Web Intervention for OEF/OIF Veterans with Mental Health Problems
Kenneth J Ruggiero Jr. PhD MA BA
Ralph H. Johnson VA Medical Center, Charleston, SC
Charleston, SC
Funding Period: April 2009 - March 2013

BACKGROUND/RATIONALE:
Combat exposure is associated with elevated risk of mental health problems, including PTSD, depression, generalized anxiety, and substance abuse. Formal evidence-based interventions are available to treat these problems, but recent research has shown that only 25-40% of veterans with mental health disorders actually seek mental health care; and that, of those who do seek care, treatment dropout and non-adherence rates are high. A study of combat veterans in Iraq and Afghanistan identified several barriers to seeking mental health care among veterans who met screening criteria for a mental health disorder (n = 731). Some barriers were around the perceived stigma associated with seeking mental health treatment, whereas others were around scheduling difficulties or access to care more broadly. Access to mental health care is particularly problematic among rural veterans. The availability of computerized and/or Web-based interventions has the potential to address many of these issues and/or serve as a useful supplement to treatment that reinforces healthy coping strategies taught to veterans in the context of traditional evidence-based treatment.

OBJECTIVE(S):
The primary purposes of the proposed project are to (a) develop an innovative, Web-based intervention for OIF/OEF veterans that addresses mental health, barriers-to-care, and treatment participation issues to facilitate healthy recovery; (b) develop video illustrations to facilitate learning of educational material; (c) develop thorough evaluation mechanisms to assess knowledge change relevant to common symptoms, healthy coping strategies, and access-to-care issues; (d) conduct a series of focus groups to guide development and refinement of intervention content; and (e) preliminarily evaluate the intervention using thematic semi-structured interviews with a small sample of OIF/OEF veterans recruited via mental health specialty clinics within the Ralph H. Johnson VA Medical Center and affiliated CBOCs.

METHODS:
Construction of the intervention will depend heavily on input from veterans. Following initial focus groups with local OIF/OEF veterans to guide intervention-development decisions (months 1-4), we will develop an initial version of the Web intervention (months 5-16). Next, we will conduct a series of focus groups (months 17-20) to gather data on usability, navigation, satisfaction, and other feedback for refinement purposes. We will then refine the intervention (months 21-25) based on this feedback. Following refinement, we will pilot the intervention (months 26-30) using individual, thematic semi-structured interviews with OIF/OEF veterans locally recruited via mental health specialty clinics within the Ralph H. Johnson VA Medical Center and affiliated CBOCs to preliminarily evaluate satisfaction; other reactions and feedback; knowledge levels relating to healthy coping strategies, treatment participation, and access to care issues; and possible symptom improvement. Finally, months 31-36 of the project will be dedicated to finalizing the intervention, disseminating study findings, and submitting a grant proposal to test the intervention using a randomized clinical trial design.

FINDINGS/RESULTS:
This 3-year project was funded in April, 2009. We recently obtained approval for a one year no-cost-extension through March, 2013. Focus group data collection for VA providers and Veterans is complete. Provider interviews have been transcribed, the qualitative analyses have been completed, and a manuscript has been prepared for submission. A second manuscript also has been outlined and will be prepared for presentation and publication. Qualitative analyses suggest that providers are generally very excited about a web-based self-help intervention for Veterans with depression, anxiety/PTSD, and substance use. Providers also see great potential for such a site to be used as an adjunctive or precursor to formal office therapy. Some providers expressed reservations about patients with severe trauma or substance use symptoms using the website without adjunctive treatment and subsequently recommended that additional safety contacts/referrals be made available on the website. Patient focus groups have been transcribed but findings are not yet fully available for report. We anticipate that all provider interview data will be fully analyzed and interpreted by mid-April 2012.

IMPACT:
This study has developed and will complete preliminary evaluations for a Web-based intervention for OIF/OEF veterans with clinical or subclinical mental health problems associated with posttraumatic stress disorder (PTSD), major depressive disorder (MDD), or substance abuse. The intervention is technologically sophisticated, interactive, and designed to educate veterans about healthy coping strategies and relevant VA resources. Data from this project has provided insight into innovative strategies to assist in addressing mental health and substance use problems in OIF/OEF veterans, and has implications for overcoming barriers to treatment participation and service utilization among veterans likely to benefit from formal treatment.

PUBLICATIONS:

Journal Articles

1. Price M, Gros DF, McCauley JL, Gros KS, Ruggiero KJ. Nonuse and dropout attrition for a web-based mental health intervention delivered in a post-disaster context. Psychiatry. 2013 Jan 8; 75:(3):267-84.
2. Strachan M, Gros DF, Ruggiero KJ, Lejuez CW, Acierno R. An integrated approach to delivering exposure-based treatment for symptoms of PTSD and depression in OIF/OEF veterans: preliminary findings. Behavior Therapy. 2012 Sep 1; 43(3):560-9.

Conference Presentations

1. Ruggiero KJ, Gros DF, Acierno R, Price M, Strachan M. The role of social support in the treatment of PTSD in OEF/OIF Veterans. Poster session presented at: Association for Behavioral and Cognitive Therapies Annual Convention; 2011 Nov 10; Toronto, Canada.
2. Ruggiero KJ, Stauffacher K, Resnick HS, Wolinsky-Taylor K, Zinzow H, Ruscio A, Schmidt NB, Acierno RE. Web-based intervention for postdisaster mental health: Preliminary efficacy data. Presented at: Association for Behavioral and Cognitive Therapies Annual Convention; 2010 Nov 18; San Francisco, CA.

DRA: Substance Abuse and Addiction, Mental, Cognitive and Behavioral Disorders, Military and Environmental Exposures
DRE: Prevention, Treatment - Observational
Keywords: Depression, Dual diagnosis – substance abuse and mental health, Operation Enduring Freedom, PTSD, Rural, Substance Use and Abuse, Telemedicine/Telehealth
MeSH Terms: none