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PTSD Treatment and Suicide Prevention: VA Research Contributions and Priorities

In this issue's commentary article, Dr. Zeiss discusses expansion of VA Mental Health Services and post-traumatic stress disorder (PTSD) treatment initiatives in the VA; she points out the importance of Clinical Practice Guidelines as a means for improving clinical care. She further discusses how the VA has not only published and updated PTSD treatment guidelines in conjunction with the DoD, but has also taken impressive, practical steps to ensure that guideline recommendations can be implemented.

Following the growing evidence for psychotherapies for PTSD, the VA leadership chose not to simply rely on dissemination of guidelines to make changes in VA clinician practices, but proceeded with a massive and unprecedented effort to "train up" and support VA mental health clinicians in providing these established PTSD psychotherapies.1 Starting in 2005-2006, the VA increased its mental health workforce capacity, hiring additional clinicians, beginning ongoing, systematic training of these clinicians, and conducting systems reorganization to support the provision of evidence-based psychotherapies.

As of May 2010, over 2,700 VA mental health clinicians had received training in either Prolonged Exposure (PE) or Cognitive Processing Therapy (CPT) for PTSD, through multi-day, in-person trainings, and weekly systematic consultation and small group supervision. VA has also placed local evidence-based psychotherapy coordinators at each medical facility to champion implementation of these treatments and to work with site leadership to organize clinic flow for improved treatment implementation. Importantly, an implementation model that established structures and processes to maintain the use of these therapies after the initial training period was developed.

This ambitious effort raises new questions regarding systems change and maintenance. Both CPT and PE require weekly delivery of treatment sessions for multiple weeks, presenting a challenge in busy VA clinics facing rising numbers of returning Veterans from the OEF/OIF conflicts. Engaging Veteran patients in completing treatment is also a challenge, with HSR&D researchers recently reporting that only a small minority (9.5 percent) of OEF/OIF Veterans with new PTSD diagnoses attended nine or more VA mental health sessions within 15 weeks in the first year following their diagnosis.2 Moving to decentralized training and maintaining clinician expertise over time presents additional challenges. VA implementation scientists have the opportunity to substantially contribute in these areas, studying factors that affect the maintenance and improvement of the system capacities to provide these complex psychotherapies to increasing numbers of Veterans with need.

The commentary article's co-author, Dr. Kemp, outlines a second area of considerable effort on the part of VA Office of Mental Health Services'suicide prevention. As she discusses, suicide prevention is integral to the VA mental health services efforts, and enormous resources have been devoted to decreasing suicide among VA Health System users and among Veterans in the community. These efforts have included increasing overall mental health capacity and quality, such as the efforts described above to improve capacity and care for PTSD. Efforts have also included suicidespecific interventions, such as the Veteran Suicide Hotline and placing Suicide Prevention Coordinators (SPCs) and Care Managers at each VA facility. The VA Crisis Line is one of the few crisis lines that can, with the Veteran's permission, integrate the call into the Veteran's medical record and facilitate the connecconnection of callers to VA care through outreach by Suicide Prevention Coordinators.

However, despite these efforts, the evidence base for suicide prevention interventions remains limited and the goal of rapidly reducing the suicide rate has remained elusive both within the VA and nationwide.

VA HSR&D researchers have conducted a synthesis of the evidence-based literature on suicide prevention, finding that although some approaches'such as multi-component intervention in military populations are promising, the quality of evidence for this and most other suicide prevention strategies is low, meaning that further research is likely to have an important impact on or change the estimate of the effect.3 Unfortunately, insufficient studies exist of suicide prevention programs specifically in Veterans from which to draw conclusions, and no studies exist that assessed the specific effectiveness of hotlines, outreach programs, peer counseling, treatment coordination programs, and other important care initiatives on suicide rates.

Thus, there is a clear need for further randomized controlled trials and high-quality observational studies to advance knowledge in the area of suicide prevention. HSR&D research is well-positioned to contribute in this high priority area for the VA, working in tandem with the Office of Mental Health Services on evaluating the impact of current efforts to reduce suicide risks and on implementing the strategies that are most effective.

  1. Karlin, B.E. et al. "Dissemination of Evidence-based Psychological Treatments for Posttraumatic Stress Disorder in the Veterans Health Administration," Journal of Traumatic Stress 2010;23(6):663-73.
  2. Seal, K.H. et al. "VA Mental Health Services Utilization in Iraq and Afghanistan Veterans in the First Year of Receiving New Mental Health Diagnoses," Journal of Traumatic Stress 2010;23(1):5-16.
  3. Bagley, S.C. et al. "A Systematic Review of Suicide Prevention Programs for Military or Veterans," Journal of Suicide and Life Threatening Behavior 2010;40(3):257-65.

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