The role of therapy delivery and clinic organizational factors in explaining therapist effects for trauma-focused psychotherapies in the Veterans Health Administration.

OBJECTIVE: This study estimated the size of therapist effects (TEs) for dropout and clinical effectiveness of two trauma-focused psychotherapies (TFPs) and evaluated whether therapy delivery and clinic organizational factors explained observed TEs. METHOD: Participants were 180 therapists (54.4% psychologists, 42.2% social workers) from 137 Veterans Health Administration facilities and 1,735 patients (24.7% women; 27.2% people of color) who completed at least two TFP sessions. Outcomes were dropout (< 8 TFP sessions) and for a subsample (n = 1,273), clinically meaningful improvement and recovery based on posttraumatic stress disorder checklist for DSM-5 (PCL-5) scores. Therapist-level predictors were ascertained through survey, manual chart review, and administrative data. Multilevel models estimated TEs. RESULTS: Over half (51.2%) of patients dropped out and those who dropped out were less likely to meet criteria for clinically meaningful improvement or recovery (ps < .001). Adjusting for case-mix and TFP type, therapists accounted for 5.812% (p < .001) of the unexplained variance in dropout. The average dropout rate for the 45 therapists in the top performing quartile was 27.0%, while the average dropout rate for the 45 therapists in the bottom performing quartile was 78.8%. Variation between therapists was reduced to 2.031% (p = .140) when therapists' mean of days between sessions, adherence, implementation climate, and caseload were added to multilevel models. TEs were nonsignificant for clinically meaningful improvement and recovery. CONCLUSIONS: Interventions targeting therapy delivery and clinic organization have the potential to reduce variation between therapists in TFP dropout, so that more patients stay engaged long enough to experience clinical benefit. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Racial and ethnic mental health disparities in U.S. Military Veterans: Results from the National Health and Resilience in Veterans Study.

Despite military veterans having a higher prevalence of several common psychiatric disorders relative to non-veterans, scarce population-based research has examined racial/ethnic differences in these disorders. The aim of this study was to examine racial/ethnic differences in the prevalence of psychiatric outcomes in a population-based sample of White, Black, and Hispanic military veterans, and to examine the role of intersectionality between sociodemographic variables and race/ethnicity in predicting these outcomes. Data were analyzed from the National Health and Resilience in Veterans Study (NHRVS), a contemporary, nationally representative survey of 4069 US veterans conducted in 2019-2020. Outcomes include self-report screening measures of lifetime and current psychiatric disorders, and suicidality. Results revealed that Hispanic and Black veterans were more likely than White veterans to screen positive for lifetime posttraumatic stress disorder (PTSD; 17.8% and 16.7% vs. 11.1%, respectively); Hispanic veterans were more likely than White veterans to screen positive for lifetime major depressive disorder (22.0% vs. 16.0%); Black veterans were more likely than White veterans to screen positive for current PTSD (10.1% vs. 5.9%) and drug use disorder (12.9% vs. 8.7%); and Hispanic veterans were more likely than Black veterans to report current suicidal ideation (16.2% vs. 8.1%). Racial/ethnic minority status interacted with lower household income, younger age, and female sex in predicting greater likelihood of some of these outcomes. Results of this population-based study suggest a disproportionate burden of certain psychiatric disorders among racial/ethnicity minority veterans, and identify high-risk subgroups that can be targeted in prevention and treatment efforts.

The role of symptom accommodation in trauma-focused treatment engagement and response.

Although trauma-focused treatments (TFTs) are generally effective, not all patients improve. Symptom accommodation (i.e., altering one's behavior in response to another's symptoms) by loved ones may be particularly relevant to TFT treatment response and engagement. We examined the role of symptom accommodation by support persons (SPs) in veterans' PTSD treatment response, including the mediating role of treatment engagement and the moderating role of relationship strain. Veterans engaging in prolonged exposure or cognitive processing therapy and a loved one (N = 172 dyads) were sampled at two time points approximately four months apart. Measures of treatment engagement (i.e., highest session completed from the treatment protocol and homework completion) were obtained from hospital records. We found that relationship strain moderated the effect of symptom accommodation on treatment response, ∆R2 = .02. Specifically, Time 1 (T1) accommodation predicted poorer treatment response (i.e., Time 2 [T2] PTSD symptom severity, controlling for T1 symptoms) among veterans who reported below-average relationship strain only. Additionally, symptom accommodation was indirectly related to treatment response such that T1 accommodation predicted higher T2 PTSD symptom severity specifically through reduced homework completion, ß = .01. The findings suggest that attending to accommodating behaviors of veterans' supportive partners may be an important way to boost both engagement in and response to TFTs for PTSD.

