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CRE 12-024 – HSR&D Study

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CRE 12-024
Helping Families Help Veterans with PTSD and Alcohol Abuse: An RCT of VA-CRAFT
Christopher R. Erbes PhD
Minneapolis VA Health Care System, Minneapolis, MN
Minneapolis, MN
Funding Period: October 2012 - March 2015

BACKGROUND/RATIONALE:
PTSD and Alcohol Use Disorders (AUDs) are highly prevalent psychiatric disorders among Veterans that can lead to substantial distress, disability, and interpersonal turmoil. Although empirically supported treatments are available, the majority of Veterans suffering from PTSD or AUDs do not engage in any mental health care. Data show that encouragement and support by family members play a key role in Veterans' willingness to engage in mental health care. However, many family members may not know how best to help their Veterans engage in mental health care. Further, both PTSD and AUDs are associated with deteriorating family functioning. VA-CRAFT is an innovative adaptation of an empirically supported family training intervention called Community Reinforcement and Family Training (CRAFT) that has been shown to dramatically increase treatment engagement among substance abusing civilian samples. Unlike CRAFT, which is traditionally administered individually by clinicians, VA-CRAFT includes Veteran-specific content, a focus on PTSD, AUDs, or both, and is delivered entirely through interactive web-technology to increase its efficiency and reach.

OBJECTIVE(S):
This project is a pilot evaluation of VA-CRAFT that was designed to provide feedback to VA-CRAFT developers for possible modifications to content and delivery, and to inform future studies. Specific aims included: 1) provide pilot data on the effectiveness of VA-CRAFT on Veterans' mental health service utilization; 2) provide pilot data on the effectiveness of VA-CRAFT on family members' wellbeing, personal quality of life, perceived relationship quality with Veteran, and communication about treatment seeking; 3) obtain pilot data to explore possible differences in intervention response between Veterans with AUDs only, PTSD only, or both; and 4) provide information regarding potential changes in content and delivery as well as potential mediators and moderators of outcome for VA-CRAFT.

METHODS:
A randomized controlled trial of VA-CRAFT was conducted with family members of Veterans drawn from a cohort of Veterans and family members enrolled in an already established, ongoing survey study. Using Veteran responses to prior surveys and administrative data, family members from this cohort were identified whose Veterans screened positive for PTSD, AUDs, or both and who were not receiving mental health or substance abuse treatment. Family members who chose to participate completed baseline questionnaires of perceived Veteran PTSD and AUD symptoms, family functioning and communication, and caregiver burden and well-being. They were then randomly assigned to a VA-CRAFT condition (n = 34) or a wait list control condition (n = 32). Veterans whose family were in the study were also invited to participate to obtain their perceptions of family functioning and personal well-being before and after the intervention (n = 18 and 25 in the VA-CRAFT and control conditions, respectively). Participants had three months to complete the course, and their progress through the course was monitored via an LMS system so that stepped outreach efforts (emails, phone contacts, letters) could be used to encourage them to complete the intervention. Three months after randomization, family members and Veterans completed follow-up questionnaires. Primary outcomes included: 1) Veteran's mental health service utilization during the 3 months following initiation of VA-CRAFT as assessed by VA administrative data and 2) family member self-reports of wellbeing, caregiver burden, and quality of life and 3) family and Veteran reports of perceived relationship quality and communication about treatment seeking. Following the post-intervention questionnaires, qualitative interviews were conducted with 20 family participants to examine possible moderators and mediators of treatment responses and to elicit participant feedback on VA-CRAFT to inform future course development.

FINDINGS/RESULTS:
There were no statistically significant differences between the two groups on Veteran mental health service utilization as assessed by VA administrative data or Veteran and family member report. There were also no significant differences between groups on Veteran and family member reports of family functioning or individual well-being. Family members in the VA-CRAFT group had a significantly greater decrease in reports of caregiver burden on the Caregiver Burden Scale (from M=1.92 to M=1.56) than family members in the control group (from M=1.81 to M=1.84, interaction p<.0001). Qualitative interviews complemented these quantitative findings. Qualitative analyses suggested that the majority of family members perceived benefit from the course and would recommend it to others. Many felt they understood their Veteran better and learned how to communicate with them more effectively. However, interview responses suggested that most family members were not actually engaging in conversations with their Veterans about getting into treatment, even when they believed the Veteran needed such care. Barriers included a lack of confidence that the conversation would work based on prior failed conversations; Veteran's denial or resistance, perception of stigma, or attitudes about VA services; and fear that such conversations would be upsetting to Veterans.

IMPACT:
This pilot project provided preliminary evidence for the role of an online training program in reducing caregiver burden among family members of Veterans screening positive for PTSD or AUDs. Results suggest a need to include additional support for family members into the implementation of VA-CRAFT, and a need to consider family member perceptions of a Veteran's need for care. Given the ongoing need to engage Veterans in care for these disorders, and its demonstrated potential to reduce caregiver burden among family members, further development of VA-CRAFT to enhance its effectiveness is indicated.


