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IIR 11-091 – HSR&D Study

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IIR 11-091
Evaluation and Treatment of Substance Use in Veterans with PTSD Disability Claims
Marc I. Rosen MD
VA Connecticut Healthcare System West Haven Campus, West Haven, CT
West Haven, CT
Funding Period: April 2013 - March 2017

BACKGROUND/RATIONALE:
Post-deployment screening suggests that approximately 10% of veterans returning from OIF endorse screening questions suggesting they have PTSD, and because of these symptoms, are at particularly high risk for alcohol and other substance use disorders. Fully half of all post 9/11-era veterans and a majority of those with PTSD are expected to apply for disability benefits. Claimants undergo the required VA Compensation examination to determine the nature and severity of their disability and ultimately, the amount they will be compensated. Veterans with PTSD symptoms who apply for Compensation benefits are at a crucial stage in their disease course because they are making far-reaching global decisions about whether to consider themselves disabled, what their diagnoses are, and whether to engage in treatment. The disability evaluation presents a perfectly-timed opportunity to evaluate veterans' concomitant substance abuse and offer treatment, but this opportunity is typically missed. There is also much speculation but little data concerning what factors determine which veterans with PTSD attend treatment and the relationship of this attendance to their Compensation claim.

OBJECTIVE(S):
The purpose of this study is to investigate what factors determine which veterans with PTSD attend treatment and the relationship of this attendance to their Compensation claim. The effectiveness of a brief intervention designed to refer post 9/11-era Veterans applying for disability claims to PTSD and/ or substance use treatment will be examined during the clinical trial component.

METHODS:
This study combined both an evaluation and clinical trial component.

In the Evaluative Component, 349 (n=218 in CT, n=131 in TN) post 9/11-era Veterans undergoing PTSD disability evaluations completed an assessment battery consisting of potential predictors of service use outcomes. Timeline Follow-back Substance Use and Service Use Calendars were used to document days of self-reported substance use and days of self-reported service use. An Ethyl Glucoronide test was conducted to test for alcohol use. The SCID substance abuse module was also completed. PTSD severity was measured using the Life Events Checklist and the Clinician Administered PTSD scale (CAPS). Data on attitudes concerning Compensation examinations were collected using the Disability Beliefs Scale and the Disability Application Appraisal Inventory. Other psychological assessments include the Beck Depression Inventory II, the Response to Stressful Experiences Scale, and the Montreal Cognitive Impairment test. The batteries were collected again twice, approximately four and twelve weeks after the baseline assessment. Long-term follow-up data was extracted from VA databases including diagnoses, the results of the Veterans' Compensation evaluations, award determination, use of VA services and attendance at mental health and/or substance abuse treatment.

Approximately half (n=172 total, n=124 in CT, n=48 in TN) of Veterans were identified as having recent (past 28 days) risky substance use (defined as risky alcohol use or self-reported use of an illicit drug) and entered the Clinical Trial Component of the study. Of those, approximately half (n=85) were randomly assigned to an experimental treatment (Screening, Brief Intervention and Referral to Treatment (SBIRT)), and half (n=87) were assigned to a No-Additional-Treatment condition.

SBIRT is an approach to identify and treat patients with substance abuse issues who are presenting for purposes other than substance abuse treatment. The SBIRT intervention consisted of one counseling session with a study therapist who used Motivational Interviewing to facilitate engagement in substance abuse treatment. It involved (1) explaining the purpose of therapy, (2) inquiring about the Veteran's experience with the Compensation examination and addressing questions about the next steps in the disability determination process (including directly addressing issues surrounding a Veterans' concern that obtaining substance abuse treatment may impact their claim), (3) discussing the relationship between PTSD and substance use (substance use as temporary coping), (4) explaining that this is an opportunity to consider if there is any other treatment the Veteran needs, screening for risky substance use and providing feedback, (5) using motivational interviewing concerning seeking substance abuse treatment and abstaining from substance use, and (6) referring interested Veterans to primary substance abuse or PTSD treatment.

Veterans assigned to the No-Additional-Treatment condition did not receive any study-related counseling. This is considered usual care, as Veterans who complete a Compensation examination ordinarily have no further treatment, referral, or debriefing as part of the Compensation exam.

FINDINGS/RESULTS:
In total, 349 Veterans (n=218 from CT, n=213 from TN) were enrolled in the study. The sample was mostly male (86%, n=303), with a median age of 32 (IQR 28-40). About 65% (n=230) of the Veterans identified as White, 18% (n=61) identified as Black, and 12% (n=42) identified as Hispanic. About half of the sample (n=172) reported risky substance use at Baseline.

Being male and having more social supports was significantly associated with a lower likelihood of having a PTSD diagnosis. Having a positive TBI screen was associated with a greater likelihood of having a PTSD diagnosis.

Risky substance use at baseline had no effect on mental health treatment, PTSD treatment, or substance use treatment attendance over time. While the probability of attending mental health and PTSD treatment remained stable over time, the probability of attending substance use treatment decreased over time. While Veterans with risky substance use at baseline had significantly higher probability of substance use compared the Veterans without baseline risky substance use, substance use remained stable over time.

Participants randomized to receive the SBIRT intervention trended toward a greater decrease in substance use over time, compared to participants randomized to treatment-as-usual.

IMPACT:
The analysis of the impact of substance abuse on the course of PTSD and attendance at treatment will suggest what complications in the treatment of dually diagnosed post 9/11-era Veterans might effectively be targeted by addressing their substance abuse. The proposed Evaluative Component analyzes Veteran attitudes about Compensation examinations and their relationship to outcomes. Such opinions and beliefs are likely to be important determinants of outcome, and these beliefs are modifiable.

If SBIRT is effective, it may suggest the utility of a similar integration of assessment and treatment for other Compensation examinations. The study results may hasten the day that a Compensation examination is routinely seen as an opportunity for both evaluation and treatment for returning post 9/11-era Veterans.

PUBLICATIONS:

Journal Articles

  1. Sakr CJ, Black AC, Slade MD, Calfo J, Rosen MI. Iraq/Afghanistan-era Veterans with Back Pain: Characteristics and Predictors of Compensation and Pension Award. Journal of rehabilitation research and development. 2016 Nov 6; 53(6):659-668.
  2. Black AC, McMahon TJ, Potenza MN, Fiellin LE, Rosen MI. Gender moderates the relationship between impulsivity and sexual risk-taking in a cocaine-using psychiatric outpatient population. Personality and Individual Differences. 2015 Mar 1; 75:190-194.
  3. Simoni JM, Huh D, Wang Y, Wilson IB, Reynolds NR, Remien RH, Goggin K, Gross R, Rosen MI, Schneiderman N, Arnsten J, Golin CE, Erlen JA, Bangsberg DR, Liu H. The validity of self-reported medication adherence as an outcome in clinical trials of adherence-promotion interventions: Findings from the MACH14 study. AIDS and behavior. 2014 Dec 1; 18(12):2285-90.
  4. Meshberg-Cohen S, Reid-Quiñones K, Black AC, Rosen MI. Veterans' attitudes toward work and disability compensation: associations with substance abuse. Addictive Behaviors. 2014 Feb 1; 39(2):445-8.


DRA: Mental, Cognitive and Behavioral Disorders, Substance Abuse and Addiction
DRE: Treatment - Observational, Prognosis, Treatment - Efficacy/Effectiveness Clinical Trial
Keywords: Clinical Diagnosis and Screening, Addictive Disorders, PTSD
MeSH Terms: none