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CDA 11-245 – HSR&D Study

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CDA 11-245
VA Healthcare Delivery for OEF/OIF Veterans with Mental & Substance Use Disorders
Kipling M. Bohnert PhD BA
VA Ann Arbor Healthcare System, Ann Arbor, MI
Ann Arbor, MI
Funding Period: July 2014 - June 2019

BACKGROUND/RATIONALE:
The prevalence of posttraumatic stress disorder (PTSD) among US Service Members returning from Iraq and Afghanistan is high, yet use of mental health treatment among these individuals is low. Therefore, it is likely that many Veterans of these conflicts receiving their healthcare through the Veterans Health Administration (VHA) have a need for PTSD mental health services. Understanding PTSD screening and subsequent services is essential.

OBJECTIVE(S):
The purpose of this project is to provide critical and timely evidence to fill in the existing gaps regarding treatment initiation and engagement among OEF/OIF/OND Veterans with PTSD in VHA. The specific aims of the research are: (1) to identify patient and provider factors associated with timely treatment initiation and continued engagement among all OEF/OIF/OND Veterans in VHA care who receive positive PTSD screens and are diagnosed with the condition; (2) to further elucidate patient factors associated with timely initiation and continued engagement in PTSD treatment using a qualitative approach with provider and Veteran patient focus groups; (3) to build on the two prior aims by developing and piloting a theory-based intervention to increase initiation and engagement in PTSD treatment among Veterans with PTSD; and (4) to identify important facility factors and variation associated with timely treatment initiation and engagement in order to inform future implementation efforts.

METHODS:
Aims 1 and 4 will be completed via secondary data analyses of existing VHA administrative data. Aim 2 will be completed via qualitative focus group interviews of OEF/OIF/OND patients with PTSD who are and are not engaged in treatment, and with providers who care for them. Aim 3 will be completed via a pilot trial of an intervention developed based on theory and results from the two prior aims.

FINDINGS/RESULTS:
Not yet available.

IMPACT:
Understanding and addressing the factors that play a role in the gap between a positive screen, treatment initiation, and treatment continuation may significantly improve our ability to reduce Veteran suffering and prevent further functional and emotional problems associated with PTSD. Recent findings regarding PC-MHI are especially relevant for VA primary care providers, who may consider engaging integrated mental health professionals to help facilitate PTSD diagnostic assessment and treatment initiation. These important findings are often cited by Central Office, and are especially relevant to the My VA Access Initiative.

Additionally, longitudinal findings from recent work among OEF/OIF NG service members have potential treatment implications, including that individuals in classes characterized by higher levels of symptoms at 6 months may have more variable outcomes and may require more intensive interventions as well as vigorous treatment of co-occurring mental health conditions to prevent movement to more severe symptom classes. Those initially in the most severe class may benefit most from PTSD-focused treatments, especially given their low likelihood of transitioning to either mild or asymptomatic classes over time.

Furthermore, emerging initial themes from qualitative work indicate that patients' attitudes regarding stigma associated with PTSD, and their PTSD screening and the care processes (including communication and treatment offerings), may play important roles in why some Veterans do or do not initiate more specialized treatment.

PUBLICATIONS:

