included work–environment predictors that appeared in all 4 years (11 in AES; 17 in MHPS). Principal Findings In 2015–2018, 31.0%–38.0% of BHPs reported burnout in AES or MHPS. Work characteristics consistently associated with significantly lower burnout were included for AES: reasonable workload; having appropriate resources to perform a job well; supervisors address concerns; given an opportunity to improve skills. For MHPS, characteristics included: reasonable workload; work improves veterans' lives; mental health care provided is well‐coordinated; and three reverse‐coded items: staffing vacancies; daily work that clerical/support staff could complete; and collateral duties reduce availability for patient care. Facility‐level staffing ratios and productivity did not significantly predict individual‐level burnout. Workload represented the strongest predictor of burnout in both surveys. Conclusions This study demonstrated substantial, ongoing impacts that having appropriate resources including staff, workload, and supervisor support had on VHA BHP burnout. VHA may consider investing in approaches to mitigate the impact of BHP burnout on employees and their patients through providing staff supports, managing workload, and goal setting.
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Affiliation(s)
- Kara Zivin
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, United States.,Department of Psychiatry, Michigan Medicine, Ann Arbor, Michigan, United States
| | - Ming-Un Myron Chang
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, United States
| | - Tony Van
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, United States
| | - Katerine Osatuke
- VHA National Center for Organization Development, Cincinnati, Ohio, United States
| | - Matthew Boden
- Program Evaluation and Resource Center and VA Office of Mental Health Operations, VA Palo Alto Health Care System, Palo Alto, California
| | - Rebecca K Sripada
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, United States.,Department of Psychiatry, Michigan Medicine, Ann Arbor, Michigan, United States
| | - Kristen M Abraham
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, United States.,Department of Psychology, University of Detroit Mercy, Detroit, Michigan, United States
| | - Paul N Pfeiffer
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, United States.,Department of Psychiatry, Michigan Medicine, Ann Arbor, Michigan, United States
| | - Hyungjin Myra Kim
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, United States.,Consulting for Statistics, Computing and Analytics Research, University of Michigan, Ann Arbor, Michigan, United States
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15
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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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16
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Lee AA, Sripada RK, Hale AC, Ganoczy D, Trivedi RB, Arnow B, Pfeiffer PN. Psychotherapy and depressive symptom trajectories among VA patients: Comparing dose-effect and good-enough level models. J Consult Clin Psychol 2021; 89:379-392. [PMID: 34124925 DOI: 10.1037/ccp0000645] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Objective: Psychotherapy for depression is effective for many veterans, but the relationship between number of treatment sessions and symptom outcomes is not well established. The Dose-Effect model predicts that greater psychotherapeutic dose (total sessions) yields greater symptom improvement with each additional session resulting in smaller session-to-session improvement. In contrast, the Good-Enough Level (GEL) model predicts that rate of symptom improvement varies by total psychotherapeutic dose with faster improvement associated with earlier termination. This study compared the dose-effect and GEL model among veterans receiving psychotherapy for depression within the Veterans Health Administration. Method: The sample included 13,647 veterans with ≥2 sessions of psychotherapy for depression with associated Patient Health Questionnaire-9 (PHQ-9) scores in primary care (n = 7,502) and specialty mental health clinics (n = 6,145) between October 2014 and September 2018. Multilevel longitudinal modeling was used to compare the Dose-Effect and GEL models within each clinic type. Results: The GEL model demonstrated greater fit for both clinic types relative to dose-effect models. In both treatment settings, veterans with fewer sessions improved faster than those with more sessions. In primary care clinics, veterans who received 4-8 total sessions achieved similar levels of symptom response. In specialty mental health clinics, increased psychotherapeutic dose was associated with greater treatment response up to 16 sessions. Veterans receiving 20 sessions demonstrated minimal treatment response. Conclusions: These findings support the GEL model and suggest a flexible approach to determining length of psychotherapy for depression may be useful for optimizing treatment response and allocation of clinical resources. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
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Affiliation(s)
- Aaron A Lee
- Department of Psychology, University of Mississippi
| | - Rebecca K Sripada
- Veterans Affairs Center for Clinical Management Research, Veterans Affairs Ann Arbor Health Care System
| | | | - Dara Ganoczy
- Veterans Affairs Center for Clinical Management Research, Veterans Affairs Ann Arbor Health Care System
| | - Ranak B Trivedi
- VA Center for Innovation to Implementation, VA Palo Alto Health Care System
| | - Bruce Arnow
- VA Center for Innovation to Implementation, VA Palo Alto Health Care System
| | - Paul N Pfeiffer
- Veterans Affairs Center for Clinical Management Research, Veterans Affairs Ann Arbor Health Care System
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Zivin K, Kononowech J, Boden M, Abraham K, Harrod M, Sripada RK, Kales HC, Garcia HA, Pfeiffer P. Correction: Predictors and Consequences of Veterans Affairs Mental Health Provider Burnout: Protocol for a Mixed Methods Study. JMIR Res Protoc 2021; 10:e26934. [PMID: 33434142 PMCID: PMC7837995 DOI: 10.2196/26934] [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] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 01/04/2021] [Indexed: 11/13/2022] Open
Abstract
[This corrects the article DOI: 10.2196/18345.].
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Affiliation(s)
- Kara Zivin
- Center for Clinical Management Research, Department of Veterans Affairs, Ann Arbor, MI, United States.,Department of Psychiatry, University of Michigan Medical School, Ann Arbor, MI, United States
| | - Jennifer Kononowech
- Center for Clinical Management Research, Department of Veterans Affairs, Ann Arbor, MI, United States
| | - Matthew Boden
- Program Evaluation and Resource Center and VA Office of Mental Health Operations, VA Palo Alto Health Care System, Palo Alto, CA, United States
| | - Kristen Abraham
- Center for Clinical Management Research, Department of Veterans Affairs, Ann Arbor, MI, United States.,Department of Psychology, University of Detroit Mercy, Detroit, MI, United States
| | - Molly Harrod
- Center for Clinical Management Research, Department of Veterans Affairs, Ann Arbor, MI, United States
| | - Rebecca K Sripada
- Center for Clinical Management Research, Department of Veterans Affairs, Ann Arbor, MI, United States.,Department of Psychiatry, University of Michigan Medical School, Ann Arbor, MI, United States
| | - Helen C Kales
- Department of Psychiatry and Behavioral Sciences, UC Davis Health, Sacramento, CA, United States
| | - Hector A Garcia
- VA Texas Valley Coastal Bend Health Care System, Harlingen, TX, United States.,Department of Psychiatry, University of Texas Health Science Center, San Antonio, TX, United States
| | - Paul Pfeiffer
- Center for Clinical Management Research, Department of Veterans Affairs, Ann Arbor, MI, United States.,Department of Psychiatry, University of Michigan Medical School, Ann Arbor, MI, United States
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18
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Zivin K, Kononowech J, Boden M, Abraham K, Harrod M, Sripada RK, Kales HC, Garcia HA, Pfeiffer P. Predictors and Consequences of Veterans Affairs Mental Health Provider Burnout: Protocol for a Mixed Methods Study. JMIR Res Protoc 2020; 9:e18345. [PMID: 33346737 PMCID: PMC7781796 DOI: 10.2196/18345] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 08/27/2020] [Accepted: 09/01/2020] [Indexed: 01/16/2023] Open
Abstract
Background In the Veterans Health Administration (VHA), mental health providers (MHPs) report the second highest level of burnout after primary care physicians. Burnout is defined as increased emotional exhaustion and depersonalization and decreased sense of personal accomplishment at work. Objective This study aims to characterize variation in MHP burnout by VHA facility over time, identifying workplace characteristics and practices of high-performing facilities. Methods Using both qualitative and quantitative methods, we will evaluate factors that influence MHP burnout and their effects on patient outcomes. We will compile annual survey data on workplace conditions and annual staffing as well as productivity data to assess same and subsequent year provider and patient outcomes reflecting provider and patient experiences. We will conduct interviews with mental health leadership at the facility level and with frontline MHPs sampled based on our quantitative findings. We will present our findings to an expert panel of operational partners, Veterans Affairs clinicians, administrators, policy leaders, and experts in burnout. We will reengage with facilities that participated in the earlier qualitative interviews and will hold focus groups that share results based on our quantitative and qualitative work combined with input from our expert panel. We will broadly disseminate these findings to support the development of actionable policies and approaches to addressing MHP burnout. Results This study will assist in developing and testing interventions to improve MHP burnout and employee engagement. Our work will contribute to improvements within VHA and will generate insights for health care delivery, informing efforts to address burnout. Conclusions This is the first comprehensive, longitudinal, national, mixed methods study that incorporates different types of MHPs. It will engage MHP leadership and frontline providers in understanding facilitators and barriers to effectively address burnout. International Registered Report Identifier (IRRID) PRR1-10.2196/18345
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Affiliation(s)
- Kara Zivin
- Center for Clinical Management Research, Department of Veterans Affairs, Ann Arbor, MI, United States.,Department of Psychiatry, University of Michigan Medical School, Ann Arbor, MI, United States
| | - Jennifer Kononowech
- Center for Clinical Management Research, Department of Veterans Affairs, Ann Arbor, MI, United States
| | - Matthew Boden
- Program Evaluation and Resource Center and VA Office of Mental Health Operations, VA Palo Alto Health Care System, Palo Alto, CA, United States
| | - Kristen Abraham
- Center for Clinical Management Research, Department of Veterans Affairs, Ann Arbor, MI, United States.,Department of Psychology, University of Detroit Mercy, Detroit, MI, United States
| | - Molly Harrod
- Center for Clinical Management Research, Department of Veterans Affairs, Ann Arbor, MI, United States
| | - Rebecca K Sripada
- Center for Clinical Management Research, Department of Veterans Affairs, Ann Arbor, MI, United States.,Department of Psychiatry, University of Michigan Medical School, Ann Arbor, MI, United States
| | - Helen C Kales
- Department of Psychiatry and Behavioral Sciences, UC Davis Health, Sacramento, CA, United States
| | - Hector A Garcia
- VA Texas Valley Coastal Bend Health Care System, Harlingen, TX, United States.,Department of Psychiatry, University of Texas Health Science Center, San Antonio, TX, United States
| | - Paul Pfeiffer
- Center for Clinical Management Research, Department of Veterans Affairs, Ann Arbor, MI, United States.,Department of Psychiatry, University of Michigan Medical School, Ann Arbor, MI, United States
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Cooper SA, Szymanski BR, Bohnert KM, Sripada RK, McCarthy JF. Association Between Positive Results on the Primary Care-Posttraumatic Stress Disorder Screen and Suicide Mortality Among US Veterans. JAMA Netw Open 2020; 3:e2015707. [PMID: 32880649 PMCID: PMC7489804 DOI: 10.1001/jamanetworkopen.2020.15707] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
IMPORTANCE Suicide rates are higher among veterans compared with nonveterans, and the prevalence of posttraumatic stress disorder (PTSD) is higher among veterans compared with the general adult population in the US. To date, no study has examined the association between PTSD screening results and suicide mortality among veterans. OBJECTIVE To examine whether veterans receiving care in the US Veterans Health Administration (VHA) health system who had positive results on the Primary Care-Posttraumatic Stress Disorder Screen (PC-PTSD) had a greater risk of suicide mortality compared with those who had negative results and to assess whether such risk decreased over time. DESIGN, SETTING, AND PARTICIPANTS Multivariable proportional hazards regression models were used to evaluate suicide mortality risk through December 31, 2016, among a cohort of veterans who received the PC-PTSD in the VHA health system. The VHA administers the PC-PTSD to patients nationwide, and screening results are routinely documented in the VHA Corporate Data Warehouse. The PC-PTSD includes 4 questions regarding PTSD symptoms, to which patients respond with either a positive (yes) or negative (no) answer. All patients who completed the PC-PTSD in 2014 and who did not have a diagnosis of PTSD in the year before screening were included in the analysis. A score of 3 or 4 on the PC-PTSD indicated a positive result, and a score of 0, 1, or 2 indicated a negative result. Data collection and analyses were performed from November 13, 2018, to June 18, 2019. EXPOSURES Primary Care-Posttraumatic Stress Disorder Screen (PC-PTSD). MAIN OUTCOMES AND MEASURES Suicide mortality risk, as assessed through data obtained from the US Veterans Affairs/Department of Defense Mortality Data Repository. RESULTS A total of 1 693 449 PC-PTSDs were completed by 1 552 581 individual veteran patients in 2014. Most of the patients were White (73.9%), married (52.2%), male (91.1%), 55 years or older (62.5%), and had completed only 1 PC-PTSD (92.1%). In multivariable analyses, positive PC-PTSD results (ie, total scores of 3 or 4) were associated with a 58% increase in the risk of suicide mortality at 1 day after screening (hazard ratio [HR], 1.58; 95% CI, 1.19-2.10) and a 26% increase in the risk of suicide mortality at 1 year after screening (HR, 1.26; 95% CI, 1.07-1.48). A positive response on item 4 ("felt numb or detached from others, activities, or your surroundings") of the PC-PTSD was associated with a 70% increase in suicide mortality risk at 1 day after screening (HR, 1.70; 95% CI, 1.27-2.28). CONCLUSIONS AND RELEVANCE Positive PC-PTSD results, and specifically reports of feeling numb or detached, were associated with increases in the risk of suicide mortality. These associations decreased over time. The findings of this study can inform interpretation of PC-PTSD responses and suggest the importance of recent improvements made to the VHA suicide risk assessment.
