Spotlight: June 27: National PTSD Awareness Day
The United States Senate has designated June 27th as National PTSD Awareness Day. Post-traumatic stress disorder (PTSD) is an anxiety disorder that results from exposure to a single or multiple traumatic events, which can include: sexual or physical assault, natural or man-made disaster, and war-related combat stress. The person who develops PTSD may be the one who was harmed, but it also can be the person who witnesses a harmful event that happened to loved ones or strangers who develop symptoms of PTSD. Symptoms of PTSD generally fall under three categories:
- Re-experiencing symptoms
- Bad dreams
- Frightening thoughts.
- Avoidance symptoms
- Staying away from places or objects that are reminders of the experience
- Losing interest in activities that once brought pleasure
- Having trouble remembering the traumatic event.
- Hyper-arousal symptoms
- Being easily startled
- Feeling tense
- Difficulty sleeping and/or angry outbursts.1
Untreated PTSD can become chronic and lead to hospitalization, unemployment, poverty, suicide, and poor health. A national study of a nationally representative sample of more than 9,000 Americans aged 18 years and older that was conducted between February 2001 and April 2003 showed that the lifetime prevalence of PTSD was 7%.2 However, other studies have shown that the prevalence of PTSD among Veterans is much higher; for example, it is estimated to be 9%-15% among Vietnam Veterans, and 10%-20% among Veterans of the Iraq and Afghanistan wars.3
HSR&D and Research on Post-Traumatic Stress Disorder
Following are descriptions of just a few select studies that HSR&D and QUERI investigators conduct on PTSD research.
Telemedicine-based Collaborative Care Improves PTSD Outcomes among Veterans in Rural Settings
A large portion (38%) of VA enrollees diagnosed with PTSD live in rural areas, and two-thirds live closer to a community-based outpatient clinic (CBOC) than a large VA medical center. Supported by HSR&D, this randomized trial sought to test a collaborative care model designed to improve access to and engagement in evidence-based psychotherapy and pharmacotherapy for Veterans with PTSD living in rural settings. Investigators developed the Telemedicine Outreach for PTSD (TOP) intervention, in which an off-site PTSD care team used telemedicine technologies to support the PTSD treatment delivered by CBOC providers. Off-site PTSD care teams included telephone nurse care managers, telephone pharmacists, tele-psychologists, and tele-psychiatrists. Nurses conducted care management activities, pharmacists reviewed medication histories, and psychologists delivered Cognitive Processing Therapy (CPT). Veterans (n=265), who were enrolled from 2009-2011, were randomized to the TOP intervention (n=133) or usual care (n=132) and were followed for 12 months. Findings show:
- Telemedicine-based collaborative care successfully engaged Veterans who lived in rural settings in evidence-based psychotherapy to improve PTSD outcomes. During the 12-month study period, 55% of the Veterans randomized to TOP received CPT compared to 12% of Veterans that were randomized to usual care.
- Veterans in the TOP group had significantly larger decreases in PTSD symptoms compared to Veterans in the usual care group - a 5.31 decrease in symptom severity on the Posttraumatic Diagnostic Scale at six months, on average, compared to 1.07 for Veterans in usual care (a 5-point decrease in the Scale represents a decrease in frequency from 2 to 4 times a week to once a week for 5 symptoms of PTSD).
- The TOP group had significantly greater reductions in depression symptom severity compared to usual care at both six and twelve months.
Fortney J, Pyne J, Kimbrell T, et al. Telemedicine-based collaborative care for post-traumatic stress disorder: A randomized clinical trial. JAMA Psychiatry. January 2015;72(1):58-67.
Social Network Encouragement Helps Veterans with PTSD Seek VA Mental Healthcare
This HSR&D study sought to determine whether beliefs about mental health treatment and/or social encouragement to seek treatment influence initiation of mental healthcare among Veterans with PTSD. Using VA data, investigators identified Veterans recently diagnosed with PTSD (between June 2008 and July 2009) who were not receiving VA mental healthcare. Within two weeks of a diagnosis of PTSD by a VA clinician, Veterans were sent a survey that assessed PTSD severity, mental health quality of life, anticipated access barriers, treatment-related beliefs, and whether VA healthcare users received encouragement from those in their social network (i.e., family members, friends and/or other Veterans) to seek care. Of those surveyed, 7,645 Veterans responded. VA administrative data were used to identify demographic and facility-level determinants of care - and to determine whether Veterans initiated VA mental healthcare in the six months after the PTSD diagnosis was made. Findings show:
- Whether Veterans initiate mental healthcare after a PTSD diagnosis depends not only on symptom severity and access to treatment, but also on encouragement by those in their social network, whether the Veteran perceives the need for treatment, how they view treatment for PTSD (e.g., positive beliefs about the efficacy of antidepressants), as well as their ability to follow treatment recommendations (i.e., self-efficacy).
- Encouragement to seek mental healthcare by individuals in their social network increased the odds of getting treatment, even after controlling for beliefs, particularly if encouragement was given by both family and friends/other Veterans.
These results suggest that involving family members and others in Veterans' social networks, as well as addressing treatment-related beliefs, may be effective strategies to engage more Veterans with PTSD in mental health treatment.
Spoont M, Nelson D, Murdoch M, et al. Impact of treatment beliefs and social network encouragement on initiation of care by VA service users with PTSD. Psychiatric Services. May 2014;65(5):654-662.