Journal Articles

  1. Hale AC, Bohnert KM, Ganoczy D, Sripada RK. Predictors of Treatment Adequacy During Evidence-Based Psychotherapy for PTSD. Psychiatric services (Washington, D.C.). 2019 May 1; 70(5):367-373.
  2. Sripada RK, Blow FC, Rauch SAM, Ganoczy D, Hoff R, Harpaz-Rotem I, Bohnert KM. Examining the nonresponse phenomenon: Factors associated with treatment response in a national sample of veterans undergoing residential PTSD treatment. Journal of anxiety disorders. 2019 Apr 1; 63:18-25.
  3. Bonar EE, Cranford JA, Arterberry BJ, Walton MA, Bohnert KM, Ilgen MA. Driving under the influence of cannabis among medical cannabis patients with chronic pain. Drug and Alcohol Dependence. 2019 Feb 1; 195:193-197.
  4. Hale AC, Bohnert KM, Grekin R, Sripada RK. Traumatic Brain Injury in the General Population: Incidence, Mental Health Comorbidity, and Functional Impact. The Journal of nervous and mental disease. 2019 Jan 1; 207(1):38-42.
  5. Goldstick JE, Bohnert KM, Davis AK, Bonar EE, Carter PM, Walton MA, Cunningham RM. Dual Trajectories of Depression/Anxiety Symptoms and Alcohol Use, and their Implications for Violence Outcomes Among Drug-Using Urban Youth. Alcohol and alcoholism (Oxford, Oxfordshire). 2018 Nov 1; 53(6):659-666.
  6. Sripada RK, Hoff R, Pfeiffer PN, Ganoczy D, Blow FC, Bohnert KM. Latent classes of PTSD symptoms in veterans undergoing residential PTSD treatment. Psychological Services. 2018 Oct 4.
  7. Duffy SA, Ignacio RV, Kim HM, Geraci MC, Essenmacher CA, Hall SV, Chow A, Pfeiffer PN, Sherman SE, Bohnert KM, Zivin K, Barnett PG. Effectiveness of tobacco cessation pharmacotherapy in the Veterans Health Administration. Tobacco Control. 2018 Sep 4.
  8. Sripada RK, Pfeiffer PN, Rauch SAM, Ganoczy D, Bohnert KM. Factors associated with the receipt of documented evidence-based psychotherapy for PTSD in VA. General hospital psychiatry. 2018 Sep 1; 54:12-17.
  9. Bohnert KM, Sripada RK, Ganoczy D, Walters H, Valenstein M. Longitudinal patterns of PTSD symptom classes among US National Guard service members during reintegration. Social psychiatry and psychiatric epidemiology. 2018 Sep 1; 53(9):911-920.
  10. Sripada RK, Bohnert KM, Ganoczy D, Pfeiffer PN. Documentation of Evidence-Based Psychotherapy and Care Quality for PTSD in the Department of Veterans Affairs. Administration and policy in mental health. 2018 May 1; 45(3):353-361.
  11. Davis AK, Arterberry BJ, Bonar EE, Bohnert KM, Walton MA. Why do young people consume marijuana? Extending motivational theory via the Dualistic Model of Passion. Translational issues in psychological science. 2018 Mar 1; 4(1):54-64.
  12. Burnett-Zeigler I, Lee Y, Bohnert KM. Ethnic Identity, Acculturation, and 12-Month Psychiatric Service Utilization Among Black and Hispanic Adults in the U.S. The journal of behavioral health services & research. 2018 Jan 1; 45(1):13-30.
  13. Hale AC, Sripada RK, Bohnert KM. Past-Year Treatment Utilization Among Individuals Meeting DSM-5 PTSD Criteria: Results From a Nationally Representative Sample. Psychiatric services (Washington, D.C.). 2018 Mar 1; 69(3):341-344.
  14. Davis AK, Walton MA, Bohnert KM, Bourque C, Ilgen MA. Factors associated with alcohol consumption among medical cannabis patients with chronic pain. Addictive Behaviors. 2018 Feb 1; 77:166-171.
  15. Sinacore DR, Hastings MK, Bohnert KL, Strube MJ, Gutekunst DJ, Johnson JE. Immobilization-induced osteolysis and recovery in neuropathic foot impairments. Bone. 2017 Dec 1; 105:237-244.