Making sense of poor adherence in PTSD treatment from the perspectives of veterans and their therapists.

OBJECTIVE: Dropout rates from trauma-focused PTSD treatments (TFTs) in VA clinics are particularly high. We conducted in-depth qualitative interviews with 29 veterans and their therapists to better understand this phenomenon. METHOD: Participants were part of a multisite, mixed-methods study of TFT adherence in VA clinics. Veterans were eligible for interviews if they exhibited poor TFT adherence and screened positive for PTSD in follow-up surveys. Interviews were analyzed using qualitative dyadic analysis approaches. RESULTS: Therapists relied on stereotypes of poor adherence to understand veterans' experiences and were missing information critical to helping veterans succeed. Veterans misunderstood aspects of the therapy and struggled in ways they inadequately expressed to therapists. Therapist attempts at course corrections were poorly matched to veterans' needs. Many dyads reported difficulties in their therapeutic relationships. Veterans reported invalidating experiences that were not prominent in therapists' interviews. CONCLUSIONS: Future work is needed to test hypotheses generated and find effective ways to help veterans fully engage in TFTs. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Divergent experiences of U.S. veterans who did and did not complete trauma-focused therapies for PTSD: A national qualitative study of treatment dropout.

Prolonged Exposure (PE) and Cognitive Processing Therapy (CPT) are first-line treatments for posttraumatic stress disorder (PTSD) and have been disseminated throughout the U.S. Veterans Health Administration. Treatment non-completion is common and lessens clinical effectiveness; however, prior work has failed to identify factors consistently associated with non-completion. Semi-structured interviews were conducted with a national sample of veterans who recently completed (n = 60) or did not complete (n = 66) PE or CPT. Non-completer interviews focused on factors that contributed to veterans' decisions to drop out and efforts undertaken to complete PE/CPT. Completer interviews focused on challenges faced in completing treatment and facilitators of completion. Transcripts were coded using a mixed deductive/inductive approach; constant comparison was used to identify differences between completers and non-completers. Completers and non-completers differed in the extent of treatment-specific therapist support received, therapists' flexibility in treatment delivery, the type of encouragement offered by the care team and social supports, their interpretation of symptom worsening, the perceived impact of treatment on functioning, and the impact of stressors on their treatment engagement. Treatment-specific therapist support, more patient-centered and flexible treatment delivery, leveraging the full care team, and addressing functional concerns are potential targets for PE and CPT engagement interventions.

Can families help veterans get more from PTSD treatment? A randomized clinical trial examining Prolonged Exposure with and without family involvement.

BACKGROUND: Posttraumatic stress disorder occurs in as many as one in five combat veterans and is associated with a host of negative, long-term consequences to the individual, their families, and society at large. Trauma-focused treatments, such as Prolonged Exposure, result in clinically significant symptom relief for many. Adherence to these treatments (i.e., session attendance and homework compliance) is vital to ensuring recovery but can be challenging for patients. Engaging families in veterans' treatment could prove to be an effective strategy for promoting treatment adherence while also addressing long-standing calls for better family inclusion in treatment for posttraumatic stress disorder. This paper describes the methods of a pragmatic randomized controlled trial designed to evaluate if family inclusion in Prolonged Exposure can improve treatment adherence. METHODS: One hundred fifty-six veterans, with clinically significant symptoms of posttraumatic stress disorder, will be randomized to receive either standard Prolonged Exposure or Prolonged Exposure enhanced through family inclusion (Family-Supported Prolonged Exposure) across three different VA facilities. Our primary outcomes are session attendance and homework compliance. Secondary outcomes include posttraumatic stress disorder symptom severity, depression, quality of life, and relationship functioning. The study includes a concurrent process evaluation to identify potential implementation facilitators and barriers to family involvement in Prolonged Exposure within VA. DISCUSSION: While the importance of family involvement in posttraumatic stress disorder treatment is non-controversial, there is no evidence base supporting best practices on how to integrate families into PE or any other individually focused trauma-focused treatments for posttraumatic stress disorder. This study is an important step in addressing this gap, contributing to the literature for both retention and family involvement in trauma-focused treatments. TRIAL REGISTRATION: ClinicalTrials.gov NCT03256227 . Registered on August 21, 2017.

Investigation of Therapist Effects on Patient Engagement in Evidence-Based Psychotherapies for Posttraumatic Stress Disorder in the Veterans Health Administration.