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Affiliation(s)
- Samantha A. Cooper
- Serious Mental Illness Treatment Resource and Evaluation Center, Office of Mental Health and Suicide Prevention, Department of Veterans Affairs, Ann Arbor, Michigan
| | - Benjamin R. Szymanski
- Serious Mental Illness Treatment Resource and Evaluation Center, Office of Mental Health and Suicide Prevention, Department of Veterans Affairs, Ann Arbor, Michigan
| | - Kipling M. Bohnert
- Department of Veterans Affairs Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
- Department of Psychiatry, University of Michigan, Ann Arbor
| | - Rebecca K. Sripada
- Department of Veterans Affairs Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
- Department of Psychiatry, University of Michigan, Ann Arbor
| | - John F. McCarthy
- Serious Mental Illness Treatment Resource and Evaluation Center, Office of Mental Health and Suicide Prevention, Department of Veterans Affairs, Ann Arbor, Michigan
- Department of Veterans Affairs Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
- Department of Psychiatry, University of Michigan, Ann Arbor
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20
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Sripada RK, Ready DJ, Ganoczy D, Astin MC, Rauch SAM. When to Change the Treatment Plan: An Analysis of Diminishing Returns in VA Patients Undergoing Prolonged Exposure and Cognitive Processing Therapy. Behav Ther 2020; 51:85-98. [PMID: 32005342 DOI: 10.1016/j.beth.2019.05.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [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: 11/09/2018] [Revised: 05/07/2019] [Accepted: 05/07/2019] [Indexed: 12/15/2022]
Abstract
Evidence-based treatments for posttraumatic stress disorder (PTSD) often produce significant symptom reduction within eight sessions. However, some patients take longer to respond and a better understanding of predictors of later response can help guide treatment. In the current study, the cohort consisted of all VA patients with a PTSD diagnosis who received at least eight sessions of documented evidence-based treatment within a 6-month period in FY16-FY17 and had at least two PTSD symptom assessments. We examined the proportion of patients who achieved meaningful change (defined as at least 50% reduction in self-reported PTSD symptoms), both within the first eight sessions and subsequently. Fourteen percent of patients achieved meaningful change within eight sessions and 10% subsequently. Symptom change within the first eight sessions was highly predictive of subsequent change. Those who experienced at least 20% symptom reduction by session eight were twice as likely to subsequently achieve meaningful change as compared with all patients who continued treatment. Patients receiving service-connected disability compensation were less likely and White patients more likely to achieve meaningful change. Without some degree of symptom reduction by session eight, patients are unlikely to achieve meaningful change if treatment is not enhanced or changed.
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Affiliation(s)
- Rebecca K Sripada
- Veterans Affairs Center for Clinical Management Research VA Ann Arbor Health Care System; University of Michigan.
| | | | - Dara Ganoczy
- Veterans Affairs Center for Clinical Management Research and Veterans Affairs Ann Arbor Health Care System
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Abstract
OBJECTIVE The U.S. Department of Veterans Affairs (VA) has placed increased emphasis on the availability and use of evidence-based psychotherapies (EBPs) for posttraumatic stress disorder (PTSD). However, many individuals do not complete a full course of EBP. The current study aimed to quantify the percentage of veterans receiving adequate EBP in VA hospitals and identify factors related to treatment completion. METHODS A national sample of 16,559 VA patients who began cognitive processing therapy (CPT) or prolonged exposure (PE) during fiscal year 2015 was obtained via administrative data. Generalized estimating equations were used to evaluate individual-level predictors of treatment adequacy, defined as eight sessions within 14 weeks. Generalized linear models were used to examine facility-level factors. RESULTS A total of 5,142 (31.1%) veterans completed eight or more sessions of psychotherapy. Older age was associated with greater odds of completing eight or more sessions (odds ratio OR=1.02, 95% confidence interval [CI]=1.01, 1.02, p<0.001), and comorbid bipolar or psychotic disorders were associated with reduced odds of completion (OR=0.89, 95% CI=0.80, 0.99, p=0.03). The percentage of patients who completed eight or more sessions was higher at facilities with higher percentages of EBP use among all patients with PTSD (β=6.55, SE=1.97, p=0.001) and greater numbers of EBP-certified providers (β=0.004, SE=0.002, p=0.038) and lower at facilities with a higher percentage of patients receiving a PTSD Checklist (β=-1.16, SE=0.46, p=0.011). CONCLUSIONS A minority of VA patients with PTSD complete an adequate dose of EBPs for PTSD. Individual and facility-level factors related to treatment adequacy may point to opportunities for intervention.
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Affiliation(s)
- Andrew C Hale
- U.S. Department of Veterans Affairs (VA) Center for Clinical Management Research, Ann Arbor, Michigan; Department of Psychiatry, University of Michigan, Ann Arbor (Hale, Bohnert, Sripada)
| | - Kipling M Bohnert
- U.S. Department of Veterans Affairs (VA) Center for Clinical Management Research, Ann Arbor, Michigan; Department of Psychiatry, University of Michigan, Ann Arbor (Hale, Bohnert, Sripada)
| | - Dara Ganoczy
- U.S. Department of Veterans Affairs (VA) Center for Clinical Management Research, Ann Arbor, Michigan; Department of Psychiatry, University of Michigan, Ann Arbor (Hale, Bohnert, Sripada)
| | - Rebecca K Sripada
- U.S. Department of Veterans Affairs (VA) Center for Clinical Management Research, Ann Arbor, Michigan; Department of Psychiatry, University of Michigan, Ann Arbor (Hale, Bohnert, Sripada)
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22
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Sripada RK, Blow FC, Rauch SAM, Ganoczy D, Hoff R, Harpaz-Rotem I, Bohnert KM. Examining the nonresponse phenomenon: Factors associated with treatment response in a national sample of veterans undergoing residential PTSD treatment. J Anxiety Disord 2019; 63:18-25. [PMID: 30785007 DOI: 10.1016/j.janxdis.2019.02.001] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [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: 06/29/2018] [Revised: 02/01/2019] [Accepted: 02/06/2019] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Although several treatments for PTSD have demonstrated efficacy, a substantial portion of patients do not experience clinically significant improvement. Predictors of treatment response are poorly understood. The current study was designed to investigate predictors of PTSD symptom change in a large national sample of treatment-seeking Veterans with PTSD. METHOD We analyzed predictors of treatment response among Veterans engaged in residential PTSD treatment from 2012 to 2013 (N = 2715). Multilevel modeling was used to assess the association between individual-level factors and symptom improvement from treatment entry to post-discharge. Guided by the theory of Resources, Life Events and Changes in Psychological States, we hypothesized that individuals with greater psychological, social/contextual, material, and physical health resources would exhibit better treatment response. RESULTS In adjusted analyses, accounting for facility, factors that predicted better treatment response included female gender, more psychological and social/contextual protective factors, and more years of education. Factors that predicted worse treatment response included Black race, comorbid personality disorder, greater pain severity, and current application for disability-related compensation. CONCLUSIONS These findings highlight factors that place individuals at risk of poor treatment response. Treatment modifications may be needed in order to optimize response for subgroups who are less likely to benefit from residential PTSD treatment.
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Affiliation(s)
- Rebecca K Sripada
- Veterans Affairs Center for Clinical Management Research and Veterans Affairs Ann Arbor Health Care System, Ann Arbor, MI, United States; University of Michigan, Department of Psychiatry, Ann Arbor, MI, United States.
| | - Frederic C Blow
- Veterans Affairs Center for Clinical Management Research and Veterans Affairs Ann Arbor Health Care System, Ann Arbor, MI, United States; University of Michigan, Department of Psychiatry, Ann Arbor, MI, United States
| | - Sheila A M Rauch
- Department of Psychiatry and Behavioral Sciences, Emory University, Atlanta, GA, United States; Atlanta VA Medical Center, Atlanta, GA, United States
| | - Dara Ganoczy
- Veterans Affairs Center for Clinical Management Research and Veterans Affairs Ann Arbor Health Care System, Ann Arbor, MI, United States
| | - Rani Hoff
- Veterans Affairs Northeast Program Evaluation Center, West Haven, CT, United States; 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
| | - Ilan Harpaz-Rotem
- Veterans Affairs Northeast Program Evaluation Center, West Haven, CT, United States; 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
| | - Kipling M Bohnert
- Veterans Affairs Center for Clinical Management Research and Veterans Affairs Ann Arbor Health Care System, Ann Arbor, MI, United States; University of Michigan, Department of Psychiatry, Ann Arbor, MI, United States
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Sripada RK, Hoff R, Pfeiffer PN, Ganoczy D, Blow FC, Bohnert KM. Latent classes of PTSD symptoms in veterans undergoing residential PTSD treatment. Psychol Serv 2018; 17:84-92. [PMID: 30284867 DOI: 10.1037/ser0000284] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Although most veterans in the Department of Veterans Affairs (VA) health system are treated for posttraumatic stress disorder (PTSD) in the outpatient setting, the VA has approximately 40 residential PTSD treatment facilities across the country for those requiring more intensive care. The symptom profiles of these veterans are poorly understood. Thus, the current study was designed to characterize classes of PTSD symptoms in a national sample of veterans undergoing residential treatment. We analyzed latent classes of PTSD symptoms among 2,452 veterans entering VA PTSD residential treatment in fiscal year 2013. The model with the best fit was a 4-class model comprising a low symptom class, moderate symptom class with high reexperiencing symptoms, a moderate symptom class with high emotional numbing, and a high symptom class. Compared to classes identified in outpatient samples, these classes were similar in type but greater in severity. Classes differed by age, race/ethnicity, trauma type, co-occurring medical conditions, co-occurring psychiatric conditions, and social functioning. Compared to the moderate class with high emotional numbing, those in the moderate class with high reexperiencing symptoms were more likely to be non-White, have greater pain severity, greater sleep problems, and were less likely to be depressed. Our findings suggest that veterans in residential treatment who have more severe PTSD symptoms also experience other medical and psychosocial stressors. A better understanding of symptom profiles may help to create more individualized treatment planning and thus potentially improve care for these veterans. (PsycINFO Database Record (c) 2020 APA, all rights reserved).