PUBLICATIONS:

Journal Articles

  1. Erbes CR, Kuhn E, Polusny MA, Ruzek JI, Spoont M, Meis LA, Gifford E, Weingardt KR, Campbell EH, Oleson H, Taylor BC. A Pilot Trial of Online Training for Family Well-Being and Veteran Treatment Initiation for PTSD. Military medicine. 2019 Oct 17.
  2. Williams EC, Gupta S, Rubinsky AD, Jones-Webb R, Bensley KM, Young JP, Hagedorn H, Gifford E, Harris AH. Racial/Ethnic Differences in the Prevalence of Clinically Recognized Alcohol Use Disorders Among Patients from the U.S. Veterans Health Administration. Alcoholism, clinical and experimental research. 2016 Feb 1; 40(2):359-66.
  3. Owen JE, Jaworski B, Kuhn ER, Makin-Byrd K, Ramsey K, Hoffman JE. mHealth in the wild: Using novel data to examine the reach, use, reception, and impact of PTSD Coach. JMIR mental health. 2015 Mar 25; 2(1, Jan-Mar):e7 (DOI: 10.2196/mental.3935).
  4. Erbes CR, Stinson R, Kuhn E, Polusny M, Urban J, Hoffman J, Ruzek JI, Stepnowsky C, Thorp SR. Access, utilization, and interest in mHealth applications among veterans receiving outpatient care for PTSD. Military medicine. 2014 Nov 1; 179(11):1218-22.
  5. Kuhn E, Eftekhari A, Hoffman JE, Crowley JJ, Ramsey KM, Reger GM, Ruzek JI. Clinician perceptions of using a smartphone app with prolonged exposure therapy. Administration and policy in mental health. 2014 Nov 1; 41(6):800-7.
  6. Whealin JM, Kuhn E, Pietrzak RH. Applying behavior change theory to technology promoting veteran mental health care seeking. Psychological Services. 2014 Nov 1; 11(4):486-94.
  7. Ruzek JI, Eftekhari A, Rosen CS, Crowley JJ, Kuhn E, Foa EB, Hembree EA, Karlin BE. Factors related to clinician attitudes toward prolonged exposure therapy for PTSD. Journal of traumatic stress. 2014 Aug 1; 27(4):423-9.
  8. Kuhn E, Greene C, Hoffman J, Nguyen T, Wald L, Schmidt J, Ramsey KM, Ruzek J. Preliminary evaluation of PTSD Coach, a smartphone app for post-traumatic stress symptoms. Military medicine. 2014 Jan 1; 179(1):12-8.
  9. Reger GM, Hoffman J, Riggs D, Rothbaum BO, Ruzek J, Holloway KM, Kuhn E. The "PE coach" smartphone application: an innovative approach to improving implementation, fidelity, and homework adherence during prolonged exposure. Psychological Services. 2013 Aug 1; 10(3):342-9.
  10. Kuhn ER, Landes S. Mental and Behavioral Health Apps for Service Members, Veterans, and Providers. Society for Media Psychology & Technology: The Amplifier. 2013 Apr 1; Spring/Summer(2013):8-10.
  11. Tran T, Kuhn ER, Walser R, Drescher K. The relationship between religiosity, PTSD, and depressive symptoms in veterans in PTSD residential treatment. Journal of psychology and theology. 2012 Oct 1; 40(Winter 2012):313-322.
Book Chapters

  1. Kuhn ER, Hoffman JE, Ruzek JI. Telemental Health Approaches for Trauma Survivors. In: Schnyder U, Cloitre M, editors. Evidence Based Treatment for Trauma-Related Psychological Disorders: A Practical Guide for Clinicians. New York, NY: Springer International Publishing; 2015. Chapter 25. 461-476 p.
Center Products

  1. Kuhn ER. Technology and Mobile Interventions for PTSD. Annual VA Sierra Pacific (VISN 21) Mental Illness Research, Education and Clinical Centers (MIRECC) PTSD Updates Webinar. 2014 Nov 14.
Conference Presentations