VA PACT Implementation Increases Primary Care among Veterans with PTSD
VA implemented a version of the patient-centered medical home (PCMH) called Patient Aligned Care Teams (PACT) in 2010. This HSR&D study assessed the association between PACT and the use of health services among Veterans with PTSD. VA clinical and administrative data were obtained for the pre-PACT period (April 1, 2009 to March 31, 2010) and the post-PACT period (June 1, 2011 to May 31, 2012) on nearly 700,000 unique Veterans. Investigators examined outcomes that included hospitalizations, primary, specialty, and mental health visits, as well as emergency department (ED) and urgent care visits. Findings show:
- The period following PACT implementation was associated with lower rates of hospitalization and specialty care visits and a higher rate of primary care visits for Veterans with PTSD, indicating enhanced access to primary care.
- Adjusted results show a 9% decrease in hospitalizations, an 8% decrease in specialty care, and an 11% increase in primary care visits in the post-PACT period. No significant effects were found on mental health, ED, or urgent care visits.
- For Veterans younger than 65 years, findings mirrored the full sample. However, for Veterans older than 65 years, there were significant increases in both primary and specialty care visits, significant decreases in urgent care visits, and no significant decrease in hospitalizations.
These results suggest that the increased rate of primary care visits after PACT implementation holds promise to improve the quality of primary care over time - and to further reduce mental and physical illness exacerbations that can lead to specialty care, hospitalizations, and ED and urgent care visits.
Randall I, Mohr D, and Maynard C. VHA patient-centered medical home associated with lower rate of hospitalizations and specialty care among Veterans with post-traumatic stress disorder. Journal of Healthcare Quality. November 10, 2014; Epub ahead of print.
PTSD Treatment via Video-Teleconferencing as Effective as In-Person Treatment
One efficacious treatment for PTSD is Cognitive Processing Therapy (CPT) - a trauma-focused psychotherapy that can be delivered in individual or group formats. CPT targets the cognitive symptoms of PTSD, and CPT-cognitive only (CPT-C) therapy is a variant of this therapy. This study, partly funded by HSR&D, is the first randomized controlled trial to compare the efficacy of delivering CPT-C via video-teleconferencing (VTC) to in-person delivery among a sample of Veterans living in rural settings. Investigators enrolled 125 male Veterans from four VA healthcare facilities across the Hawaiian Islands; of these patients, 64 received in-person treatment and 61 received treatment via VTC. Approximately 77% of Veterans completed treatment by attending at least 10 of the 12 group treatment sessions, which occurred twice each week over six weeks. Veterans were assessed at baseline, mid-treatment, immediately post-treatment, and 3 and 6 months post-treatment. Measures included attrition, treatment adherence, patient satisfaction, treatment expectancy, and group therapeutic alliance. Findings show:
- The use of VTC services to provide CPT-C therapy to Veterans with PTSD who lived in rural settings was found to be as effective as face-to-face treatment. Significant reductions in PTSD symptoms were identified at post-treatment and 3- and 6-month follow-ups.
- High levels of therapeutic alliance, treatment compliance, and satisfaction, and moderate levels of treatment expectancies were reported, with no differences between groups. For example, at post-treatment, Veterans reported high levels of satisfaction with both in-person and VTC therapies, rating 11 of 14 items on the satisfaction scale as "very good" or "excellent."
Morland L, Mackintosh M, Greene C, et al. Cognitive processing therapy for post-traumatic stress disorder delivered to rural Veterans via telemental health: A randomized non-inferiority clinical trial. Journal of Clinical Psychiatry. May 2014;75(5):470-76.
Racial/Ethnic Disparities in Treatment Retention for Veterans with PTSD
Many Veterans with PTSD do not receive sufficient treatment to ensure clinical benefits. This HSR&D study of 6,788 Veterans (44% White, 20% Hispanic or Latino, and 19% African-American) recently diagnosed with PTSD sought to determine whether the odds of premature mental health treatment termination varied by patient race/ethnicity, and, if so, whether such variation is due to differences in treatment need or treatment-related beliefs, differential access to services, or whether there is a disparity in the provision of treatment. Using VA data, investigators identified Veterans who had been recently diagnosed with PTSD during an outpatient visit at any VA facility from June 2008 to July 2009 and sent them a survey within two weeks of that diagnosis. The survey assessed barriers, treatment need, and treatment beliefs. VA data were used to assess mental health treatment across racial/ethnic groups in the six months following diagnosis. For this study, three dichotomous outcome measures reflecting a "minimal" trial of PTSD treatment were: 1) at least eight therapy sessions, 2), at least four 30-day supplies of antidepressants, and 3) either eight therapy sessions or four 30-day antidepressant supplies. Findings show:
- Compared to white Veterans, African-American and Latino Veterans were less likely to receive a minimal trial of pharmacotherapy, and, overall, African-Americans were less likely to receive a minimal trial of any treatment in the six months after being diagnosed with PTSD.
- Controlling for beliefs about mental health treatments diminished the lower odds of pharmacotherapy retention among Latino Veterans, but not African-American Veterans.
- As expected, positive beliefs about psychotherapy or pharmacotherapy facilitated treatment retention.
- Access barriers did not contribute to treatment retention disparities. They significantly impacted psychotherapy participation, but equally across the entire sample.
Study results suggest that there are racial and ethnic disparities in PTSD treatment.
Spoont M, Nelson D, Murdoch M, et al. Are there racial/ethnic disparities in VA PTSD treatment retention? Depression and Anxiety. November 24, 2014; Epub ahead of print.
1. National Institute of Mental Health. Post-traumatic Stress Disorder (PTSD).
2. National Institute of Mental Health. Epidemiology of PTSD.
3. Morland L, Mackintosh M, Greene C, et al. Cognitive processing therapy for post-traumatic stress disorder delivered to rural Veterans via telemental health: A randomized non-inferiority clinical trial. Journal of Clinical Psychiatry. May 2014;75(5):470-76.
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