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IIR 11-023 – HSR&D Study

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IIR 11-023
OEF/OIF Veterans with PTSD in Mental Health Residential Treatment Programs
Eric P Slade PhD
Baltimore VA Medical Center VA Maryland Health Care System, Baltimore, MD
Baltimore, MD
Funding Period: October 2012 - September 2015

BACKGROUND/RATIONALE:
This study compares OEF/OIF veterans' mental health service use outcomes following entry into PTSD residential treatment programs to their outcomes following entry into PTSD inpatient hospital and PTSD outpatient services. Residential treatment programs are voluntary overnight domiciliary programs that have program staff onsite 24 hours a day. All VA PTSD residential treatment programs are all expected to provide evidence-based PTSD treatment therapies, especially prolonged exposure therapy (PET) and cognitive processing therapy (CPT). No prior studies have examined the effectiveness of PTSD residential treatment.

OBJECTIVE(S):
This study provides quantitative results on comparisons of OEF/OIF Veterans' receipt of adequate psychotherapy and adequate psychotropic medication following admission to one of the VA's specialized PTSD treatment settings. We also assessed the predictors of OEF/OIF Veterans' entry into the three different PTSD program settings (i.e., residential, inpatient, and outpatient). We also report preliminary findings from qualitative interviews with PTSD residential treatment program directors and specialized PTSD treatment clinicians, in which we inquired about gaps in the quality of care and access to programs for OEF/OIF Veterans.

METHODS:
The quantitative study was a retrospective study of all N=34,815 VA OEF/OIF veterans who were admitted to a VA specialized PTSD treatment program in FY09 or FY10, using VA administrative health care utilization data. Study groups were: (1) PTSD residential treatment (N=2102; 6%); (2) acute inpatient PTSD (N=6888, 20%); and (3) specialized outpatient PTSD clinics (N=25,825; 74%). The study period included two consecutive 6-month periods starting with the veteran's date of admission to a PTSD program, and also included the 90 days prior to program entry. For all study groups, we constructed dependent variable measures of healthcare services utilization.
Measures
We used two measures of minimally adequate PTSD treatment: (i) at least 9 psychotherapy encounters; and (ii) a more than 30-day supply of psychotropic medication.

Analyses
Multinomial logit regression was used to analyze predictors of entry into one of the PTSD treatment settings. Multivariate regression analyses were used to examine the relationship between entry into a particular PTSD setting and receipt of minimally adequate PTSD therapy and psychotropic medication. Individual level fixed effects were used to adjust for unmeasured factors that may be related to severity of PTSD illness.

Qualitative interviews were conducted with PTSD residential treatment program directors and with PTSD specialist mental health care providers who work in PTSD outpatient programs. Interview transcripts were abstracted by three individuals using an abstraction template.

FINDINGS/RESULTS:
In multivariate logit analyses, females were 1.0% less likely to be admitted to a PTSD residential treatment program than were males, and females were 2.3% less likely to be admitted to a PTSD inpatient program than males. For reference, approximately 6% of the overall sample was admitted to a PTSD residential treatment program and 20% was admitted to a PTSD inpatient program. These results also show that black and Hispanic Veterans with PTSD were substantially less likely than white Veterans with PTSD to be admitted to either residential or inpatient PTSD care.

The fixed effects regression results indicated that entry into a PTSD residential program results in a 47.5% likelihood of completing at least 9 psychotherapy visits, compared to 35.2% after entry into PTSD inpatient care and 22.7% after entry into PTSD outpatient therapy programs. Tests of differences in these probabilities were all significant at the P<.001 level. Meanwhile, entry into both PTSD inpatient care and PTSD outpatient programs resulted in greater probabilities of receiving more than 30 days of psychotropic medication than entry into a PTSD residential program (74.4% in PTSD inpatient and 73.4% in PTSD outpatient versus 66.1% in PTSD residential).

Results of qualitative interviews are preliminary. PTSD Residential Treatment Programs serve a population with complex illness and must overcome many challenges that relate to program administration, limitations of their facilities, and Veterans' behavior problems. One of the most common challenges described was around addressing Veterans' substance use problems. Substance use problems result in sometimes severe conflicts between program staff and Veterans. Most Program Directors also listed problems with their physical facilities (e.g., lack of wifi and travel time to the VA hospital) as impeding the effectiveness of their programs.

IMPACT:
The results of this study and those of previous research indicate that less than 50% of OEF/OIF/OND Veterans who enter a VA specialized outpatient PTSD program complete at least 9 psychotherapy visits. PTSD residential treatment programs were able to achieve a rate of psychotherapy completion that is three times the completion rated achieved in the VA's specialized outpatient PTSD programs.

Evidence of lower rates of entry into PTSD residential treatment by women and racial-ethnic minority Veterans, compared with males and white Non-Hispanics, are troubling because the residential programs are more effective in engaging Veterans in evidence-based PTSD therapies compared to the specialized outpatient programs.

Based on the quantitative and qualitative findings of this study, VA program leaders should consider increased investment in the PTSD Residential Treatment Programs. Investment in modernized facilities should be a priority. Additional priorities to consider are expansion of these programs (i.e., more beds and staff) and increased specialization to address the needs of female Veterans. VA program leaders should consider how to relieve the regulatory reporting burden on PTSD Residential Programs, and should implement training requirements for how Veterans with substance use problems should be handled in PTSD Residential Treatment Programs. VA program leaders should also consider providing childcare to families of Veterans who are clients of PTSD residential treatment. Finally, VA program leaders should consider increased budgets for transportation to and from PTSD residential programs.

PUBLICATIONS:

Journal Articles

  1. Aakre JM, Himelhoch S, Slade EP. Mental health service utilization by Iraq and Afghanistan veterans after entry into PTSD specialty treatment. Psychiatric services (Washington, D.C.). 2014 Aug 1; 65(8):1066-9.
  2. Hermes ED, Hoff R, Rosenheck RA. Sources of the increasing number of Vietnam era veterans with a diagnosis of PTSD using VHA services. Psychiatric services (Washington, D.C.). 2014 Jun 1; 65(6):830-2.
Center Products

  1. Trafton JA, Greenberg G, McCarthy J, Blow F, Desai R, Harris AH, Katz I, Schohn M. Mental Health Information System: Customizable intranet-based report/tool of over 200 performance indicators assessing adherence to VA requirements for mental health service delivery. (Updated quarterly). 2013 Oct 1.


DRA: Mental, Cognitive and Behavioral Disorders
DRE: Epidemiology, Prognosis
Keywords: Best Practices, Care Coordination, Cost-Effectiveness, PTSD, Serious Mental Illness
MeSH Terms: none

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