  1. Erbes CR, Kuhn E, Gifford E, Spoont MR, Meis LA, Polusny MA, Oleson H, Taylor BC, Hagel Campbell EM, Wright J. A pilot trial of VA-CRAFT: Online training to enhance family well-being and Veteran mental health service use. Paper presented at: VA HSR&D / QUERI National Meeting; 2015 Jul 10; Philadelphia, PA.
  2. Kuhn ER, Hugo E. Using PEWeb in psychiatry resident training and supervision in Prolonged Exposure therapy. Presented at: International Society for Traumatic Stress Studies Annual Symposium; 2014 Nov 6; Miami, FL.
  3. Kuhn ER, Owen J, Hoffman JE, Jaworski B, Ramsey KM, Ruzek JI. Using traditional and novel data sources to assess reach, reception, use, and impact of the PTSD Coach mobile app. Presented at: International Society for Traumatic Stress Studies Annual Symposium; 2014 Nov 6; Miami, FL.
  4. O'Donnell J, Hoffman JE, Kuhn ER, Smith S. Usability testing for PTSD Cancer Coach: a mobile application to manage posttraumatic stress symptoms in cancer survivors. Presented at: mhealth@Duke Annual Conference; 2014 Apr 15; Durham, NC.
  5. Kuhn ER, Hoffman JE, Miner A, Taylor CB, Thorp SR, Stepnowsky CJ, Ramsey KM, Ruzek JI. PTSD Coach: A mobile app for self-management of posttraumatic stress symptoms. In Symposium: M. Carper & P. Kendall (Chairs), New directions in computer-based psychological interventions: How we got there and where we are going. Presented at: Association for Behavioral and Cognitive Therapies Annual Convention; 2013 Nov 21; Nashville, TN.
  6. Lavoie C, Miner A, Taylor K, Hoffman JE, Kuhn ER, Taylor CB, Ramsey K, Ruzek JI. Design strategies and challenges: Creating novel mobile device applications to support and enhance evidenced-based treatments for mental health. Poster session presented at: Association for Behavioral and Cognitive Therapies Annual Convention; 2013 Nov 21; Nashville, TN.
  7. Hoffman J, Kuhn ER, Miner A, Taylor C, Ramsey K, Ruzek JI. PTSD Coach: Feasibility, Usability, and Perceived Helpfulness of a Mobile Application for Self-Management of PTSD. In Symposium: J. Hamblen (Chair), Evaluation of Technology-based PTSD Educational Products for Clinicians and Trauma Survivors. Presented at: International Society for Traumatic Stress Studies Annual Meeting; 2013 Nov 9; Philadelphia, PA.
  8. Kuhn ER, Hoffman J, Reger G, Eftekhari A, Crowley J, Ramsay K, Ruzek JI. Provider Perceptions of a Patient Smartphone App for Prolonged Exposure Therapy. In Symposium: M. Price (Chair), Building an Evidence Base for Technology in Treatment: Adoption, Assessment, Engagement, and Efficacy. Presented at: International Society for Traumatic Stress Studies Annual Meeting; 2013 Nov 9; Philadelphia, PA.
  9. Belsher B, Fast E, France D, Kuhn ER, Prins A, Cueva D. Feasibility of an Internet-Based, Brief Telephone Monitoring Intervention for OEF/OIF Veterans Experiencing Post-Traumatic Stress Symptoms. Poster session presented at: International Society for Traumatic Stress Studies Annual Symposium; 2013 Nov 7; Philadelphia, PA.
  10. Hoffman JE, Kuhn ER, Ramsey KM, Ruzek JI. Mobile applications for flexible and scalable mental health management. In W. Tenhula (Chair), Presidential program – Reaching Veterans when and where they need us: Innovations to optimize engagement in care. Presented at: American Psychological Association Annual Convention; 2013 Aug 2; Honolulu, HI.
  11. Kuhn ER, Hoffman JE, Reger G, Ruzek JI. Smartphone apps as adjuncts to empirically supported treatments for PTSD and its comorbidities. In M. Alvord (Chair), Apps, telehealth, virtual reality – addressing mental health needs of service women and men and Veterans. Presented at: American Psychological Association Annual Convention; 2013 Aug 1; Honolulu, HI.
  12. Kuhn ER. PTSD: Best Practices and Promising Interventions. Presented at: Philippine Nurses Association of Northern California Annual Conference; 2013 May 22; South San Francisco, CA.
  13. Ruzek JI, Kuhn ER, Hoffman J. Evidence-based psychotherapy for PTSD: Mobile apps as implementation supports. Presented at: American Psychiatric Association Annual Meeting; 2013 May 18; San Francisco, CA.
  14. Ruzek JI, Hoffman J, Kuhn ER. Technology and management of traumatic stress. Presented at: Anxiety Disorders Association of America Annual Conference; 2013 Apr 6; La Jolla, CA.
  15. Ruzek JI, Hoffman J, Kuhn ER. How mobile apps can improve PTSD prevention and treatment. Presented at: Anxiety Disorders Association of America Annual Conference; 2013 Apr 5; La Jolla, CA.
  16. Kuhn ER. Discussant for N. Afari (Chair), Technology use to improve screening and treatment of Veterans. Presented at: Anxiety Disorders Association of America Annual Conference; 2013 Apr 4; La Jolla, CA.
  17. Kuhn ER. VA Mobile Apps for Mental Health. In Social Media and Mobile Apps Demo and Discussion. Presented at: Anxiety Disorders Association of America Annual Conference; 2013 Apr 4; San Diego, CA.
  18. Kuhn ER. Effectively Treating PTSD: Best Practices and Promising Innovations. Paper presented at: San Mateo County Behavioral Health and Recovery Services Grand Rounds; 2012 Nov 27; San Mateo, CA.
  19. Kuhn ER, Hoffman JE, Wald LH, Ruzek JI. Stay Quit Coach: A Mobile App for Smoking Cessation in PTSD Patients. Presented at: International Society for Traumatic Stress Studies Annual Meeting; 2012 Nov 1; Los Angeles, CA.


DRA: Substance Abuse and Addiction, Mental, Cognitive and Behavioral Disorders
DRE: Treatment - Efficacy/Effectiveness Clinical Trial
Keywords: none
MeSH Terms: none

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