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CRE 12-039 – HSR&D Study

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CRE 12-039
Web and Shared Decision Making for Reserve/National Guard Women's PTSD Care
Anne G. Sadler PhD RN
Iowa City VA Health Care System, Iowa City, IA
Iowa City, IA
Funding Period: May 2013 - March 2017

BACKGROUND/RATIONALE:
Women and OEF/OIF/OND Reserve/National Guard (RNG) war Veterans are among the fastest growing groups of new VHA users. PTSD is highly prevalent in this group of Veterans yet most choose not to seek care. This gap between need for and use of VA PTSD care shows barriers to engaging Veterans in mental health (MH) care persist. Removing these barriers requires new approaches to support Veterans post-deployment adjustment to mediate the severity of post-deployment MH conditions, alleviate concerns over MH diagnoses, and interrupt the cycle of chronicity found in many with PTSD.

OBJECTIVE(S):
1) Identify perceptions, preferences, barriers and facilitators to accessing VHA MH services and EBP for PTSD (including cognitive processing therapies (CPT) and prolonged exposure therapy (PE)) of a community sample of recent VHA users among PTSD+ OEF/OIF/OND RNG female war Veterans.

2) Evaluate study participants' perceptions of and satisfaction with a web-based interface (WEB-ED, developed in QUERI-funded studies) that screens for post-deployment readjustment and MH concerns and provides immediate tailored education.

3) Evaluate and test differences in VHA initiation and use, for those who screen positive for PTSD on the web-based interface randomly assigned to: A) Study nurse case manager (NCM) or B) existing outreach.

METHODS:
Our study population of OEF/OIF/OND female Veterans, recently returned from Iraq/Afghanistan, were identified by VA/DoD Identity Repository. Participants were selected from the Women's Practice Based Research Network founder sites (California, North Carolina, Iowa) and the Evidence-Based Therapy for PTSD CREATE leadership site (Minnesota). In Phase 1, we interviewed OEF/OIF/OND RNG female war Veterans' who screened PTSD+ on an online VA PTSD screener to assess their preferences, barriers and facilitators to accessing VHA MH services and evidence based psychotherapy (EBP) for PTSD. This information was used to refine this team's existing WEB-ED. Phase 2 implemented the revised WEB-ED and assessed Veteran satisfaction with it. Phase 3 recruited participants who screened PTSD+ on WEB-ED and were randomly assigned to: A) Study NCM who facilitated use of a PTSD decision aid and shared decision-making (SDM)to assist with VHA MH evaluation and treatment; or B) existing outreach (current care). Phase 4 included follow-up assessments conducted at 6 and 12 months to compare the efficacy of two approaches to promote VHA MH initiation.

FINDINGS/RESULTS:
1) Phase 1 qualitative interviews were conducted with a community sample of RNG servicewomen who met the following criteria: returned from Iraq/Afghanistan in the preceding 36 months; screened PTSD+ with an online VA screen and had a VHA encounter within the prior 18 months (N=19). Most (74%) had no EBP treatment. Veterans with no EBP reported numerous care barriers (shame, career concerns, time constraints, concerns about RNG access to VA, perception of insufficient VA staffing) and 80% indicated no provider education or SDM about PTSD treatment options.

2) Phase 2, 577 RNG servicewomen returning from Iraq/Afghanistan deployment within prior 60 months completed on-line screening/tailored education (WEB-ED) about post-deployment MH conditions. Half (49%) screened PTSD+. Among those screening PTSD+, most had one or more trauma exposures: combat (87%), military sexual trauma (67%), head injury (25%). Many screened positive for other post-deployment conditions: depression (29%), substance use disorder (50%), prescription drug misuse (49%), family readjustment (21%), intimate partner violence (9%), anger (60%). Veterans reported satisfaction with WEB-ED:80% indicating they would recommend WEB-ED to a peer and 67% learned information not received otherwise. 60% reported as a direct result of WEB-ED, they would subsequently seek MH care.

3) In Phase 3, PTSD+ Veterans who continued RCT study participation were randomly assigned to the NCM treatment (n=85) and existing outreach (n=86) arms. Using the Patient Activation Measure, we found that PCL-5 PTSD+ Veterans had significantly lower patient activation scores than PTSD- peers, indicating PTSD+ Veterans felt disengaged/overwhelmed (60%) whereas PTSD- (most with other MH+ screens) reported high activation (taking action/pushing further (71%)). Participants reported PTSD treatment avoidance given: fear will make life worse, not wanting to relive traumas, privacy concerns, and disbelief therapy helps. Those in the NCM treatment arm reported high satisfaction with the Iowa PTSD treatment option grid (e.g.,100% liked/felt useful). They reported benefits of the option grid included 1) new information, 2) conciseness, and 3) support for doctor-patient communication. Veterans found SDM to be useful (88%) and that a lot/every effort was made to include what matters most to them in choosing what to do next (96%). Participants liked: "talking to a person and not a computer" and "felt listened to, my own words were important".