The present study examined whether certain Veterans Health Administration (VHA) therapists have more success than others in keeping patients engaged in evidence-based psychotherapies for posttraumatic stress disorder (PTSD). Our objective was to use multilevel modeling to quantify the variability between therapists in two indicators of patient engagement: early dropout (i.e., < 3 sessions) and adequate dose (i.e., ≥ 8 sessions). The phenomenon of systematic variability between therapists in patients' treatment experience and outcomes is referred to as "therapist effects." The sample included the 2,709 therapists who provided individual cognitive processing therapy (CPT) or prolonged exposure (PE) to 18,461 veterans with PTSD across 140 facilities in 2017. Data were extracted from administrative databases. For CPT, therapist effects accounted for 10.9% of the variance in early dropout and 8.9% of the variance in adequate dose. For PE, therapist effects accounted for 6.0% and 8.8% of the variance in early dropout and adequate dose, respectively. Facility only accounted for an additional 1.1%-3.1% of the variance in early dropout and adequate dose. For CPT, patients' odds of receiving an adequate dose almost doubled, OR = 1.41/0.72 = 1.96, if they were seen by a therapist in the highest compared with the lowest retention decile. For PE, the odds of a patient receiving an adequate dose were 84% higher, OR = 1.38/0.75 = 1.84, when treated by a therapist in the highest compared with the lowest retention decile. Therapist skills and work environment may contribute to variability across therapists in early dropout and adequate dose.

Physical functioning and mental health treatment initiation and retention for veterans with posttraumatic stress disorder: a prospective cohort study.

BACKGROUND: Most US adults with posttraumatic stress disorder (PTSD) do not initiate mental health treatment within a year of diagnosis. Increasing treatment uptake can improve health and quality of life for those with PTSD. Individuals with PTSD are more likely to report poor physical functioning, which may contribute to difficulty with treatment initiation and retention. We sought to determine the effects of poor physical functioning on mental health treatment initiation and retention for individuals with PTSD. METHODS: We used data for a national cohort of veterans in VA care; diagnosed with PTSD in June 2008-July 2009; with no mental health treatment in the prior year; and who responded to baseline surveys on physical functioning and PTSD symptoms (n = 6,765). Physical functioning was assessed using Veterans RAND 12-item Short Form Health Survey, and encoded as limitations in physical functioning and role limitations due to physical health. Treatment initiation (within 6 months of diagnosis) was determined using VA data and categorized as none (reference), only medications, only psychotherapy, or both. Treatment retention was defined as having ≥ 4 months of appropriate antidepressant or ≥ 8 psychotherapy encounters. RESULTS: In multinomial models, greater limitations in physical functioning were associated with lower odds of initiating only psychotherapy (OR 0.82 [95 % CI 0.68, 0.97] for limited a little and OR 0.74 [0.61, 0.90] for limited a lot, compared to reference "Not limited at all"). However, it was not associated with initiation of medications alone (OR 1.04 [0.85, 1.28] for limited a little and OR 1.07 [0.86, 1.34] for limited a lot) or combined with psychotherapy (OR 1.03 [0.85, 1.25] for limited a little and OR 0.95 [0.78, 1.17] for limited a lot). Greater limitations in physical functioning were also associated with lower odds of psychotherapy retention (OR 0.69 [0.53, 0.89] for limited a lot) but not for medications (e.g., OR 0.96 [0.79, 1.17] for limited a lot). Role limitations was only associated with initiation of both medications and psychotherapy, but there was no effect gradient (OR 1.38 [1.03, 1.86] for limitations a little or some of the time, and OR 1.18 [0.63, 1.06] for most or all of the time, compared to reference "None of the time"). Accounting for chronic physical health conditions did not attenuate associations between limitations in physical functioning (or role limitations) and PTSD treatment; having more chronic conditions was associated with lower odds of both initiation and retention for all treatments (e.g., for 2 + conditions OR 0.53 [0.41, 0.67] for initiation of psychotherapy). CONCLUSIONS: Greater limitations in physical functioning may be a barrier to psychotherapy initiation and retention. Future interventions addressing physical functioning may enhance uptake of psychotherapy.

Effectiveness and harms of mental health treatments in service members and veterans with deployment-related mild traumatic brain injury.

