2023 HSR&D/QUERI National Conference
1071 — Results from a Pragmatic Randomized Clinical Trial of Clinician Supported PTSD Coach in VA Primary Care Patients
Lead/Presenter: Kyle Possemato, VA Center for Integrated Healthcare
All Authors: Possemato K (VA Center for Integrated Healthcare), Johnson EM (VA Center for Integrated Healthcare, Syracuse) Barrie, K (VA Center for Integrated Healthcare, Syracuse) Puran, D (National Center for PTSD, Palo Alto) Ghaus, S (National Center for PTSD, Palo Alto) Rosen, C (National Center for PTSD, Palo Alto & Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine) Cloitre, M ((National Center for PTSD, Palo Alto & Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine) Owen, J (National Center for PTSD, Palo Alto) Jain, S (National Center for PTSD, Palo Alto & Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine) Beehler, G (VA Center for Integrated Healthcare, Syracuse) Prins, A (National Center for PTSD, Palo Alto) Seal, K (San Francisco VA Health Care System & Departments of Medicine and Psychiatry, U of California, San Francisco) Kuhn, E (National Center for PTSD, Palo Alto & Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine)
PTSD is common in VA primary care patients; however, evidence-based treatments are typically only offered in specialty mental health settings and often not accessed by Veterans due to patient and system-level barriers. This study tested whether a brief, scalable treatment in primary care increased access to effective PTSD treatment. Clinician Supported PTSD Coach (CS PTSD Coach) was designed to be implemented in VAâ€™s Primary Care Mental Health Integration (PCMHI) system and combines mental health clinician support with the widely used â€œPTSD Coachâ€ VA mobile app. We hypothesized that CS PTSD Coach would be superior to PCMHI Treatment as Usual (TAU) in 1) reducing PTSD (measured by clinician-rated and self-report assessments), 2) engaging Veterans in initial and continued mental health care (measured by engagement in two sessions of specialty care post-study intervention) and 3) patient satisfaction with care.
A multi-site randomized pragmatic clinical trial of CS PTSD Coach vs. PCMHI TAU enrolled a diverse sample of 233 Veterans with PTSD who were not currently accessing PTSD treatment. CS PTSD Coach is intended to be delivered in four 30-minute sessions and encourages daily use of symptom management strategies guided by the app. CS PTSD Coach was designed to match patient preferences for a flexible approach that can be delivered in person or virtually, and respects Veteransâ€™ desire for self-reliance. It uses the VHA stepped-care model: Veterans who continue to have PTSD symptoms (PTSD Checklist-5 [PCL-5] ? 33) after 4 sessions are offered facilitated referrals to specialty mental health services. Outcomes were measured at 2 (post-treatment), 4, and 6 months.
Clinician-rated PTSD symptoms did not significantly differ by condition at post-treatment. However, Veterans randomized to CS PTSD Coach were more likely to 1) drop below 33 on the PCL-5 (Coach 41%, TAU 26%, p = .014), 2) have larger decreases in patient-reported PTSD symptoms at post-treatment (Coach M[SD] = 9.9 [12.8] points, TAU M[SD] = 6.5 points, p < . 05) and 3) maintain symptom gains though 6-month follow-up compared to PCMHI TAU. Veterans randomized to CS PTSD Coach were more likely to access mental health care during the intervention period (p = .019) and continued to have more engagement in care than TAU in the follow-up period (p < .001). Among participants who continued to have significant symptoms of PTSD at post-treatment, 36% of CS PTSD Coach participants and 25% of TAU participants engaged in two specialty mental health care visits post study intervention (p = .097). Patients reported significantly higher treatment satisfaction with CS PTSD Coach than TAU (p < .001).
A structured 4-session intervention that matches Veteran preferences for care resulted in high patient satisfaction, better initial and continued mental health access and more self-reported symptom relief but not a larger reduction in clinician-rated PTSD symptoms compared to treatment as usual.
Brief mental health interventions for PTSD can be provided in VA primary care. Clinician Supported PTSD Coach results in greater patient-report PTSD symptom relief and more engagement in mental health care than PCMHI Treatment as Usual.