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:
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
Following are descriptions of just a few select studies that HSR&D and QUERI investigators conduct on PTSD research.
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:
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.
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:
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 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:
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.
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:
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.
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:
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.
If you are a Veteran in crisis, there are qualified and caring VA responders available 24/7 at 1-800-273-8255 and Press 1, or send a text message to 838255. You also may chat online.