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Affiliation(s)
| | - Rani Hoff
- Veteran Affairs Northeast Program Evaluation Center
| | | | - Dara Ganoczy
- Veterans Affairs Center for Clinical Management Research
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24
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Sripada RK, Pfeiffer PN, Rauch SAM, Ganoczy D, Bohnert KM. Factors associated with the receipt of documented evidence-based psychotherapy for PTSD in VA. Gen Hosp Psychiatry 2018; 54:12-17. [PMID: 30029159 DOI: 10.1016/j.genhosppsych.2018.07.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [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] [Received: 03/07/2018] [Revised: 07/06/2018] [Accepted: 07/08/2018] [Indexed: 11/20/2022]
Abstract
OBJECTIVES The VA has mandated that evidence-based psychotherapies (EBPs) be offered to patients with PTSD, but only a small minority of the psychotherapy delivered to VA patients with PTSD is a documented EBP. It is unknown what factors are associated with receiving a documented EBP. METHOD Patients who received an EBP in FY2015 that was documented using a templated progress note (N = 21,808) were compared with patients who received psychotherapy for PTSD that was not documented using a template (N = 251,886). RESULTS Among psychotherapy recipients, VA patients with markers of clinical complexity such as service connection for PTSD, comorbid bipolar or psychotic disorder, longer duration of PTSD diagnosis, and a benzodiazepine prescription for PTSD had lower odds of receiving a documented EBP. CONCLUSIONS Recipients of documented EBPs differed from those who did not receive documented EBPs on several sociodemographic characteristics and indicators of treatment need. A limitation of our study is that some individuals in the group without EBP documentation may still have received an EBP, but did not receive EBP documentation in the electronic health record. Nevertheless, our results suggest that high-need or complex VA patients with PTSD may be less likely to receive documented EBPs.
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Affiliation(s)
- Rebecca K Sripada
- VA Center for Clinical Management Research, Ann Arbor, MI, USA; VA Ann Arbor Health Care System, Ann Arbor, MI, USA; University of Michigan, Department of Psychiatry, Ann Arbor, MI, USA.
| | - Paul N Pfeiffer
- VA Center for Clinical Management Research, Ann Arbor, MI, USA; VA Ann Arbor Health Care System, Ann Arbor, MI, USA; University of Michigan, Department of Psychiatry, Ann Arbor, MI, USA
| | - Sheila A M Rauch
- Department of Psychiatry and Behavioral Sciences, Emory University, Atlanta, GA, USA; Atlanta VA Medical Center, Decatur, GA, USA
| | - Dara Ganoczy
- VA Center for Clinical Management Research, Ann Arbor, MI, USA
| | - Kipling M Bohnert
- VA Center for Clinical Management Research, Ann Arbor, MI, USA; VA Ann Arbor Health Care System, Ann Arbor, MI, USA; University of Michigan, Department of Psychiatry, Ann Arbor, MI, USA
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25
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Knowles KA, Sripada RK, Defever M, Rauch SAM. Comorbid mood and anxiety disorders and severity of posttraumatic stress disorder symptoms in treatment-seeking veterans. Psychol Trauma 2018; 11:451-458. [PMID: 29963890 DOI: 10.1037/tra0000383] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Comorbidity is the rule and not the exception among veterans with posttraumatic stress disorder (PTSD). Examining comorbidities in a veteran population allows us to better understand veterans' symptoms and recognize when mental health treatment may need to be tailored to other co-occurring issues. This article evaluates comorbid mood and anxiety disorders and PTSD symptom severity in a large sample of veterans from multiple eras of service, including the recent wars in Iraq and Afghanistan. METHOD The current study used data from veterans who sought treatment for PTSD at a VA PTSD Clinical Team from 2005 to 2013. Veterans were assessed for PTSD, mood, and anxiety disorders using a structured clinical interview and completed self-report symptom measures as part of the PTSD clinic intake procedure. A total of 2,460 veterans were evaluated, and 867 met diagnostic criteria for PTSD. RESULTS Veterans with PTSD were significantly more likely than those without PTSD to be diagnosed with social anxiety disorder and obsessive-compulsive disorder, but significantly less likely to be diagnosed with depression. In addition, veterans who had at least one comorbid diagnosis in addition to PTSD reported significantly higher PTSD symptom severity than veterans with PTSD alone. PTSD symptom severity also varied by era of service. CONCLUSION These results suggest that among veterans seeking treatment for PTSD, comorbid mood and anxiety disorders may be associated with greater severity of PTSD symptoms. Future work is needed to determine the impact of specific comorbidities on trauma-focused treatment outcomes. (PsycINFO Database Record (c) 2019 APA, all rights reserved).
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Sripada RK, Hannemann CM, Schnurr PP, Marx BP, Pollack SJ, McCarthy JF. Mental Health Service Utilization before and after Receipt of a Service-Connected Disability Award for PTSD: Findings from a National Sample. Health Serv Res 2018; 53:4565-4583. [PMID: 29667171 DOI: 10.1111/1475-6773.12859] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To determine patterns of mental health service use before and after VA disability compensation awards for posttraumatic stress disorder (PTSD). DATA SOURCES A 10 percent random sample of VHA-enrolled Veterans with new or increased PTSD service connection between 2012 and 2014 (n = 22,249). STUDY DESIGN We used latent trajectory analysis to identify utilization patterns and multinomial logistic regression to assess associations between Veteran characteristics and trajectory membership. DATA EXTRACTION METHODS We assessed receipt of VHA mental health encounters in each of the 52 weeks prior to and following PTSD disability rating or rating increase. PRINCIPAL FINDINGS The best fitting model had five groups: No Use (36.6 percent), Low Use (37.7 percent), Increasing Use (9.4 percent), Decreasing Use (11.2 percent), and High Use (5.1 percent). Adjusting for demographic characteristics and compared with the No Use group, Veterans in the other groups were more likely to reside closer to a VHA facility, receive a higher PTSD disability rating, and screen positive for military sexual trauma. CONCLUSIONS Service use remained stable (80 percent) or increased (9 percent) for the vast majority of Veterans. Service utilization declined for only 11 percent. Data did not indicate substantial service discontinuation following rating. Low VHA service utilization suggests opportunities to enhance outreach for Veterans with PTSD-related disability benefits.
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Affiliation(s)
- Rebecca K Sripada
- Veterans Affairs Center for Clinical Management Research, Ann Arbor, MI.,Veterans Affairs Ann Arbor Health Care System, Ann Arbor, MI.,Department of Psychiatry, University of Michigan, Ann Arbor, MI.,Veterans Affairs Serious Mental Illness Treatment Resource and Evaluation Center, Ann Arbor, MI
| | - Claire M Hannemann
- Veterans Affairs Serious Mental Illness Treatment Resource and Evaluation Center, Ann Arbor, MI.,Office of Mental Health and Suicide Prevention, VA Central Office, Department of Veterans Affairs, Washington, DC
| | - Paula P Schnurr
- Executive Division, National Center for PTSD, White River Junction, VT.,Department of Psychiatry, Geisel School of Medicine at Dartmouth, Hanover, NH
| | - Brian P Marx
- Behavioral Science Division, National Center for PTSD, Boston, MA.,Veterans Affairs Boston Healthcare System, Boston, MA.,Department of Psychiatry, School of Medicine, Boston University, Boston, MA
| | - Stacey J Pollack
- Office of Mental Health and Suicide Prevention, VA Central Office, Department of Veterans Affairs, Washington, DC
| | - John F McCarthy
- Veterans Affairs Center for Clinical Management Research, Ann Arbor, MI.,Department of Psychiatry, University of Michigan, Ann Arbor, MI.,Veterans Affairs Serious Mental Illness Treatment Resource and Evaluation Center, Ann Arbor, MI.,Office of Mental Health and Suicide Prevention, VA Central Office, Department of Veterans Affairs, Washington, DC
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Hale AC, Sripada RK, Bohnert KM. Past-Year Treatment Utilization Among Individuals Meeting DSM-5 PTSD Criteria: Results From a Nationally Representative Sample. Psychiatr Serv 2018; 69:341-344. [PMID: 29241430 DOI: 10.1176/appi.ps.201700021] [Citation(s) in RCA: 6] [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] [Indexed: 12/01/2022]
Abstract
OBJECTIVE Little is known regarding treatment utilization among individuals meeting DSM-5 criteria for posttraumatic stress disorder (PTSD). METHODS Data were analyzed from the third wave of the National Epidemiologic Survey on Alcohol and Related Conditions, a nationally representative sample using DSM-5 criteria. RESULTS Factors related to increased odds of PTSD treatment utilization for individuals meeting lifetime criteria included some college education versus less than a high school degree (odds ratio [OR]=3.17), having health insurance versus no insurance (OR=2.86), having a comorbid phobia disorder versus not having a phobia disorder (OR=1.36), and greater PTSD symptom count (OR=1.11). Older age (OR=.40), identifying as black or Asian versus white non-Hispanic (OR=.70 and OR=.28, respectively), and greater social functioning (OR=.98) were associated with decreased odds of PTSD treatment utilization. CONCLUSIONS Results highlight factors that may be useful in identifying population subgroups with PTSD that are at risk for underutilization of services.
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Affiliation(s)
- Andrew C Hale
- The authors are with the U.S. Department of Veterans Affairs (VA) Center for Clinical Management Research and the Department of Psychiatry, University of Michigan Medical School, both in Ann Arbor, Michigan
| | - Rebecca K Sripada
- The authors are with the U.S. Department of Veterans Affairs (VA) Center for Clinical Management Research and the Department of Psychiatry, University of Michigan Medical School, both in Ann Arbor, Michigan
| | - Kipling M Bohnert
- The authors are with the U.S. Department of Veterans Affairs (VA) Center for Clinical Management Research and the Department of Psychiatry, University of Michigan Medical School, both in Ann Arbor, Michigan
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Levine DS, Sripada RK, Ganoczy D, Walters H, Gorman LA, Valenstein M. Poorer Physical Health is Associated With Greater Mental Health Service Utilization in a Sample of Depressed U.S. Army National Guard Soldiers. Mil Med 2018; 181:803-10. [PMID: 27483517 DOI: 10.7205/milmed-d-15-00287] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
OBJECTIVE Operation Iraqi Freedom/Operation Enduring Freedom service members returning from deployment suffer from high rates of depression and report low levels of physical functioning compared to age-adjusted norms. Treatment for depression may be limited in this group and there are few data on whether Veterans receive medication treatment versus psychotherapy. We assessed rates of depression, physical functioning, and treatment with either medication or psychotherapy among recently returning service members. METHODS Study participants were recruited from National Guard soldiers in a Midwestern state (n = 1,448). Logistic regression modeling was used to examine associations between physical health and odds of receiving different types of mental health treatment for depressed individuals (n = 299). RESULTS 21% of soldiers reported significant depression and 44% of depressed service members reported poor physical health. Poorer physical health was associated with increased odds of any treatment (odds ratio: 1.27, confidence interval: 1.1-1.45) and medication treatment (odds ratio: 1.23, confidence interval: 1.08-1.40) but physical health was not associated with individual psychotherapy. CONCLUSIONS Poor physical health is associated with increased likelihood of pharmacological but not individual psychotherapeutic treatment. Physical health problems may increase the need for depression care or increase contact with the medical system leading to higher levels of pharmacological treatment. Access to psychotherapy may need to be increased for Veterans with poor physical health.