  16. Davis AK, Lin LA, Ilgen MA, Bohnert KM. Recent cannabis use among Veterans in the United States: Results from a national sample. Addictive Behaviors. 2018 Jan 1; 76:223-228.
  17. Bohnert KM, Bonar EE, Arnedt JT, Conroy DA, Walton MA, Ilgen MA. Utility of the comprehensive marijuana motives questionnaire among medical cannabis patients. Addictive Behaviors. 2018 Jan 1; 76:139-144.
  18. Buchholz KR, Bohnert KM, Pfeiffer PN, Valenstein M, Ganoczy D, Anderson RE, Sripada RK. Reengagement in PTSD psychotherapy: A case-control study. General hospital psychiatry. 2017 Sep 1; 48:20-24.
  19. Britton PC, Bohnert KM, Ilgen MA, Kane C, Stephens B, Pigeon WR. Suicide mortality among male veterans discharged from Veterans Health Administration acute psychiatric units from 2005 to 2010. Social psychiatry and psychiatric epidemiology. 2017 Sep 1; 52(9):1081-1087.
  20. Bohnert KM, Ilgen MA, Louzon S, McCarthy JF, Katz IR. Substance use disorders and the risk of suicide mortality among men and women in the US Veterans Health Administration. Addiction (Abingdon, England). 2017 Jul 1; 112(7):1193-1201.
  21. Sripada RK, Pfeiffer PN, Rampton J, Ganoczy D, Rauch SA, Polusny MA, Bohnert KM. Predictors of PTSD Symptom Change Among Outpatients in the U.S. Department of Veterans Affairs Health Care System. Journal of traumatic stress. 2017 Feb 1; 30(1):45-53.
  22. Buchholz KR, Bohnert KM, Sripada RK, Rauch SA, Epstein-Ngo QM, Chermack ST. Associations between PTSD and intimate partner and non-partner aggression among substance using veterans in specialty mental health. Addictive Behaviors. 2017 Jan 1; 64:194-199.
  23. Sripada RK, Henry J, Yosef M, Levine DS, Bohnert KM, Miller E, Zivin K. Occupational functioning and employment services use among VA primary care patients with posttraumatic stress disorder. Psychological trauma : theory, research, practice and policy. 2018 Mar 1; 10(2):140-143.
  24. Matusiewicz AK, Ilgen MA, Bohnert KM. Changes in alcohol use following the transition to motherhood: Findings from the National Epidemiologic Survey on Alcohol and Related Conditions. Drug and Alcohol Dependence. 2016 Nov 1; 168:204-210.
  25. Sripada RK, Bohnert KM, Ganoczy D, Blow FC, Valenstein M, Pfeiffer PN. Initial group versus individual therapy for posttraumatic stress disorder and subsequent follow-up treatment adequacy. Psychological Services. 2016 Nov 1; 13(4):349-355.
  26. Gorman LA, Sripada RK, Ganoczy D, Walters HM, Bohnert KM, Dalack GW, Valenstein M. Determinants of National Guard Mental Health Service Utilization in VA versus Non-VA Settings. Health services research. 2016 Oct 1; 51(5):1814-37.
  27. Lin LA, Ilgen MA, Jannausch M, Bohnert KM. Comparing adults who use cannabis medically with those who use recreationally: Results from a national sample. Addictive Behaviors. 2016 Oct 1; 61:99-103.
  28. Glass JE, Bohnert KM, Brown RL. Alcohol Screening and Intervention Among United States Adults who Attend Ambulatory Healthcare. Journal of general internal medicine. 2016 Jul 1; 31(7):739-45.
  29. Bohnert KM, Sripada RK, Mach J, McCarthy JF. Same-Day Integrated Mental Health Care and PTSD Diagnosis and Treatment Among VHA Primary Care Patients With Positive PTSD Screens. Psychiatric services (Washington, D.C.). 2016 Jan 1; 67(1):94-100.
