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IAC 06-266 – HSR&D Study

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IAC 06-266
Participation in PTSD: Who Starts, Who Stays and Who Drops Out
Michele R. Spoont PhD
Minneapolis VA Health Care System, Minneapolis, MN
Minneapolis, MN
Funding Period: July 2007 - June 2010

BACKGROUND/RATIONALE:
PTSD increases risks for poverty, unemployment, hospitalization, substance abuse, and chronic medical conditions. In direct costs alone, the VA's provision of compensation and treatment to veterans with PTSD exceeds $1.2 billion dollars annually. How can the human and institutional costs of PTSD be minimized? Although many factors contribute to PTSD's chronicity, one particularly notable factor is inconsistent treatment participation. About three-quarters patients receiving VA outpatient PTSD treatment participate only episodically, with long periods of non-use interspersed between episodes of care. Our pilot study sampled over a one year period veterans with no non-substance abuse mental health-related visits in the prior year who received a PTSD diagnosis (n=20,284). In the six months after the index PTSD-related episode, 36% received no follow-up care and only 18% received an adequate trial of antidepressants. Of great concern is the fact that women and racial minorities were even less likely to receive an adequate antidepressant trial. In order to replicate and determine the implications of this finding, models of treatment receipt would need to include factors associated with illness severity, functioning, and perceived need for care.

OBJECTIVE(S):
1) Fill the gap in the PTSD treatment evidence base by ascertaining rates and extent of treatment participation among veterans for whom PTSD was recently identified as a problem, 2) Identify patient, treatment and contextual factors associated with treatment drop-out or lack of follow-up in the six months following receipt of a PTSD diagnosis, 3). Identify specific targets in the PTSD treatment pathway amenable to intervention.

METHODS:
To determine factors predicting treatment participation, this study uses a longitudinal panel design to follow veterans from an initial diagnosis of PTSD through the subsequent six months. The study will sample nationally and stratify by race, ethnicity and gender, since these groups are of primary interest. Primary outcome measures : 1) the presence or absence of participation in behavioral counseling and/or pharmacotherapy, and 2) among those in treatment, the presence or absence of a minimally adequate trial of treatment. Outcome measures will be determined by administrative data. Participants were surveyed twice -- immediately following the index appointment and six months later. The initial survey will assessed variables believed to impact PTSD treatment behavior: race, ethnicity, gender, beliefs about PTSD and MH treatment, PTSD symptoms, physical and mental health quality of life, treatment access, satisfaction with care and whether the facility in which they were diagnosed has specialty PTSD services. Administrative data, including demographics, diagnoses, pharmacy information and utilization of MH services, were extracted for each participant for the six months following the index appointment. Non-response bias was addressed by using imputation techniques and propensity scores. Simple regression models were constructed to predict treatment receipt.

FINDINGS/RESULTS:
In the population of veterans recently diagnosed with PTSD, only 55% received either an antidepressant or some psychotherapy in the six months following the diagnosis. Only about half of those who received a prescription for antidepressants received four 30-day supplies, and less than 20% who had any psychotherapy received at least eight sessions. The final surveyed sample consisted of 7,645 veterans (RR=65.6%). Regression models of outcome measures demonstrated that both patient and facility factors influenced the odds of whether veterans received treatment, what type of treatment they received and whether they received a minimally adequate trial of care.

IMPACT:
This study provides information about systems and patient factors that affect whether a veteran newly diagnosed with PTSD receives mental health treatment, what kind of treatment is received and whether they remain in treatment long enough to get some benefit. Possible targets for intervention include expansion of strategies used to engage OEF/OIF veterans in treatment to the larger population of veterans suffering from PTSD, further expansion of mental health care into community based outpatient clinics, and development of interventions that address veterans' concerns about treatment harms or lack of efficacy.

PUBLICATIONS:

Journal Articles

  1. Valenstein-Mah H, Kehle-Forbes S, Nelson D, Danan ER, Vogt D, Spoont M. Gender differences in rates and predictors of individual psychotherapy initiation and completion among Veterans Health Administration users recently diagnosed with PTSD. Psychological trauma : theory, research, practice and policy. 2019 Jan 28.
  2. Spoont MR, Sayer NA, Kehle-Forbes SM, Meis LA, Nelson DB. A Prospective Study of Racial and Ethnic Variation in VA Psychotherapy Services for PTSD. Psychiatric services (Washington, D.C.). 2017 Mar 1; 68(3):231-237.
  3. Spoont MR, Nelson DB, Murdoch M, Sayer NA, Nugent S, Rector T, Westermeyer J. Are there racial/ethnic disparities in VA PTSD treatment retention? Depression and anxiety. 2015 Jun 1; 32(6):415-25.
  4. Sayer NA, Hagel EM, Noorbaloochi S, Spoont MR, Rosenheck RA, Griffin JM, Arbisi PA, Murdoch M. Gender differences in VA disability status for PTSD over time. Psychiatric services (Washington, D.C.). 2014 May 1; 65(5):663-9.
  5. Spoont MR, Nelson DB, Murdoch M, Rector T, Sayer NA, Nugent S, Westermeyer J. Impact of treatment beliefs and social network encouragement on initiation of care by VA service users with PTSD. Psychiatric services (Washington, D.C.). 2014 May 1; 65(5):654-62.
  6. Gravely AA, Cutting A, Nugent S, Grill J, Carlson K, Spoont M. Validity of PTSD diagnoses in VA administrative data: comparison of VA administrative PTSD diagnoses to self-reported PTSD Checklist scores. Journal of rehabilitation research and development. 2011 Jan 1; 48(1):21-30.
  7. Bangerter A, Gravely A, Cutting A, Clothier B, Spoont M, Sayer N. Brief report: Comparison of methods to identify Iraq and Afghanistan war veterans using Department of Veterans Affairs administrative data. Journal of rehabilitation research and development. 2010 Nov 9; 47(8):815-21.
  8. Spoont MR, Murdoch M, Hodges J, Nugent S. Treatment receipt by veterans after a PTSD diagnosis in PTSD, mental health, or general medical clinics. Psychiatric services (Washington, D.C.). 2010 Jan 1; 61(1):58-63.
  9. Spoont MR, Hodges J, Murdoch M, Nugent S. Race and ethnicity as factors in mental health service use among veterans with PTSD. Journal of traumatic stress. 2009 Dec 1; 22(6):648-53.
Center Products

  1. Spoont MR. PTSD Treatment Disparities. PTSD Consultation Program Lecture Series 2015. 2015 Apr 15.
VA Cyberseminars

  1. Spoont MR, Nelson DB, Murdoch M, Sayer NA, Rector TS, Westermeyer J. Racial and Ethnic Disparities in PTSD Treatment: Findings from a National Cohort Study. [Cyberseminar]. 2015 Jun 24.
Conference Presentations

  1. Spoont MR, Nelson DB, Kehle-Forbes SM, Meis LA. Inequity in Psychotherapy Services among Racial and Ethnic Minority Veterans with PTSD. Presented at: VA HSR&D / QUERI National Meeting; 2015 Jul 10; Philadelphia, PA.
  2. Spoont MR, Nelson DB, Murdoch M, Sayer NA, Nugent SM, Rector TS, Westermeyer J. Recommendations to VHA leadership to Address Racial and Ethnic Disparities in VHA Treatment of PTSD: Prepared for the Office of Health Equity and Performance. Paper presented at: VA Office of Health Equity and Performance Meeting; 2015 Jan 30; Washington, DC.
  3. Spoont MR, Nelson DB, Alegria M, Van Ryn M. Patients’ perceptions of their providers and retention in PTSD pharmacotherapy. Poster session presented at: International Society for Traumatic Stress Studies Annual Symposium; 2014 Nov 8; Miami, FL.
  4. Spoont MR, Nelson DB, Kehle-Forbes SM, Meis LA, Bass D. Veteran race/ethnicity and variation in adjunctive pharmacotherapy for PTSD. Poster session presented at: International Society for Traumatic Stress Studies Annual Symposium; 2014 Nov 6; Miami, FL.
  5. Spoont MR, Nelson DB, Murdoch M, Rector TS, Sayer NA. Do Veterans with PTSD Receive Evidence Based Antidepressants? Paper presented at: International Society for Traumatic Stress Studies Annual Meeting; 2012 Nov 1; Los Angeles, CA.
  6. Spoont MR, Nelson DB, Sayer NA, Murdoch M, Rector TS. Predictors of Mental Health Treatment Engagement: A Prospective Cohort Study of Veterans Recently Diagnosed with PTSD. Poster session presented at: VA HSR&D / QUERI National Meeting; 2012 Jul 16; National Harbor, MD.
  7. Spoont MR, Sayer NA, Murdoch M, Rector TS, Westermeyer J, Hodges JS, Nugent SM. A preliminary look at perceived mental health treatment needs in a national sample of veterans with PTSD. Paper presented at: VA HSR&D National Meeting; 2009 Feb 12; Baltimore, MD.


DRA: Military and Environmental Exposures, Mental, Cognitive and Behavioral Disorders
DRE: Epidemiology, Treatment - Observational, Prevention
Keywords: Operation Enduring Freedom, Operation Iraqi Freedom, PTSD
MeSH Terms: none