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Affiliation(s)
- Debra S Levine
- VA Serious Mental Illness Treatment Resource and Evaluation Center, 2800 Plymouth Road, Ann Arbor, MI 48109
| | - Rebecca K Sripada
- VA Serious Mental Illness Treatment Resource and Evaluation Center, 2800 Plymouth Road, Ann Arbor, MI 48109
| | - Dara Ganoczy
- VA Serious Mental Illness Treatment Resource and Evaluation Center, 2800 Plymouth Road, Ann Arbor, MI 48109
| | - Heather Walters
- VA Serious Mental Illness Treatment Resource and Evaluation Center, 2800 Plymouth Road, Ann Arbor, MI 48109
| | - Lisa A Gorman
- Michigan Public Health Institute, 2436 Woodlake Drive, Okemos, MI 48864
| | - Marcia Valenstein
- VA Serious Mental Illness Treatment Resource and Evaluation Center, 2800 Plymouth Road, Ann Arbor, MI 48109
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Sripada RK, Bohnert KM, Ganoczy D, Pfeiffer PN. Documentation of Evidence-Based Psychotherapy and Care Quality for PTSD in the Department of Veterans Affairs. Adm Policy Ment Health 2017; 45:353-361. [DOI: 10.1007/s10488-017-0828-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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30
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Rauch SAM, King AP, Liberzon I, Sripada RK. Changes in Salivary Cortisol During Psychotherapy for Posttraumatic Stress Disorder: A Pilot Study in 30 Veterans. J Clin Psychiatry 2017; 78:599-603. [PMID: 28102979 DOI: 10.4088/jcp.15m10596] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [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: 12/16/2015] [Accepted: 03/15/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Convergent evidence suggests that the hypothalamic-pituitary-adrenal (HPA) axis is disrupted in posttraumatic stress disorder (PTSD) and that HPA axis normalization may be associated with symptom improvement. Thus, the current study was designed to test the association between HPA axis reactivity and treatment response in psychotherapy for PTSD. METHODS Thirty returning veterans with DSM-IV-TR PTSD were randomly assigned to receive 10 sessions of prolonged exposure therapy or present-centered therapy as part of a previously published randomized clinical trial (2008-2010). Treatment groups were collapsed for the current analyses. Salivary cortisol was collected 3 times during 3 therapy sessions. Cortisol reactivity was calculated by area under the curve with respect to ground. Hierarchical linear modeling was used to measure longitudinal change in salivary cortisol nested within patients and to test the effects of treatment responder status at both levels. RESULTS Session number was significant in the final model, indicating linear increases in cortisol output across sessions (β = 1.06, P = .02). In addition, responder status significantly predicted slope of cortisol reactivity across sessions (β = 1.35, P = .04). Compared to high responders, low responders exhibited a 1.35 (μg/dL) mean increase in cortisol reactivity between sessions. Responder status accounted for 6% of the previously unexplained variance in cortisol reactivity. CONCLUSIONS As compared to high treatment responders, low treatment responders showed greater increases in salivary cortisol output over the course of treatment. These results indicate that increases in HPA axis reactivity over the course of psychotherapy may be associated with worse treatment response. Future work is needed to investigate how modulation of HPA axis reactivity may be targeted in order to optimize PTSD treatment outcomes. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT00475241.
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Affiliation(s)
- Sheila A M Rauch
- Emory University School of Medicine, 12 Executive Park Dr, Ste 300, Atlanta, GA 30329. .,Emory University School of Medicine, Atlanta, Georgia, USA.,Atlanta VA Medical Center, Atlanta, Georgia, USA
| | - Anthony P King
- University of Michigan Medical School, Ann Arbor, Michigan, USA.,VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
| | - Israel Liberzon
- University of Michigan Medical School, Ann Arbor, Michigan, USA.,VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
| | - Rebecca K Sripada
- University of Michigan Medical School, Ann Arbor, Michigan, USA.,VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA.,VA Center for Clinical Management Research, Ann Arbor, Michigan, USA
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Sripada RK, Pfeiffer PN, Rampton J, Ganoczy D, Rauch SAM, Polusny MA, Bohnert KM. Predictors of PTSD Symptom Change Among Outpatients in the U.S. Department of Veterans Affairs Health Care System. J Trauma Stress 2017; 30:45-53. [PMID: 28103415 DOI: 10.1002/jts.22156] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [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: 02/03/2016] [Revised: 09/21/2016] [Accepted: 09/22/2016] [Indexed: 11/09/2022]
Abstract
Although the U.S. Department of Veterans Affairs (VA) has prioritized care for posttraumatic stress disorder (PTSD), many patients with PTSD remain symptomatic. Patterns of PTSD symptom change are not well understood. Thus, the current study was designed to categorize and investigate potential predictors of symptom trajectories in patients with PTSD. The sample comprised 2,237 VA patients who were diagnosed with PTSD in 2013 and completed at least 4 PTSD Checklist (PCL) assessments over 12 weeks. Latent trajectory analysis was used to identify latent classes of patients based on PCL scores. Based on model fit indices, 3 trajectories were identified. Compared to patients in the mild-improving trajectory (21.9%), those in the severe-stable trajectory (34.3%) were more likely to be male, relative risk ratio (RRR) = 1.48, 95% CI [1.08, 2.02]; non-White, RRR = 1.77, 95% CI [1.33, 2.35]; Hispanic, RRR = 2.07, 95% CI [1.40, 3.04]; and have comorbid depression, RRR = 1.58, 95% CI [1.25, 1.99]. Compared to patients in the moderate-improving trajectory (43.8%), those in the severe-stable trajectory were more likely to have sleep disorders, RRR = 1.25, 95% CI [1.01, 1.55]. Our findings suggest that male veterans, minority veterans, and veterans with certain comorbid conditions may be less likely to achieve improved PTSD symptoms. Targeted efforts are needed to improve outcomes for PTSD patients on nonremitting trajectories and to improve the consistency of PTSD assessment across the VA health care system.
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Affiliation(s)
- Rebecca K Sripada
- Veterans Affairs Center for Clinical Management Research, Health Services Research and Development, Ann Arbor, Michigan, USA.,Veterans Affairs Ann Arbor Health Care System, Ann Arbor, Michigan, USA.,Department of Psychiatry, University of Michigan, Ann Arbor, Michigan, USA
| | - Paul N Pfeiffer
- Veterans Affairs Center for Clinical Management Research, Health Services Research and Development, Ann Arbor, Michigan, USA.,Veterans Affairs Ann Arbor Health Care System, Ann Arbor, Michigan, USA.,Department of Psychiatry, University of Michigan, Ann Arbor, Michigan, USA
| | - Jessica Rampton
- Veterans Affairs Center for Clinical Management Research, Health Services Research and Development, Ann Arbor, Michigan, USA
| | - Dara Ganoczy
- Veterans Affairs Center for Clinical Management Research, Health Services Research and Development, Ann Arbor, Michigan, USA.,Veterans Affairs Ann Arbor Health Care System, Ann Arbor, Michigan, USA
| | - Sheila A M Rauch
- Department of Psychiatry and Behavioral Sciences, Emory University, Atlanta, Georgia, USA.,Atlanta Veteran Affairs Health Care System, Atlanta, Georgia, USA
| | - Melissa A Polusny
- Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota, USA.,Veteran Affairs Center for Chronic Disease Outcomes Research, Health Services Research and Development, Minneapolis, Minnesota, USA.,Department of Psychiatry, University of Minnesota, Minneapolis, Minnesota, USA
| | - Kipling M Bohnert
- Veterans Affairs Center for Clinical Management Research, Health Services Research and Development, Ann Arbor, Michigan, USA.,Veterans Affairs Ann Arbor Health Care System, Ann Arbor, Michigan, USA.,Department of Psychiatry, University of Michigan, Ann Arbor, Michigan, USA
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Sripada RK, Henry J, Yosef M, Levine DS, Bohnert KM, Miller E, Zivin K. Occupational functioning and employment services use among VA primary care patients with posttraumatic stress disorder. Psychol Trauma 2016; 10:140-143. [PMID: 27936849 DOI: 10.1037/tra0000241] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [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 Veterans with posttraumatic stress disorder (PTSD) exhibit high levels of unemployment. The Department of Veterans Affairs' Veterans Health Administration (VHA) offers a variety of employment services; however, few veterans with PTSD use these services. Because many veterans with mental health conditions are seen in primary care clinics, employment service needs may be best addressed in this setting. The current study was designed to assess employment status and support needs in VHA primary care patients who screen positive for PTSD. METHOD In the study, 287 working-age VHA patients with recent primary care use completed web-based surveys that assessed employment status, PTSD symptoms, employment support preferences, and barriers to service usage. RESULTS Individuals who screened positive for PTSD were less likely to be employed than were those without PTSD (55% vs. 69%; p = .03). After adjusting for sociodemographic characteristics, individuals with PTSD had higher barriers to employment (β = 3.52, p < .001) and higher barriers to employment service use (β = 0.57, p = .02). Only 14% of those with PTSD had used VHA employment services, but 86% said they would use those services. CONCLUSIONS Although the single site included in the study may not be representative of all VHA primary care clinics, our results suggest that there is high need for and substantial interest in VHA employment services among VHA patients with PTSD. Future work should focus on implementing employment support services for individuals with PTSD in primary care settings. (PsycINFO Database Record
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Affiliation(s)
- Rebecca K Sripada
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System
| | - Jennifer Henry
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System
| | | | - Debra S Levine
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System
| | - Kipling M Bohnert
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System
| | - Erin Miller
- Department of Psychiatry, University of Michigan
| | - Kara Zivin
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System
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Abstract
Psychological mechanisms can be defined as processes or events that are responsible for specific changes in psychological outcomes. In psychotherapy research, mechanisms are the factors through which interventions produce change. In this article, we explain the importance of identifying psychological mechanisms, describe methods for identifying them, and analyze recent literature on the psychological mechanisms underlying the development and treatment of posttraumatic stress disorder (PTSD). Based on the findings of recent investigations (from 2013 to present), we focus on four putative mechanisms: emotional engagement, extinction and contextualization, distress tolerance, and negative posttraumatic cognitions. Future directions for psychological mechanism research are also outlined, including possible opportunities for capitalizing on the most promising mechanisms identified to date.
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Affiliation(s)
- Rebecca K Sripada
- VA Center for Clinical Management Research, Health Services Research and Development, 2800 Plymouth Road, 48109, Ann Arbor, MI, USA. .,VA Ann Arbor Health Care System, 2215 Fuller Road, Ann Arbor, 48105, MI, USA. .,Department of Psychiatry, University of Michigan, 2450 Plymouth Road, 48109, Ann Arbor, MI, USA.
| | - Sheila A M Rauch
- Department of Psychiatry and Behavioral Sciences, Emory University, 12 Executive Park Drive NE #200, 30329, Atlanta, GA, USA.,Atlanta VA Medical Center, 1670 Clairmont Road, 30033, Decatur, GA, USA
| | - Israel Liberzon
- VA Ann Arbor Health Care System, 2215 Fuller Road, Ann Arbor, 48105, MI, USA.,Department of Psychiatry, University of Michigan, 2450 Plymouth Road, 48109, Ann Arbor, MI, USA
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Sripada RK, Bowersox NW, Ganoczy D, Valenstein M, Pfeiffer PN. Self-Determination Theory and Outpatient Follow-Up After Psychiatric Hospitalization. Community Ment Health J 2016; 52:662-6. [PMID: 26319610 DOI: 10.1007/s10597-015-9929-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [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: 11/06/2014] [Accepted: 08/11/2015] [Indexed: 11/28/2022]
Abstract
The objective of this study was to assess whether the constructs of self-determination theory-autonomy, competence, and relatedness-are associated with adherence to outpatient follow-up appointments after psychiatric hospitalization. 242 individuals discharged from inpatient psychiatric treatment within the Veterans Health Administration completed surveys assessing self-determination theory constructs as well as measures of depression and barriers to treatment. Medical records were used to count the number of mental health visits and no-shows in the 14 weeks following discharge. Logistic regression models assessed the association between survey items assessing theory constructs and attendance at mental healthcare visits. In multivariate models, none of the self-determination theory factors predicted outpatient follow-up attendance. The constructs of self-determination theory as measured by a single self-report survey may not reliably predict adherence to post-hospital care. Need factors such as depression may be more strongly predictive of treatment adherence.
