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RRP 10-056 – HSR&D Study

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RRP 10-056
Treatment Preferences and Barriers in OIF Soldiers with mild TBI and/or PTSD
Shannon M. Kehle-Forbes PhD
Minneapolis VA Health Care System, Minneapolis, MN
Minneapolis, MN
Funding Period: July 2010 - June 2011

BACKGROUND/RATIONALE:
PTSD is the most deleterious mental health diagnosis among OEF/OIF veterans and there is concern that a history of mild traumatic brain injury (mTBI) may further complicate the presentation and treatment of PTSD. Thus, it is imperative to identify and implement best practices for veterans with a history of mTBI and PTSD. However, there is a lack of research on how to best treat such veterans. As such, experts in the field have suggested that clinicians utilize existing best practices for individually occurring mTBI and PTSD. To date, the extent to which veterans with a history of mTBI and/or PTSD receive best practices is unknown and predictors of receiving such care have not been examined.

OBJECTIVE(S):
The primary objective of the proposed study was to examine the receipt of best practices and to identify barriers to PTSD treatment among veterans with a history of mTBI. Specifically, our primary aims were to (1) describe the rehabilitation and mental health treatment history, with a focus on receipt of best practices, among OIF deployed veterans with a history of mTBI and/or PTSD and (2) better understand PTSD treatment seeking among veterans with and without a history of mTBI.

METHODS:
This project gathered a third wave of longitudinal (in-theater and one-year postdeployment data already collected) data from a panel of National Guard soldiers (OIF veterans) deployed to Iraq from March 2006 to July 2007. Using self-report survey methodology, we assessed mental health and rehabilitation treatment history and patient-level factors hypothesized to impact treatment-seeking. Semi-structured phone interviews were conducted with Veterans who screened positive for PTSD on the Posttraumatic Checklist (PCL) in order to further assess attitudes and preferences. Veterans were read descriptions of two treatments for PTSD (PE and sertraline). Participants were asked which treatment they would choose to help with trauma related symptoms, their reactions to the treatments (credibility and personal reactions), what factors influenced that choice, and potential barriers to participation.

FINDINGS/RESULTS:
Surveys were mailed to 895 participants (25 Veterans were deployed, 27 were untrackable, and 5 requested not to be contacted again). 563 Veterans returned completed surveys (63% of those who received surveys; 59% of one year post-deployment sample). Preliminary analyses found that 16.2% (n = 91) of Veterans screened positive for PTSD on the Posttraumatic Checklist (PCL); 24.2% reported experiencing a mTBI while deployed to Iraq.

Based on preliminary analyses, nearly one-half (47.2%) of Veterans received a psychosocial treatment for a mental health condition in the past two years; 22.4% reported receiving psychiatric medications. 6.6% of Veterans reported engagement in cognitive rehabilitation services. Veterans who screened positive for PTSD were significantly more likely to have received psychosocial treatments (76.9% vs. 41.4%, 2= 38.51, p < .001), psychiatric medications (59.3% vs. 15.0%, 2= 86.41, p < .001), and cognitive rehabilitation (18.7% vs. 4.1%, 2= 26.86, p < .001) than those without PTSD. Similarly, Veterans who screened positive for mTBI while in Iraq were significantly more likely to have received psychosocial treatments (64.7% vs. 41.7%, 2= 21.93, p < .001), psychiatric medications (38.2% vs. 17.3%, 2= 25.95, p < .001), and cognitive rehabilitation (19.9% vs. 2.3%, 2= 51.51, p < .001) than those without an in-theater history of mTBI. In regard to receipt of best practices, 5.9% of Veterans reported receiving either prolonged exposure therapy (PE) or cognitive processing therapy (CPT) for PTSD. Veterans who sustained a mTBI in Iraq were more likely to have received PE / CPT than Veterans without a history of mTBI (13.7% vs. 3.7%, 2= 17.01, p < .001). 22.8% of Veterans who sustained a mTBI reported receiving education about natural recovery from mTBI.