  30. Johnson JE, Paxton ES, Lippe J, Bohnert KL, Sinacore DR, Hastings MK, McCormick JJ, Klein SE. Outcomes of the Bridle Procedure for the Treatment of Foot Drop. Foot & Ankle International / American Orthopaedic Foot and Ankle Society [And] Swiss Foot and Ankle Society. 2015 Nov 1; 36(11):1287-96.
  31. Sripada RK, Richards SK, Rauch SA, Walters HM, Ganoczy D, Bohnert KM, Gorman LA, Kees M, Blow AJ, Valenstein M. Socioeconomic Status and Mental Health Service Use Among National Guard Soldiers. Psychiatric services (Washington, D.C.). 2015 Sep 1; 66(9):992-5.
  32. Perron BE, Bohnert K, Perone AK, Bonn-Miller MO, Ilgen M. Use of prescription pain medications among medical cannabis patients: comparisons of pain levels, functioning, and patterns of alcohol and other drug use. Journal of studies on alcohol and drugs. 2015 May 1; 76(3):406-13.
  33. Pfeiffer PN, Bohnert KM, Zivin K, Yosef M, Valenstein M, Aikens JE, Piette JD. Mobile health monitoring to characterize depression symptom trajectories in primary care. Journal of affective disorders. 2015 Mar 15; 174:281-6.
  34. Ashrafioun L, Bohnert KM, Jannausch M, Ilgen MA. Characteristics of substance use disorder treatment patients using medical cannabis for pain. Addictive Behaviors. 2015 Mar 1; 42:185-8.
  35. Bohnert KM, Walton MA, Ranney M, Bonar EE, Blow FC, Zimmerman MA, Booth BM, Cunningham RM. Understanding the service needs of assault-injured, drug-using youth presenting for care in an urban Emergency Department. Addictive Behaviors. 2015 Feb 1; 41:97-105.
  36. Sripada RK, Pfeiffer PN, Rauch SA, Bohnert KM. Social support and mental health treatment among persons with PTSD: results of a nationally representative survey. Psychiatric services (Washington, D.C.). 2015 Jan 1; 66(1):65-71.
  37. Sripada RK, Pfeiffer PN, Valenstein M, Bohnert KM. Medical illness burden is associated with greater PTSD service utilization in a nationally representative survey. General hospital psychiatry. 2014 Nov 1; 36(6):589-93.
  38. Bohnert KM, Perron BE, Ashrafioun L, Kleinberg F, Jannausch M, Ilgen MA. Positive posttraumatic stress disorder screens among first-time medical cannabis patients: prevalence and association with other substance use. Addictive Behaviors. 2014 Oct 1; 39(10):1414-7.
  39. Duax JM, Bohnert KM, Rauch SA, Defever AM. Posttraumatic stress disorder symptoms, levels of social support, and emotional hiding in returning veterans. Journal of rehabilitation research and development. 2014 Jul 1; 51(4):571-8.
Journal Other

  1. Bohnert KM, Ilgen MA, McCarthy JF. Response to Aubin et al. (2017). Addiction (Abingdon, England). 2017 Nov 1; 112(11):2066-2067.
Conference Presentations

  1. Sripada RK, Bohnert KM, Ganoczy D, Blow FC, Valenstein MT, Pfeiffer PN. Initial Group versus Individual therapy for Posttraumatic Stress Disorder and Subsequent Follow-Up Treatment Adequacy. Paper presented at: VA HSR&D / QUERI National Meeting; 2015 Jul 9; Philadelphia, PA.
  2. Bohnert KM, Sripada RK, Mach J, McCarthy JF. Same-day integrated mental health services for those who screen positive for PTSD in VHA primary Care: Implications for diagnosis and treatment. Poster session presented at: VA HSR&D / QUERI National Meeting; 2015 Jul 8; Philadelphia, PA.


DRA: Mental, Cognitive and Behavioral Disorders, Substance Abuse and Addiction, Health Systems
DRE: Treatment - Observational, Prevention, Technology Development and Assessment, Treatment - Efficacy/Effectiveness Clinical Trial
Keywords: Care Coordination
MeSH Terms: none