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Affiliation(s)
- Rebecca K Sripada
- VA Serious Mental Illness Treatment Resource and Evaluation Center (SMITREC), 2800 Plymouth Road Bldg 16, Ann Arbor, MI, 48109, USA. .,VA Ann Arbor Health Care System, Ann Arbor, MI, USA. .,Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA.
| | - Nicholas W Bowersox
- VA Serious Mental Illness Treatment Resource and Evaluation Center (SMITREC), 2800 Plymouth Road Bldg 16, Ann Arbor, MI, 48109, USA.,VA Ann Arbor Health Care System, Ann Arbor, MI, USA.,Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
| | - Dara Ganoczy
- VA Serious Mental Illness Treatment Resource and Evaluation Center (SMITREC), 2800 Plymouth Road Bldg 16, Ann Arbor, MI, 48109, USA.,VA Ann Arbor Health Care System, Ann Arbor, MI, USA
| | - Marcia Valenstein
- VA Serious Mental Illness Treatment Resource and Evaluation Center (SMITREC), 2800 Plymouth Road Bldg 16, Ann Arbor, MI, 48109, USA.,VA Ann Arbor Health Care System, Ann Arbor, MI, USA.,Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
| | - Paul N Pfeiffer
- VA Serious Mental Illness Treatment Resource and Evaluation Center (SMITREC), 2800 Plymouth Road Bldg 16, Ann Arbor, MI, 48109, USA.,VA Ann Arbor Health Care System, Ann Arbor, MI, USA.,Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
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Yao B, Sripada RK, Klumpp H, Abelson JL, Muzik M, Zhao Z, Rosenblum K, Briggs H, Kaston M, Warren R. Penn State Worry Questionnaire - 10: A new tool for measurement-based care. Psychiatry Res 2016; 239:62-7. [PMID: 27137962 DOI: 10.1016/j.psychres.2016.02.069] [Citation(s) in RCA: 8] [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: 10/30/2015] [Revised: 02/21/2016] [Accepted: 02/29/2016] [Indexed: 10/22/2022]
Abstract
The Penn State Worry Questionnaire - Past Week (PSWQ-PW) is an adaptation of the widely used Penn State Worry Questionnaire, measuring pathological worry weekly. However, it contains problematic negatively worded items and has not been validated in a large sample yet. To meet the needs of measurement-based care (MBC), we developed a shortened version (PSWQ-10) based on the PSWQ-PW, retaining only positively worded items, and examined its psychometric properties and clinical utility. Patients with Generalized Anxiety Disorder (GAD), Major Depressive Disorder (MDD), and other anxiety disorders completed the PSWQ-10 and other instruments during routine evaluation in an academic anxiety clinic. A second cohort from a perinatal clinic was evaluated similarly. The PSWQ-10 displayed excellent internal consistency, convergent and discriminant validity, and criterion group validity. Patients with GAD scored significantly higher than those with other anxiety disorders but did not differ from those with MDD. The PSWQ-10 showed sensitivity to change over time and demonstrated excellent psychometric properties in the perinatal population. The PSWQ-10 is a reliable, valid, efficient, and straightforward worry-focused instrument that can be readily used in MBC and help clinicians objectively measure worry as a treatment outcome in broad clinical populations.
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Affiliation(s)
- Beier Yao
- Psychiatry, University of Michigan, Ann Arbor, MI, USA.
| | - Rebecca K Sripada
- Psychiatry, University of Michigan, Ann Arbor, MI, USA; Veterans Affairs Serious Mental Illness Treatment Resource and Evaluation Center (SMITREC), Veterans Affairs Ann Arbor Health Care System, Ann Arbor, MI, USA
| | - Heide Klumpp
- Psychiatry, University of Illinois at Chicago, Chicago, IL, USA
| | | | - Maria Muzik
- Psychiatry, University of Michigan, Ann Arbor, MI, USA
| | - Zhuo Zhao
- Psychiatry, University of Michigan, Ann Arbor, MI, USA
| | | | - Hedieh Briggs
- Psychiatry, University of Michigan, Ann Arbor, MI, USA
| | | | - Ricks Warren
- Psychiatry, University of Michigan, Ann Arbor, MI, USA.
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Sripada RK, Bohnert KM, Ganoczy D, Blow FC, Valenstein M, Pfeiffer PN. Initial group versus individual therapy for posttraumatic stress disorder and subsequent follow-up treatment adequacy. Psychol Serv 2016; 13:349-355. [PMID: 27175477 DOI: 10.1037/ser0000077] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Accessibility of psychotherapy for individuals with posttraumatic stress disorder (PTSD) and retention in treatment are major concerns for the Veterans Health Administration (VA). Group therapy is a common method for improving access to psychotherapy; however, PTSD patients may prefer individual therapy. This study assessed whether initial treatment with individual versus group psychotherapy relates to subsequent psychotherapy adequacy among VA patients with PTSD. The sample consisted of all VA patients who received a new PTSD diagnosis during a subspecialty PTSD clinical team visit in fiscal year 2010. Logistic and negative binomial regression analyses examined the relationship between modality of the first psychotherapy encounter and subsequent number of psychotherapy encounters within 14 weeks. Among 35,144 VA patients who initiated treatment for PTSD, 38% initiated group therapy and 62% initiated individual therapy. Patients who initiated with group therapy received a greater mean number of psychotherapy visits than those who initiated with individual therapy (4.7 vs. 2.8), and were about twice as likely (29.5% vs. 14.2%) to receive a minimally effective dose of 8 or more psychotherapy encounters. Group therapy predicted a greater number of psychotherapy visits (β = 0.46, SE = .01, p < .001) and greater likelihood of 8 or more sessions of psychotherapy (OR = 2.31, 95% CI [2.19, 2.45], p < .001), after adjusting for differences in demographic characteristics, comorbid conditions, and other service use. Greater treatment adequacy among group therapy participants suggests that these patients have greater access to frequent psychotherapy sessions or are more likely to persist with psychotherapy for PTSD than those treated individually. (PsycINFO Database Record
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Affiliation(s)
| | | | - Dara Ganoczy
- Veterans Affairs Center for Clinical Management Research
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Sripada RK, Bohnert KM, Ganoczy D, Blow FC, Pfeiffer PN. Facility-level factors associated with guideline-concordant prazosin dosing for Veterans with posttraumatic stress disorder. J Clin Psychiatry 2016; 77:548. [PMID: 27137423 DOI: 10.4088/jcp.15lr10250] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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King AP, Block SR, Sripada RK, Rauch S, Giardino N, Favorite T, Angstadt M, Kessler D, Welsh R, Liberzon I. ALTERED DEFAULT MODE NETWORK (DMN) RESTING STATE FUNCTIONAL CONNECTIVITY FOLLOWING A MINDFULNESS-BASED EXPOSURE THERAPY FOR POSTTRAUMATIC STRESS DISORDER (PTSD) IN COMBAT VETERANS OF AFGHANISTAN AND IRAQ. Depress Anxiety 2016; 33:289-99. [PMID: 27038410 DOI: 10.1002/da.22481] [Citation(s) in RCA: 127] [Impact Index Per Article: 15.9] [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: 01/19/2016] [Revised: 02/05/2016] [Accepted: 02/09/2016] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND Recent studies suggest that mindfulness may be an effective component for posttraumatic stress disorder (PTSD) treatment. Mindfulness involves practice in volitional shifting of attention from "mind wandering" to present-moment attention to sensations, and cultivating acceptance. We examined potential neural correlates of mindfulness training using a novel group therapy (mindfulness-based exposure therapy (MBET)) in combat veterans with PTSD deployed to Afghanistan (OEF) and/or Iraq (OIF). METHODS Twenty-three male OEF/OIF combat veterans with PTSD were treated with a mindfulness-based intervention (N = 14) or an active control group therapy (present-centered group therapy (PCGT), N = 9). Pre-post therapy functional magnetic resonance imaging (fMRI, 3 T) examined resting-state functional connectivity (rsFC) in default mode network (DMN) using posterior cingulate cortex (PCC) and ventral medial prefrontal cortex (vmPFC) seeds, and salience network (SN) with anatomical amygdala seeds. PTSD symptoms were assessed at pre- and posttherapy with Clinician Administered PTSD Scale (CAPS). RESULTS Patients treated with MBET had reduced PTSD symptoms (effect size d = 0.92) but effect was not significantly different from PCGT (d = 0.46). Increased DMN rsFC (PCC seed) with dorsolateral dorsolateral prefrontal cortex (DLPFC) regions and dorsal anterior cingulate cortex (ACC) regions associated with executive control was seen following MBET. A group × time interaction found MBET showed increased connectivity with DLPFC and dorsal ACC following therapy; PCC-DLPFC connectivity was correlated with improvement in PTSD avoidant and hyperarousal symptoms. CONCLUSIONS Increased connectivity between DMN and executive control regions following mindfulness training could underlie increased capacity for volitional shifting of attention. The increased PCC-DLPFC rsFC following MBET was related to PTSD symptom improvement, pointing to a potential therapeutic mechanism of mindfulness-based therapies.
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Affiliation(s)
- Anthony P King
- VA Ann Arbor Health Care System, Ann Arbor, Michigan.,Department of Psychiatry, University of Michigan, Ann Arbor, Michigan
| | - Stefanie R Block
- VA Ann Arbor Health Care System, Ann Arbor, Michigan.,Department of Psychiatry, University of Michigan, Ann Arbor, Michigan.,Department of Psychology, University of Michigan, Ann Arbor, Michigan
| | - Rebecca K Sripada
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan.,VA Serious Mental Illness Treatment Resource & Evaluation Center, Ann Arbor, Michigan
| | - Sheila Rauch
- Department of Psychiatry, Emory University, Atlanta, Georgia
| | - Nicholas Giardino
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan
| | - Todd Favorite
- VA Ann Arbor Health Care System, Ann Arbor, Michigan.,Department of Psychiatry, University of Michigan, Ann Arbor, Michigan.,Psychological Clinic, University of Michigan, Ann Arbor, Michigan
| | - Michael Angstadt
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan
| | - Daniel Kessler
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan
| | - Robert Welsh
- VA Ann Arbor Health Care System, Ann Arbor, Michigan.,Department of Radiology, University of Michigan, Ann Arbor, Michigan
| | - Israel Liberzon
- VA Ann Arbor Health Care System, Ann Arbor, Michigan.,Department of Psychiatry, University of Michigan, Ann Arbor, Michigan.,Department of Psychology, University of Michigan, Ann Arbor, Michigan
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Zivin K, Yosef M, Levine DS, Abraham KM, Miller EM, Henry J, Nelson CB, Pfeiffer PN, Sripada RK, Harrod M, Valenstein M. Employment status, employment functioning, and barriers to employment among VA primary care patients. J Affect Disord 2016; 193:194-202. [PMID: 26773911 DOI: 10.1016/j.jad.2015.12.054] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [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: 10/15/2015] [Revised: 12/18/2015] [Accepted: 12/26/2015] [Indexed: 11/26/2022]
Abstract
BACKGROUND Prior research found lower employment rates among working-aged patients who use the VA than among non-Veterans or Veterans who do not use the VA, with the lowest reported employment rates among VA patients with mental disorders. This study assessed employment status, employment functioning, and barriers to employment among VA patients treated in primary care settings, and examined how depression and anxiety were associated with these outcomes. METHODS The sample included 287 VA patients treated in primary care in a large Midwestern VA Medical Center. Bivariate and multivariable analyses were conducted examining associations between socio-demographic and clinical predictors of six employment domains, including: employment status, job search self-efficacy, work performance, concerns about job loss among employed Veterans, and employment barriers and likelihood of job seeking among not employed Veterans. RESULTS 54% of respondents were employed, 36% were not employed, and 10% were economically inactive. In adjusted analyses, participants with depression or anxiety (43%) were less likely to be employed, had lower job search self-efficacy, had lower levels of work performance, and reported more employment barriers. Depression and anxiety were not associated with perceived likelihood of job loss among employed or likelihood of job seeking among not employed. LIMITATIONS Single VA primary care clinic; cross-sectional study. DISCUSSION Employment rates are low among working-aged VA primary care patients, particularly those with mental health conditions. Offering primary care interventions to patients that address mental health issues, job search self-efficacy, and work performance may be important in improving health, work, and economic outcomes.