We conducted a series of preliminary logistical regressions to determine the impact of mTBI, PTSD symptomology, attitudes towards psychotherapy and medication, self-efficacy, and ambiguous symptom interpretation style (normalizing, physical, emotional) on the receipt of psychosocial treatment ( 2 (8, N = 539) = 11.76, p = .16), psychiatric medications ( 2 (8, N = 539) = 6.60, p = .58), and PE and/or CPT ( 2 (8, N = 517) = 4.24, p = .84). As indicated above, the Hosmer and Lemeshow fit statistic indicated that all three models were a good fit for the data. Emotional symptom interpretation style, PTSD symptomology, beliefs about medication, and mTBI status were each significantly associated with self-reported treatment engagement in at least one of the three models.

We completed interviews with 59 of the 91 Veterans (65%) who screened positive for PTSD. 53.4% of those interviewed said they would choose to participate in PE, 36.2% preferred SSRI treatment, and 8.6% chose no treatment. Those interviewed found PE (M = 4.88, SD = 1.23) to be significantly more credible than sertraline (M = 4.05, SD = 1.54; t(56) = 3.17, p = .002). They also had more favorable personal reactions to PE (M = 4.87, SD = 1.52) than sertraline (M = 3.46, SD = 1.80; t(57) = 4.39, p < .001). mTBI status did not significantly impact Veterans' choice of treatment or their ratings of the treatments (credibility and personal reactions). Preliminary qualitative analyses suggest that the primary reasons for treatment choice were past experiences with either psychotherapy or medication and beliefs about the efficacy of the treatments. The primary barrier to engaging in their chosen treatment was time to attend sessions and engage in the treatment.

IMPACT:
This project is the first to provide data regarding the impact of mTBI on the receipt of evidence-based treatment for PTSD and rates of early education for those who sustained an mTBI. Preliminary results suggest that a history of mTBI does not negatively impact mental health treatment seeking or participation in evidence-based treatments for PTSD. While opinions regarding evidence-based psychotherapies for PTSD were largely positive, engagement in PE/CPT was minimal. Continued research into strategies to improve receipt of evidence-based strategies for PTSD and mTBI are needed.

PUBLICATIONS:

Journal Articles

  1. Meis LA, Erbes CR, Kramer MD, Arbisi PA, Kehle-Forbes SM, DeGarmo DS, Shallcross SL, Polusny MA. Using reinforcement sensitivity to understand longitudinal links between PTSD and relationship adjustment. Journal of family psychology : JFP : journal of the Division of Family Psychology of the American Psychological Association (Division 43). 2017 Feb 1; 31(1):71-81.
  2. Kehle-Forbes SM, Polusny MA, Erbes CR, Gerould H. Acceptability of prolonged exposure therapy among U.S. Iraq war veterans with PTSD symptomology. Journal of traumatic stress. 2014 Aug 1; 27(4):483-7.
Conference Presentations

  1. Kehle-Forbes SM, Polusny MA, Erbes CR, Meis LA, Arbisi PA. Treatment Preferences and Barriers in OIF Soldiers with PTSD and/or mTBI. Paper presented at: Association for Behavioral and Cognitive Therapies Annual Convention; 2011 Nov 12; Toronto, Ontario, Canada.
  2. Kehle-Forbes SM, Polusny MA, Meis LA, Erbes CR, Arbisi PA, Marut E. PTSD Treatment Choice among OIF Veterans. Paper presented at: Association for Behavioral and Cognitive Therapies Annual Convention; 2011 Nov 12; Toronto, Canada.


DRA: Military and Environmental Exposures, Mental, Cognitive and Behavioral Disorders, Acute and Combat-Related Injury, Brain and Spinal Cord Injuries and Disorders
DRE: Treatment - Observational
Keywords: Patient preferences, PTSD, QUERI Implementation, Traumatic Brain Injury
MeSH Terms: none

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