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CDA 15-251 – HSR&D Study

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CDA 15-251
Optimizing treatment response in VA Specialized Intensive/Inpatient PTSD programs
Rebecca Kaufman Sripada PhD MS
VA Ann Arbor Healthcare System, Ann Arbor, MI
Ann Arbor, MI
Funding Period: April 2017 - March 2022

BACKGROUND/RATIONALE:
Posttraumatic Stress Disorder (PTSD) affects up to 23% of returning Veterans and produces significant psychological, physical, and economic burdens. Although most Veterans with PTSD are treated on an outpatient basis, the VA has 39 Specialized Intensive/Inpatient PTSD programs (SIPPs) designed to treat high-needs Veterans who require more intensive and closely monitored care. The treatment of patients enrolled in SIPPs is extremely costly; only 1% of VA patients with a PTSD diagnosis enroll in SIPPs but SIPPs account for 33% of VA's budget for specialized PTSD care. Unfortunately, despite these costs, many patients undergoing treatment in SIPPs may experience only modest improvements in PTSD symptoms. Thus, the Institute of Medicine has recently called for strategies to improve treatment outcomes of VA PTSD treatment in general and residential programs in particular, making it clear the VA needs to carefully assess and address poor treatment response among Veterans receiving residential and other PTSD treatment.

OBJECTIVE(S):
The goal of this CDA is to optimize PTSD care by identifying individual- and program-level factors associated with poor treatment response in residential programs. Aim 1 will identify individual- and program-level predictors of treatment response in residential programs nationwide. Aim 2 will further elucidate factors associated with poor PTSD treatment response, using a qualitative approach with patient, provider, and administrator interviews to provide additional perspectives and identify relevant site-level factors. Aim 3 will pilot an adaptation of an existing treatment or health services intervention based on findings from the initial study aims and data on treatment practices at high-performing sites.

METHODS:
This research will be guided by the theory of Resources, Life Events and Changes in Psychological States. Aim 1 will assess predictors of poor response using multilevel modeling of nationwide clinical information collected by the Northeast Program Evaluation Center. Variables of interest will include individual-level resources and factors such as comorbidities, social contextual resources, and program resources such the availability of evidence-based treatments. Aim 2 will utilize qualitative analytic methods to assess individual and program-level predictors of response by interviewing SIPP patients, providers, and administrators. Aim 3 will consist of a feasibility pilot conducted at a VISN 10 residential program for PTSD.

FINDINGS/RESULTS:
Not yet available.

IMPACT:
This project addresses key VA and ORD priority areas including mental health services research and advancing Point of Care Research in PTSD. Identifying factors associated with poor treatment response in SIPPs will greatly enhance VA's ability to target and improve treatment approaches for the high-need, high-risk individuals requiring intensive care. In addition, optimizing the outcomes and functioning of Veterans with a high burden of illness is critical in improving the efficiency of care and reducing the costs of care.

Year 1 Annual Report Update (June 2018): Preliminary analyses identifying factors associated with poor treatment response have been completed and submitted as manuscripts for peer review. Thus, these findings are likely to be published during Year 2.

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. 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.
  4. 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.
  5. Knowles KA, Sripada RK, Defever M, Rauch SAM. Comorbid mood and anxiety disorders and severity of posttraumatic stress disorder symptoms in treatment-seeking veterans. Psychological trauma : theory, research, practice and policy. 2019 May 1; 11(4):451-458.
  6. 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.
  7. 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.
  8. Sripada RK, Hannemann CM, Schnurr PP, Marx BP, Pollack SJ, McCarthy JF. Mental Health Service Utilization before and after Receipt of a Service-Connected Disability Award for PTSD: Findings from a National Sample. Health services research. 2018 Dec 1; 53(6):4565-4583.
  9. 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.
  10. McLean CP, Rauch SAM, Foa EB, Sripada RK, Tannahill HS, Mintz J, Yarvis J, Young-McCaughan S, Dondanville KA, Hall-Clark BN, Fina BA, Keane TM, Peterson AL, STRONG STAR Consortium and the Consortium to Alleviate PTSD. Design of a randomized controlled trial examining the efficacy and biological mechanisms of web-prolonged exposure and present-centered therapy for PTSD among active-duty military personnel and veterans. Contemporary clinical trials. 2018 Jan 1; 64:41-48.
  11. 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.
  12. Rauch SAM, King AP, Liberzon I, Sripada RK. Changes in Salivary Cortisol During Psychotherapy for Posttraumatic Stress Disorder: A Pilot Study in 30 Veterans. The Journal of clinical psychiatry. 2017 May 1; 78(5):599-603.
  13. Russman Block S, King AP, Sripada RK, Weissman DH, Welsh R, Liberzon I. Behavioral and neural correlates of disrupted orienting attention in posttraumatic stress disorder. Cognitive, affective & behavioral neuroscience. 2017 Apr 1; 17(2):422-436.
  14. 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.
  15. King AP, Block SR, Sripada RK, Rauch SA, Porter KE, Favorite TK, Giardino N, Liberzon I. A Pilot Study of Mindfulness-Based Exposure Therapy in OEF/OIF Combat Veterans with PTSD: Altered Medial Frontal Cortex and Amygdala Responses in Social-Emotional Processing. Frontiers in psychiatry. 2016 Sep 20; 7:154.


DRA: Mental, Cognitive and Behavioral Disorders, Acute and Combat-Related Injury
DRE: Prognosis, Technology Development and Assessment
Keywords: none
MeSH Terms: none