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Affiliation(s)
- Kara Zivin
- Department of Veterans Affairs, Center for Clinical Management Research, Ann Arbor, MI, USA; Department of Psychiatry, University of Michigan Medical School, Ann Arbor, MI, USA; Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, MI, USA; Institute for Social Research, University of Michigan, Ann Arbor, MI, USA.
| | - Matheos Yosef
- Department of Psychiatry, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Debra S Levine
- Department of Veterans Affairs, Center for Clinical Management Research, Ann Arbor, MI, USA; Department of Psychiatry, University of Michigan Medical School, Ann Arbor, MI, USA; Department of Veterans Affairs, Serious Mental Illness Treatment Resource and Evaluation Center, Ann Arbor, MI, USA
| | - Kristen M Abraham
- Department of Veterans Affairs, Serious Mental Illness Treatment Resource and Evaluation Center, Ann Arbor, MI, USA; Department of Psychology, University of Detroit Mercy, USA
| | - Erin M Miller
- Department of Psychiatry, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Jennifer Henry
- Department of Veterans Affairs, Center for Clinical Management Research, Ann Arbor, MI, USA
| | - C Beau Nelson
- Department of Psychiatry, University of Michigan Medical School, Ann Arbor, MI, USA; Mental Health Service, VA Ann Arbor Healthcare System, USA
| | - Paul N Pfeiffer
- Department of Veterans Affairs, Center for Clinical Management Research, Ann Arbor, MI, USA; Department of Psychiatry, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Rebecca K Sripada
- Department of Veterans Affairs, Center for Clinical Management Research, Ann Arbor, MI, USA; Department of Psychiatry, University of Michigan Medical School, Ann Arbor, MI, USA; Department of Veterans Affairs, Serious Mental Illness Treatment Resource and Evaluation Center, Ann Arbor, MI, USA
| | - Molly Harrod
- Department of Veterans Affairs, Center for Clinical Management Research, Ann Arbor, MI, USA
| | - Marcia Valenstein
- Department of Veterans Affairs, Center for Clinical Management Research, Ann Arbor, MI, USA; Department of Psychiatry, University of Michigan Medical School, Ann Arbor, MI, USA
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Gorman LA, Sripada RK, Ganoczy D, Walters HM, Bohnert KM, Dalack GW, Valenstein M. Determinants of National Guard Mental Health Service Utilization in VA versus Non-VA Settings. Health Serv Res 2016; 51:1814-37. [PMID: 26840993 DOI: 10.1111/1475-6773.12446] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To determine associations between need, enabling, and predisposing factors with mental health service use among National Guard soldiers in the first year following a combat deployment to Iraq or Afghanistan. DATA SOURCES/STUDY SETTING Primary data were collected between 2011 and 2013 from 1,426 Guard soldiers representing 36 units. STUDY DESIGN Associations between Guard soldier factors and any mental health service use were assessed using multivariable logistic regression models in a cross-sectional study. Further analysis among service users (N = 405) assessed VA treatment versus treatment in other settings. PRINCIPAL FINDINGS Fifty-six percent of Guard soldiers meeting cutoffs on symptom scales received mental health services with 81 percent of those reporting care from the VA. Mental health service use was associated with need (mental health screens and physical health) and residing in micropolitan communities. Among service users, predisposing factors (middle age range and female gender) and enabling factors (employment, income above $50,000, and private insurance) were associated with greater non-VA services use. CONCLUSION Overall service use was strongly associated with need, whereas sector of use (non-VA vs. VA) was insignificantly associated with need but strongly associated with enabling factors. These findings have implications for the recent extension of veteran health coverage to non-VA providers.
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Affiliation(s)
| | - Rebecca K Sripada
- Department of Psychiatry, University of Michigan, Ann Arbor, MI.,VA Center for Clinical Management Research, Ann Arbor Health Care System, Ann Arbor, MI
| | - Dara Ganoczy
- VA Center for Clinical Management Research, Ann Arbor Health Care System, Ann Arbor, MI
| | - Heather M Walters
- VA Center for Clinical Management Research, Ann Arbor Health Care System, Ann Arbor, MI
| | - Kipling M Bohnert
- Department of Psychiatry, University of Michigan, Ann Arbor, MI.,VA Center for Clinical Management Research, Ann Arbor Health Care System, Ann Arbor, MI
| | - Gregory W Dalack
- Department of Psychiatry, University of Michigan, Ann Arbor, MI.,VA Center for Clinical Management Research, Ann Arbor Health Care System, Ann Arbor, MI
| | - Marcia Valenstein
- Department of Psychiatry, University of Michigan, Ann Arbor, MI.,VA Center for Clinical Management Research, Ann Arbor Health Care System, Ann Arbor, MI
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Bohnert KM, Sripada RK, Mach J, McCarthy JF. Same-Day Integrated Mental Health Care and PTSD Diagnosis and Treatment Among VHA Primary Care Patients With Positive PTSD Screens. Psychiatr Serv 2016; 67:94-100. [PMID: 26423103 DOI: 10.1176/appi.ps.201500035] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [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] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The study examined whether same-day integrated mental health services are associated with increased diagnosis and treatment initiation among primary care patients with positive posttraumatic stress disorder (PTSD) screens. METHODS Data were from a national sample of Veterans Health Administration (VHA) primary care patients with a positive PTSD screen (N=21,427). Patients were assessed for PTSD diagnosis and treatment initiation on the screening day and ≤ 7 days, ≤ 12 weeks, ≤ 6 months, and ≤ 1 year after screening positive. The service setting on screening day was categorized as primary care only, same-day primary care-mental health integration (PC-MHI), or same-day specialty mental health care. Multivariable generalized estimating equations logistic regression was used to estimate associations between category of screening day services and diagnosis and treatment initiation, with adjustment for demographic characteristics, prior psychiatric diagnoses, prior VHA service utilization, and PTSD screen score. RESULTS Of the 21,427 patients with positive PTSD screens, 10,809 (50.4%) received a diagnosis within one year of screening positive. Same-day PC-MHI services were associated with greater odds of PTSD diagnosis, both on the same day as (odds ratio [OR]=2.23) and one year (OR=1.67) after screening positive compared with primary care-only services (p<.001). Among those who received a diagnosis on the same day as their positive screen, same-day PC-MHI services were associated with increased odds of initiating PTSD treatment (OR=3.39) within 12 weeks of diagnosis, compared with primary care only (p<.001). CONCLUSIONS Same-day integrated mental health services may help facilitate PTSD diagnosis and treatment initiation after a positive screen.
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Affiliation(s)
- Kipling M Bohnert
- Dr. Bohnert and Dr. Sripada are with the Center for Clinical Management Research and all authors are with the Serious Mental Illness Treatment Resource and Evaluation Center (SMITREC), U.S. Department of Veterans Affairs (VA), Ann Arbor, Michigan. Dr. Bohnert, Dr. Sripada, and Dr. McCarthy are also with the Department of Psychiatry, University of Michigan Medical School, Ann Arbor (e-mail: )
| | - Rebecca K Sripada
- Dr. Bohnert and Dr. Sripada are with the Center for Clinical Management Research and all authors are with the Serious Mental Illness Treatment Resource and Evaluation Center (SMITREC), U.S. Department of Veterans Affairs (VA), Ann Arbor, Michigan. Dr. Bohnert, Dr. Sripada, and Dr. McCarthy are also with the Department of Psychiatry, University of Michigan Medical School, Ann Arbor (e-mail: )
| | - Jennifer Mach
- Dr. Bohnert and Dr. Sripada are with the Center for Clinical Management Research and all authors are with the Serious Mental Illness Treatment Resource and Evaluation Center (SMITREC), U.S. Department of Veterans Affairs (VA), Ann Arbor, Michigan. Dr. Bohnert, Dr. Sripada, and Dr. McCarthy are also with the Department of Psychiatry, University of Michigan Medical School, Ann Arbor (e-mail: )
| | - John F McCarthy
- Dr. Bohnert and Dr. Sripada are with the Center for Clinical Management Research and all authors are with the Serious Mental Illness Treatment Resource and Evaluation Center (SMITREC), U.S. Department of Veterans Affairs (VA), Ann Arbor, Michigan. Dr. Bohnert, Dr. Sripada, and Dr. McCarthy are also with the Department of Psychiatry, University of Michigan Medical School, Ann Arbor (e-mail: )
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King AP, Block SR, Sripada RK, Rauch SAM, Porter KE, Favorite TK, Giardino N, Liberzon I. A Pilot Study of Mindfulness-Based Exposure Therapy in OEF/OIF Combat Veterans with PTSD: Altered Medial Frontal Cortex and Amygdala Responses in Social-Emotional Processing. Front Psychiatry 2016; 7:154. [PMID: 27703434 PMCID: PMC5028840 DOI: 10.3389/fpsyt.2016.00154] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Accepted: 08/25/2016] [Indexed: 01/04/2023] Open
Abstract
Combat-related posttraumatic stress disorder (PTSD) is common among returning veterans, and is a serious and debilitating disorder. While highly effective treatments involving trauma exposure exist, difficulties with engagement and early drop may lead to sub-optimal outcomes. Mindfulness training may provide a method for increasing emotional regulation skills that may improve engagement in trauma-focused therapy. Here, we examine potential neural correlates of mindfulness training and in vivo exposure (non-trauma focused) using a novel group therapy [mindfulness-based exposure therapy (MBET)] in Afghanistan (OEF) or Iraq (OIF) combat veterans with PTSD. OEF/OIF combat veterans with PTSD (N = 23) were treated with MBET (N = 14) or a comparison group therapy [Present-centered group therapy (PCGT), N = 9]. PTSD symptoms were assessed at pre- and post-therapy with Clinician Administered PTSD scale. Functional neuroimaging (3-T fMRI) before and after therapy examined responses to emotional faces (angry, fearful, and neutral faces). Patients treated with MBET had reduced PTSD symptoms (effect size d = 0.92) but effect was not significantly different from PCGT (d = 0.43). Improvement in PTSD symptoms from pre- to post-treatment in both treatment groups was correlated with increased activity in rostral anterior cingulate cortex, dorsal medial prefrontal cortex (mPFC), and left amygdala. The MBET group showed greater increases in amygdala and fusiform gyrus responses to Angry faces, as well as increased response in left mPFC to Fearful faces. These preliminary findings provide intriguing evidence that MBET group therapy for PTSD may lead to changes in neural processing of social-emotional threat related to symptom reduction.
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Affiliation(s)
- Anthony P King
- Mental Health Service, VA Ann Arbor Health System, Ann Arbor, MI, USA; Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
| | - Stefanie R Block
- Department of Psychology, University of Michigan , Ann Arbor, MI , USA
| | - Rebecca K Sripada
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA; VA Center for Clinical Management Research, Ann Arbor, MI, USA
| | - Sheila A M Rauch
- Department of Psychiatry and Behavioral Sciences, Emory University, Atlanta, GA, USA; Mental Health Service, Atlanta VA Medical Center, Atlanta, GA, USA
| | | | - Todd K Favorite
- Mental Health Service, VA Ann Arbor Health System, Ann Arbor, MI, USA; Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA; Mary A. Rackham Institute (MARI), University of Michigan, Ann Arbor, MI, USA
| | - Nicholas Giardino
- Department of Psychiatry, University of Michigan , Ann Arbor, MI , USA
| | - Israel Liberzon
- Mental Health Service, VA Ann Arbor Health System, Ann Arbor, MI, USA; Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
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Sripada RK, Richards SKH, Rauch SAM, Walters HM, Ganoczy D, Bohnert KM, Gorman LA, Kees M, Blow AJ, Valenstein M. Socioeconomic Status and Mental Health Service Use Among National Guard Soldiers. Psychiatr Serv 2015; 66:992-5. [PMID: 25930042 DOI: 10.1176/appi.ps.201400346] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [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] [Indexed: 12/01/2022]
Abstract
OBJECTIVE Convergent evidence suggests that low socioeconomic status (SES) may be related to reduced mental health service use. However, this relationship has not been tested in the National Guard (NG) population, in which the prevalence of mental health symptoms is high. METHODS Surveys were completed by 1,262 NG soldiers. SES was measured by education and income. Adjusted multivariable regression models assessed associations between SES, overall service use, and use of specific types of services. RESULTS SES was not associated with overall use but was associated with use of certain types of services. Higher SES was associated with lower likelihood of psychotropic medication use (odds ratio=.83, 95% confidence interval=.72-.96), and higher SES strengthened the positive relationship between PTSD and use of individual therapy. CONCLUSIONS Higher SES may increase the use of individual therapy among soldiers with PTSD. Barriers to care among individuals with low SES merit continued attention and outreach efforts.