Phase 4 documented more than half (58%) obtained MH treatment for PTSD. Among those who got care, approximately half received EBP (42% CPT; 11% PE). The majority sought VHA care (85%). RCT participants had similar rates of MH engagement regardless of their treatment arm.

IMPACT:
This study provides valuable insights about female RNG war Veterans' need for and decisions to seek MH services and EBP for PTSD. Study interventions focused on moving information and not people, addressing the needs of a high-risk population that might delay or not otherwise access PTSD treatment or VHA care, and providing Veteran-centered approaches. However, the subgroup of PTSD+ Veterans with low patient-activation scores represent a special population requiring additional support for engaging in needed MH care. The study provides important information regarding the efficacy of relatively inexpensive and resource-sparing interventions that can be readily implemented within existing models of patient care delivery and illustrating that one-size does not fit all. Participants reported high satisfaction with these approaches, suggesting Veteran usability and spread potential. Next steps include engaging providers with PTSD decision aid/SDM use, refining interventions to further focus on Veteran-provider partnership, eg, Veteran self-management collaboration. While this web interface and SDM intervention is currently directed at RNG women Veterans' post-deployment, there are clear implications for expansion to other populations and health/MH concerns as well. Findings have important policy implications for operational partners invested in the improved access and delivery of evidence-based MH care for Veterans with PTSD.

PUBLICATIONS:

Conference Presentations

  1. Sadler AG, Mengeling M, Torner J, Booth B. Online Interventions to Promote PTSD Treatment Engagement for a Community Sample of OEF/OIF/OND Reserve/National Guard and Active Component Servicewomen. Paper presented at: International Society for Traumatic Stress Studies Annual Symposium; 2016 Nov 10; Dallas, TX.
  2. Mengeling M, Torner J, Booth B, Sadler AG. Differences in Endorsement of Perceived Barriers to Seeking Mental Health Services by Deployment, Efficacy, and Past Year Mental Health Care Use. Paper presented at: American Public Health Association Annual Meeting and Exposition; 2016 Oct 31; Denver, CO.
  3. Sadler AG, Mengeling M, Torner J, Booth B. Post-Traumatic Stress Disorder (PTSD) and Reserve and National Guard Female War Veteran's Care Activation. Paper presented at: American Public Health Association Annual Meeting and Exposition; 2016 Oct 31; Denver, CO.
  4. Sadler AG, Mengeling M, Torner J, Barron S, Booth B. Intimate Partner Violence During Military Service in OEF/OIF Era Active Component and Reserve and National Guard Service Women. Paper presented at: International Family Violence and Child Victimization Research Conference; 2016 Jul 11; Portsmouth, NH.
  5. Sadler AG, Hamilton AB, Booth B, Torner J, Mengeling M. OEF/OIF/OND Reserve and National Guard War Veterans Perceptions of a Decision Aid for PTSD Treatment Options. Poster session presented at: AcademyHealth Annual Research Meeting; 2016 Jun 27; Boston, MA.
  6. Sadler AG, Mengeling M, Booth B, Torner J. The Military Environment: Factors Associated With Active Component And Reserve/National Guard Servicewomen’s Risk Of Sexual Assault In Non-Deployed Settings. Paper presented at: International Society for Traumatic Stress Studies Annual Symposium; 2015 Nov 6; New Orleans, LA.
  7. Sadler AG, Mengeling M, Torner J, Booth B. Hypervigilance In OEF/OIF Servicewomen: Use Of Guns/Weapons For Personal Safety Post-Deployment To Combat Regions. Paper presented at: International Society for Traumatic Stress Studies Annual Symposium; 2015 Nov 5; New Orleans, LA.
  8. Sadler AG, Mengeling M, Booth BM, Torner J, Hamilton AB. OEF/OIF Reserve/National Guard Service Women’s Perceptions of Evidence-Based Psychotherapy for PTSD Post-Deployment. Poster session presented at: VA HSR&D / QUERI National Meeting; 2015 Jul 8; Philadelphia, PA.


DRA: Mental, Cognitive and Behavioral Disorders
DRE: Treatment - Efficacy/Effectiveness Clinical Trial
Keywords: PTSD, Reintegration Post-Deployment
MeSH Terms: none

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