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Affiliation(s)
- Rebecca K Sripada
- Dr. Sripada, Ms. Walters, Ms. Ganoczy, Dr. Bohnert, and Dr. Valenstein are with the Serious Mental Illness Treatment Resource and Evaluation Center, Center for Clinical Management Research, and Ms. Richards and Dr. Rauch are with the Mental Health Service, all at the U.S. Department of Veterans Affairs Ann Arbor Health Care System, Ann Arbor, Michigan. Dr. Sripada, Ms. Walters, Dr. Bohnert, Dr. Kees, and Dr. Valenstein are also with the Department of Psychiatry, University of Michigan Medical School, Ann Arbor (e-mail: ). Dr. Gorman is with the Michigan Public Health Institute, Okemos. Dr. Blow is with the Department of Family and Child Ecology, Michigan State University, East Lansing
| | - Sarah K H Richards
- Dr. Sripada, Ms. Walters, Ms. Ganoczy, Dr. Bohnert, and Dr. Valenstein are with the Serious Mental Illness Treatment Resource and Evaluation Center, Center for Clinical Management Research, and Ms. Richards and Dr. Rauch are with the Mental Health Service, all at the U.S. Department of Veterans Affairs Ann Arbor Health Care System, Ann Arbor, Michigan. Dr. Sripada, Ms. Walters, Dr. Bohnert, Dr. Kees, and Dr. Valenstein are also with the Department of Psychiatry, University of Michigan Medical School, Ann Arbor (e-mail: ). Dr. Gorman is with the Michigan Public Health Institute, Okemos. Dr. Blow is with the Department of Family and Child Ecology, Michigan State University, East Lansing
| | - Sheila A M Rauch
- Dr. Sripada, Ms. Walters, Ms. Ganoczy, Dr. Bohnert, and Dr. Valenstein are with the Serious Mental Illness Treatment Resource and Evaluation Center, Center for Clinical Management Research, and Ms. Richards and Dr. Rauch are with the Mental Health Service, all at the U.S. Department of Veterans Affairs Ann Arbor Health Care System, Ann Arbor, Michigan. Dr. Sripada, Ms. Walters, Dr. Bohnert, Dr. Kees, and Dr. Valenstein are also with the Department of Psychiatry, University of Michigan Medical School, Ann Arbor (e-mail: ). Dr. Gorman is with the Michigan Public Health Institute, Okemos. Dr. Blow is with the Department of Family and Child Ecology, Michigan State University, East Lansing
| | - Heather M Walters
- Dr. Sripada, Ms. Walters, Ms. Ganoczy, Dr. Bohnert, and Dr. Valenstein are with the Serious Mental Illness Treatment Resource and Evaluation Center, Center for Clinical Management Research, and Ms. Richards and Dr. Rauch are with the Mental Health Service, all at the U.S. Department of Veterans Affairs Ann Arbor Health Care System, Ann Arbor, Michigan. Dr. Sripada, Ms. Walters, Dr. Bohnert, Dr. Kees, and Dr. Valenstein are also with the Department of Psychiatry, University of Michigan Medical School, Ann Arbor (e-mail: ). Dr. Gorman is with the Michigan Public Health Institute, Okemos. Dr. Blow is with the Department of Family and Child Ecology, Michigan State University, East Lansing
| | - Dara Ganoczy
- Dr. Sripada, Ms. Walters, Ms. Ganoczy, Dr. Bohnert, and Dr. Valenstein are with the Serious Mental Illness Treatment Resource and Evaluation Center, Center for Clinical Management Research, and Ms. Richards and Dr. Rauch are with the Mental Health Service, all at the U.S. Department of Veterans Affairs Ann Arbor Health Care System, Ann Arbor, Michigan. Dr. Sripada, Ms. Walters, Dr. Bohnert, Dr. Kees, and Dr. Valenstein are also with the Department of Psychiatry, University of Michigan Medical School, Ann Arbor (e-mail: ). Dr. Gorman is with the Michigan Public Health Institute, Okemos. Dr. Blow is with the Department of Family and Child Ecology, Michigan State University, East Lansing
| | - Kipling M Bohnert
- Dr. Sripada, Ms. Walters, Ms. Ganoczy, Dr. Bohnert, and Dr. Valenstein are with the Serious Mental Illness Treatment Resource and Evaluation Center, Center for Clinical Management Research, and Ms. Richards and Dr. Rauch are with the Mental Health Service, all at the U.S. Department of Veterans Affairs Ann Arbor Health Care System, Ann Arbor, Michigan. Dr. Sripada, Ms. Walters, Dr. Bohnert, Dr. Kees, and Dr. Valenstein are also with the Department of Psychiatry, University of Michigan Medical School, Ann Arbor (e-mail: ). Dr. Gorman is with the Michigan Public Health Institute, Okemos. Dr. Blow is with the Department of Family and Child Ecology, Michigan State University, East Lansing
| | - Lisa A Gorman
- Dr. Sripada, Ms. Walters, Ms. Ganoczy, Dr. Bohnert, and Dr. Valenstein are with the Serious Mental Illness Treatment Resource and Evaluation Center, Center for Clinical Management Research, and Ms. Richards and Dr. Rauch are with the Mental Health Service, all at the U.S. Department of Veterans Affairs Ann Arbor Health Care System, Ann Arbor, Michigan. Dr. Sripada, Ms. Walters, Dr. Bohnert, Dr. Kees, and Dr. Valenstein are also with the Department of Psychiatry, University of Michigan Medical School, Ann Arbor (e-mail: ). Dr. Gorman is with the Michigan Public Health Institute, Okemos. Dr. Blow is with the Department of Family and Child Ecology, Michigan State University, East Lansing
| | - Michelle Kees
- Dr. Sripada, Ms. Walters, Ms. Ganoczy, Dr. Bohnert, and Dr. Valenstein are with the Serious Mental Illness Treatment Resource and Evaluation Center, Center for Clinical Management Research, and Ms. Richards and Dr. Rauch are with the Mental Health Service, all at the U.S. Department of Veterans Affairs Ann Arbor Health Care System, Ann Arbor, Michigan. Dr. Sripada, Ms. Walters, Dr. Bohnert, Dr. Kees, and Dr. Valenstein are also with the Department of Psychiatry, University of Michigan Medical School, Ann Arbor (e-mail: ). Dr. Gorman is with the Michigan Public Health Institute, Okemos. Dr. Blow is with the Department of Family and Child Ecology, Michigan State University, East Lansing
| | - Adrian J Blow
- Dr. Sripada, Ms. Walters, Ms. Ganoczy, Dr. Bohnert, and Dr. Valenstein are with the Serious Mental Illness Treatment Resource and Evaluation Center, Center for Clinical Management Research, and Ms. Richards and Dr. Rauch are with the Mental Health Service, all at the U.S. Department of Veterans Affairs Ann Arbor Health Care System, Ann Arbor, Michigan. Dr. Sripada, Ms. Walters, Dr. Bohnert, Dr. Kees, and Dr. Valenstein are also with the Department of Psychiatry, University of Michigan Medical School, Ann Arbor (e-mail: ). Dr. Gorman is with the Michigan Public Health Institute, Okemos. Dr. Blow is with the Department of Family and Child Ecology, Michigan State University, East Lansing
| | - Marcia Valenstein
- Dr. Sripada, Ms. Walters, Ms. Ganoczy, Dr. Bohnert, and Dr. Valenstein are with the Serious Mental Illness Treatment Resource and Evaluation Center, Center for Clinical Management Research, and Ms. Richards and Dr. Rauch are with the Mental Health Service, all at the U.S. Department of Veterans Affairs Ann Arbor Health Care System, Ann Arbor, Michigan. Dr. Sripada, Ms. Walters, Dr. Bohnert, Dr. Kees, and Dr. Valenstein are also with the Department of Psychiatry, University of Michigan Medical School, Ann Arbor (e-mail: ). Dr. Gorman is with the Michigan Public Health Institute, Okemos. Dr. Blow is with the Department of Family and Child Ecology, Michigan State University, East Lansing
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Sripada RK, Bohnert ASB, Teo AR, Levine DS, Pfeiffer PN, Bowersox NW, Mizruchi MS, Chermack ST, Ganoczy D, Walters H, Valenstein M. Social networks, mental health problems, and mental health service utilization in OEF/OIF National Guard veterans. Soc Psychiatry Psychiatr Epidemiol 2015; 50:1367-78. [PMID: 26032182 DOI: 10.1007/s00127-015-1078-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [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: 01/30/2015] [Accepted: 05/25/2015] [Indexed: 12/27/2022]
Abstract
PURPOSE Low social support and small social network size have been associated with a variety of negative mental health outcomes, while their impact on mental health services use is less clear. To date, few studies have examined these associations in National Guard service members, where frequency of mental health problems is high, social support may come from military as well as other sources, and services use may be suboptimal. METHODS Surveys were administered to 1448 recently returned National Guard members. Multivariable regression models assessed the associations between social support characteristics, probable mental health conditions, and service utilization. RESULTS In bivariate analyses, large social network size, high social network diversity, high perceived social support, and high military unit support were each associated with lower likelihood of having a probable mental health condition (p < .001). In adjusted analyses, high perceived social support (OR .90, CI .88-.92) and high unit support (OR .96, CI .94-.97) continued to be significantly associated with lower likelihood of mental health conditions. Two social support measures were associated with lower likelihood of receiving mental health services in bivariate analyses, but were not significant in adjusted models. CONCLUSIONS General social support and military-specific support were robustly associated with reduced mental health symptoms in National Guard members. Policy makers, military leaders, and clinicians should attend to service members' level of support from both the community and their units and continue efforts to bolster these supports. Other strategies, such as focused outreach, may be needed to bring National Guard members with need into mental health care.
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Affiliation(s)
- Rebecca K Sripada
- VA Serious Mental Illness Treatment Resource and Evaluation Center (SMITREC), 2800 Plymouth Road Bldg 16, Ann Arbor, MI, 48105, USA. .,VA Ann Arbor Health Care System, Ann Arbor, MI, USA. .,Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA.
| | - Amy S B Bohnert
- VA Serious Mental Illness Treatment Resource and Evaluation Center (SMITREC), 2800 Plymouth Road Bldg 16, Ann Arbor, MI, 48105, USA.,VA Ann Arbor Health Care System, Ann Arbor, MI, USA.,Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
| | - Alan R Teo
- Portland VA Medical Center, Portland, OR, USA.,Oregon Health and Science University, Portland, OR, USA
| | - Debra S Levine
- VA Serious Mental Illness Treatment Resource and Evaluation Center (SMITREC), 2800 Plymouth Road Bldg 16, Ann Arbor, MI, 48105, USA.,VA Ann Arbor Health Care System, Ann Arbor, MI, USA.,Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
| | - Paul N Pfeiffer
- VA Serious Mental Illness Treatment Resource and Evaluation Center (SMITREC), 2800 Plymouth Road Bldg 16, Ann Arbor, MI, 48105, USA.,VA Ann Arbor Health Care System, Ann Arbor, MI, USA.,Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
| | - Nicholas W Bowersox
- VA Serious Mental Illness Treatment Resource and Evaluation Center (SMITREC), 2800 Plymouth Road Bldg 16, Ann Arbor, MI, 48105, USA.,VA Ann Arbor Health Care System, Ann Arbor, MI, USA.,Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
| | - Mark S Mizruchi
- Department of Sociology, University of Michigan, Ann Arbor, MI, USA
| | - Stephen T Chermack
- VA Serious Mental Illness Treatment Resource and Evaluation Center (SMITREC), 2800 Plymouth Road Bldg 16, Ann Arbor, MI, 48105, USA.,VA Ann Arbor Health Care System, Ann Arbor, MI, USA.,Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
| | - Dara Ganoczy
- VA Serious Mental Illness Treatment Resource and Evaluation Center (SMITREC), 2800 Plymouth Road Bldg 16, Ann Arbor, MI, 48105, USA
| | - Heather Walters
- VA Serious Mental Illness Treatment Resource and Evaluation Center (SMITREC), 2800 Plymouth Road Bldg 16, Ann Arbor, MI, 48105, USA.,VA Ann Arbor Health Care System, Ann Arbor, MI, USA.,Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
| | - Marcia Valenstein
- VA Serious Mental Illness Treatment Resource and Evaluation Center (SMITREC), 2800 Plymouth Road Bldg 16, Ann Arbor, MI, 48105, USA.,VA Ann Arbor Health Care System, Ann Arbor, MI, USA.,Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
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Sripada RK, Pfeiffer PN, Rauch SAM, Bohnert KM. Social support and mental health treatment among persons with PTSD: results of a nationally representative survey. Psychiatr Serv 2015; 66:65-71. [PMID: 25269889 PMCID: PMC4283571 DOI: 10.1176/appi.ps.201400029] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [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] [Indexed: 12/21/2022]
Abstract
OBJECTIVE Despite continued outreach efforts, levels of mental health care utilization for posttraumatic stress disorder (PTSD) remain low. As such, it is important to identify factors that may promote or discourage treatment engagement. This study was designed to examine the association between perceived social support and utilization of several types of PTSD services. METHODS Data came from wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions, which was administered between 2004 and 2005. PTSD was assessed via structured interview, and perceived social support was assessed via the Interpersonal Support Evaluation List-12. Participants were asked about receipt of four modalities of PTSD-specific treatment: outpatient, hospitalization, emergency department visits, and psychiatric medication prescriptions. Weighted logistic regression modeling was performed to examine associations between social support scores and the odds of receiving treatment for PTSD, and the analyses were adjusted for sociodemographic characteristics and PTSD severity. RESULTS The final sample consisted of 2,811 individuals with PTSD. Social support was not associated with the odds of receiving any type of PTSD treatment. CONCLUSIONS Among individuals in the general population with PTSD, perceived social support may not be related to PTSD treatment utilization. Other factors, such as sociodemographic characteristics and symptom severity, may be more important predictors of receipt of PTSD-specific treatment.
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Affiliation(s)
- Rebecca K Sripada
- Dr. Sripada, Dr. Pfeiffer, and Dr. Bohnert are with the U.S. Department of Veterans Affairs (VA) Serious Mental Illness Treatment Resource and Evaluation Center, Ann Arbor, Michigan. Dr. Rauch is affiliated with the Mental Health Service of the VA Ann Arbor Healthcare System. All of the authors are with the Department of Psychiatry, University of Michigan, Ann Arbor (e-mail: )
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Sripada RK, Welsh RC, Marx CE, Liberzon I. The neurosteroids allopregnanolone and dehydroepiandrosterone modulate resting-state amygdala connectivity. Hum Brain Mapp 2013; 35:3249-61. [PMID: 24302681 DOI: 10.1002/hbm.22399] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2012] [Revised: 06/18/2013] [Accepted: 08/19/2013] [Indexed: 02/01/2023] Open
Abstract
The neurosteroids allopregnanolone and dehydroepiandrosterone (DHEA) are integral components of the stress response and exert positive modulatory effects on emotion in both human and animal studies. Although these antidepressant and anxiolytic effects have been well established, to date, little research has examined their neural correlates, and no research has been conducted into the effects of neurosteroids on large-scale networks at rest. To investigate the neurosteroid impact on intrinsic connectivity networks, participants were administered 400 mg of pregnenolone (N = 16), 400 mg of DHEA (N = 14), or placebo (N = 15) and underwent 3T fMRI. Resting-state brain connectivity was measured using amygdala as a seed region. When compared with placebo, pregnenolone administration reduced connectivity between amygdala and dorsal medial prefrontal cortex, between amygdala and precuneus, and between amygdala and hippocampus. DHEA reduced connectivity between amygdala and periamygdala and between amygdala and insula. Reductions in amygdala to precuneus connectivity were associated with less self-reported negative affect. These results demonstrate that neurosteroids modulate amygdala functional connectivity during resting state and may be a target for pharmacological intervention. Additionally, allopregnanolone and DHEA may shift the balance between salience network and default network, a finding that could provide insight into the neurocircuitry of anxiety psychopathology.
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Affiliation(s)
- Rebecca K Sripada
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan; Ann Arbor VA Medical Center, Ann Arbor, Michigan
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Sripada RK, Garfinkel SN, Liberzon I. Avoidant symptoms in PTSD predict fear circuit activation during multimodal fear extinction. Front Hum Neurosci 2013; 7:672. [PMID: 24146643 PMCID: PMC3797966 DOI: 10.3389/fnhum.2013.00672] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2013] [Accepted: 09/26/2013] [Indexed: 01/13/2023] Open
Abstract
Convergent evidence suggests that individuals with posttraumatic stress disorder (PTSD) exhibit exaggerated avoidance behaviors as well as abnormalities in Pavlonian fear conditioning. However, the link between the two features of this disorder is not well understood. In order to probe the brain basis of aberrant extinction learning in PTSD, we administered a multimodal classical fear conditioning/extinction paradigm that incorporated affectively relevant information from two sensory channels (visual and tactile) while participants underwent fMRI scanning. The sample consisted of fifteen OEF/OIF veterans with PTSD. In response to conditioned cues and contextual information, greater avoidance symptomatology was associated with greater activation in amygdala, hippocampus, vmPFC, dmPFC, and insula, during both fear acquisition and fear extinction. Heightened responses to previously conditioned stimuli in individuals with more severe PTSD could indicate a deficiency in safety learning, consistent with PTSD symptomatology. The close link between avoidance symptoms and fear circuit activation suggests that this symptom cluster may be a key component of fear extinction deficits in PTSD and/or may be particularly amenable to change through extinction-based therapies.
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Affiliation(s)
- Rebecca K Sripada
- Department of Psychiatry, University of Michigan Ann Arbor, MI, USA ; Veterans Affairs Center for Clinical Management Research, Department of Veterans Affairs Healthcare System Ann Arbor, MI, USA
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Sripada RK, Marx CE, King AP, Rajaram N, Garfinkel SN, Abelson JL, Liberzon I. DHEA enhances emotion regulation neurocircuits and modulates memory for emotional stimuli. Neuropsychopharmacology 2013; 38:1798-807. [PMID: 23552182 PMCID: PMC3717538 DOI: 10.1038/npp.2013.79] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [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: 11/25/2012] [Revised: 02/17/2013] [Accepted: 03/27/2013] [Indexed: 12/31/2022]
Abstract
Dehydroepiandrosterone (DHEA) is a neurosteroid with anxiolytic, antidepressant, and antiglucocorticoid properties. It is endogenously released in response to stress, and may reduce negative affect when administered exogenously. Although there have been multiple reports of DHEA's antidepressant and anxiolytic effects, no research to date has examined the neural pathways involved. In particular, brain imaging has not been used to link neurosteroid effects to emotion neurocircuitry. To investigate the brain basis of DHEA's impact on emotion modulation, patients were administered 400 mg of DHEA (N=14) or placebo (N=15) and underwent 3T fMRI while performing the shifted-attention emotion appraisal task (SEAT), a test of emotional processing and regulation. Compared with placebo, DHEA reduced activity in the amygdala and hippocampus, enhanced connectivity between the amygdala and hippocampus, and enhanced activity in the rACC. These activation changes were associated with reduced negative affect. DHEA reduced memory accuracy for emotional stimuli, and also reduced activity in regions associated with conjunctive memory encoding. These results demonstrate that DHEA reduces activity in regions associated with generation of negative emotion and enhances activity in regions linked to regulatory processes. Considering that activity in these regions is altered in mood and anxiety disorders, our results provide initial neuroimaging evidence that DHEA may be useful as a pharmacological intervention for these conditions and invite further investigation into the brain basis of neurosteroid emotion regulatory effects.
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Affiliation(s)
- Rebecca K Sripada
- Department of Psychiatry, University of Michigan, Ann Arbor, MI 48109, USA.
| | - Christine E Marx
- Department of Psychiatry, Duke University, Durham, NC, USA,Durham VA Medical Center, Durham, NC, USA
| | - Anthony P King
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA,Ann Arbor VA Medical Center, Ann Arbor, MI, USA
| | - Nirmala Rajaram
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA,Ann Arbor VA Medical Center, Ann Arbor, MI, USA
| | - Sarah N Garfinkel
- Department of Psychiatry, Brighton and Sussex Medical School, University of Sussex, Falmer, UK
| | - James L Abelson
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
| | - Israel Liberzon
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA,Department of Psychology, University of Michigan, Ann Arbor, MI, USA,Ann Arbor VA Medical Center, Ann Arbor, MI, USA
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49
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Sripada RK, Rauch SAM, Tuerk PW, Smith E, Defever AM, Mayer RA, Messina M, Venners M. Mild traumatic brain injury and treatment response in prolonged exposure for PTSD. J Trauma Stress 2013; 26:369-75. [PMID: 23696427 DOI: 10.1002/jts.21813] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [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] [Indexed: 12/19/2022]
Abstract
A proportion of U.S. veterans returning from Iraq and Afghanistan have experienced mild traumatic brain injury (mTBI), which is associated with increased risk for developing posttraumatic stress disorder (PTSD). Prolonged Exposure (PE) has proven effectiveness in the treatment of PTSD; however, some clinicians have reservations about using PE with individuals with a history of mTBI. We examined the impact of PE for veterans with PTSD and with or without a history of mTBI in a naturalistic sample of 51 veterans who received PE at a Veterans Health Administration PTSD clinic. We also analyzed previously collected data from a controlled trial of 22 veterans randomly assigned to PE or present centered therapy. For both sets of data, we found that PE reduced symptom levels and we also did not detect an effect for mTBI, suggesting that PE may be helpful for individuals with PTSD and a history of mTBI.
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Affiliation(s)
- Rebecca K Sripada
- VA Ann Arbor Health Care System/University of Michigan Medical School, Ann Arbor, Michigan, USA.
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50
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Sripada RK, Marx CE, King AP, Rampton JC, Ho S, Liberzon I. Allopregnanolone elevations following pregnenolone administration are associated with enhanced activation of emotion regulation neurocircuits. Biol Psychiatry 2013; 73:1045-53. [PMID: 23348009 PMCID: PMC3648625 DOI: 10.1016/j.biopsych.2012.12.008] [Citation(s) in RCA: 76] [Impact Index Per Article: 6.9] [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: 08/13/2012] [Revised: 11/16/2012] [Accepted: 12/09/2012] [Indexed: 02/08/2023]
Abstract
BACKGROUND The neurosteroid allopregnanolone is a potent allosteric modulator of the gamma-aminobutyric acid type A receptor with anxiolytic properties. Exogenous administration of allopregnanolone reduces anxiety, and allopregnanolone blockade impairs social and affective functioning. However, the neural mechanism whereby allopregnanolone improves mood and reduces anxiety is unknown. In particular, brain imaging has not been used to link neurosteroid effects to emotion regulation neurocircuitry. METHODS To investigate the brain basis of allopregnanolone's impact on emotion regulation, participants were administered 400 mg of pregnenolone (n=16) or placebo (n=15) and underwent 3T functional magnetic resonance imaging while performing the shifted-attention emotion appraisal task, which probes emotional processing and regulation. RESULTS Compared with placebo, allopregnanolone was associated with reduced activity in the amygdala and insula across all conditions. During the appraisal condition, allopregnanolone increased activity in the dorsal medial prefrontal cortex and enhanced connectivity between the amygdala and dorsal medial prefrontal cortex, an effect that was associated with reduced self-reported anxiety. CONCLUSIONS These results demonstrate that in response to emotional stimuli, allopregnanolone reduces activity in regions associated with generation of negative emotion. Furthermore, allopregnanolone may enhance activity in regions linked to regulatory processes. Aberrant activity in these regions has been linked to anxiety psychopathology. These results thus provide initial neuroimaging evidence that allopregnanolone may be a target for pharmacologic intervention in the treatment of anxiety disorders and suggest potential future directions for research into neurosteroid effects on emotion regulation neurocircuitry.
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Affiliation(s)
- Rebecca K. Sripada
- Psychiatry, University of Michigan, Ann Arbor, MI,Psychology, University of Michigan, Ann Arbor, MI,Corresponding author: Rebecca K. Sripada, 4250 Plymouth Road, 2702 Rachel Upjohn Building, Ann Arbor, MI 48109, , Tel : (734) 232-0190, Fax : (734) 936-7868
| | - Christine E. Marx
- Psychiatry, Duke University, Durham, NC,Durham VA Medical Center, Durham, NC
| | - Anthony P. King
- Psychiatry, University of Michigan, Ann Arbor, MI,Ann Arbor VA Medical Center, Ann Arbor, MI
| | | | - Shaun Ho
- Psychiatry, University of Michigan, Ann Arbor, MI
| | - Israel Liberzon
- Psychiatry, University of Michigan, Ann Arbor, MI,Psychology, University of Michigan, Ann Arbor, MI,Ann Arbor VA Medical Center, Ann Arbor, MI
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