BACKGROUND: Co-morbidity of psychiatric conditions with traumatic brain injury (TBI) is common among service members and Veterans from recent deployments. Practice guidelines for mild TBI (mTBI) recommend management of co-occurring psychiatric conditions with existing treatments, but it is unclear whether the effectiveness of treatments for psychiatric conditions is impacted by mTBI. We conducted a systematic literature review to examine the effectiveness and harms of pharmacological and non-pharmacological treatments for posttraumatic stress disorder, depressive disorders, substance use disorders, suicidal ideation or attempts, and anxiety disorders in the presence of co-morbid deployment-related mTBI. METHODS: We searched bibliographic databases for peer-reviewed, English language studies published from 2000 to October 2017. Two reviewers independently completed abstract triage and full text review. RESULTS: We identified 7 studies (5 pre-post and 2 secondary analysis). Six assessed psychotherapy and one reported on hyperbaric oxygen therapy (HBO2). Studies comparing outcomes by TBI history found that a history of TBI does not affect treatment outcomes. Harms were reported only for HBO2 and were mild. No study examined the effectiveness of treatments for substance use disorders or suicidal ideation, or the effectiveness of pharmacological interventions for the psychiatric conditions of interest in service members and Veterans with mTBI. LIMITATIONS: Studies lacked usual care or wait-list control groups and no randomized trials were found, making the strength of evidence insufficient. CONCLUSIONS: Evidence is insufficient to fully assess the impact of TBI on the effectiveness of treatments for psychiatric conditions. Higher quality evidence with definitive guidance for providers treating this population is needed.

Sticking it out in trauma-focused treatment for PTSD: It takes a village.

OBJECTIVE: One in 3 veterans will dropout from trauma-focused treatments for posttraumatic stress disorder (PTSD). Social environments may be particularly important to influencing treatment retention. We examined the role of 2 support system factors in predicting treatment dropout: social control (direct efforts by loved ones to encourage veterans to participate in treatment and face distress) and symptom accommodation (changes in loved ones' behavior to reduce veterans' PTSD-related distress). METHOD: Veterans and a loved one were surveyed across 4 VA hospitals. All veterans were initiating prolonged exposure therapy or cognitive processing therapy (n = 272 dyads). Dropout was coded through review of VA hospital records. RESULTS: Regression analyses controlled for traditional, individual-focused factors likely to influence treatment dropout. We found that, even after accounting for these factors, veterans who reported their loved ones encouraged them to face distress were twice as likely to remain in PTSD treatment than veterans who denied such encouragement. CONCLUSIONS: Clinicians initiating trauma-focused treatments with veterans should routinely assess how open veterans' support systems are to encouraging veterans to face their distress. Outreach to support networks is warranted to ensure loved ones back the underlying philosophy of trauma-focused treatments. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Experiences with VHA care: a qualitative study of U.S. women veterans with self-reported trauma histories.

BACKGROUND: Women veterans in the United States, particularly those with posttraumatic stress disorder (PTSD) or a history of military sexual assault, have unique health care needs, but their minority status in the US Veterans Health Administration (VHA) has led to documented healthcare disparities when compared to men. This study's objective was to obtain a richer understanding of the challenges and successes encountered by women veterans with self-reported service-related trauma histories (particularly those with a history of military sexual assault and/or posttraumatic stress symptomology) receiving VHA care. METHODS: Thirty-seven female Vietnam and post-Vietnam (1975-1998) era veterans were randomly selected from a cohort of PTSD disability benefit applicants to complete semi-structured interviews in 2011-2012. Grounded-theory informed procedures were used to identify interview themes; differences between veterans with and without a history of military sexual assault were examined through constant comparison. RESULTS: At the time of the interviews, many women believed that VHA was falling short of meeting women veterans' needs (e.g., lack of women-only mental health programming). Also common, but particularly among those with a military sexual assault history, was the perception that VHA's environment was unwelcoming; being "surrounded by men" yielded emotions ranging from discomfort and mistrust to severe anxiety. A few veterans reported recent positive changes and offered additional suggestions for improvement. CONCLUSIONS: Findings suggest that while at the time of the interviews gains had been made in the delivery of gender-sensitive outpatient medical care, women veterans with a history of military sexual assault and/or posttraumatic stress symptomology perceived that they were not receiving the same quality of care as male veterans.

A Prospective Study of Racial and Ethnic Variation in VA Psychotherapy Services for PTSD.

OBJECTIVES: To determine whether there are racial or ethnic disparities in receipt of U.S. Department of Veterans Affairs (VA) psychotherapy services for veterans with posttraumatic stress disorder (PTSD), the authors examined the odds of receipt of any psychotherapy and of individual psychotherapy among self-identified racial and ethnic groups for six months after individuals were diagnosed as having PTSD. METHODS: Data were from a national prospective cohort study of 6,884 veterans with PTSD. Patients with no mental health care in the prior year were surveyed immediately following receipt of a PTSD diagnosis. VA databases were used to determine mental health service use. Analyses controlled for treatment need, access to services, and treatment beliefs. RESULTS: Among veterans with PTSD initially seen in VA mental health treatment settings, Latino veterans were less likely than white veterans to receive any psychotherapy, after the analyses controlled for treatment need, access, and beliefs. Among those initially seen in mental health settings who received some psychotherapy services, Latinos, African Americans, and Asian/Pacific Islanders were less likely than white veterans to receive any individual therapy. These racial-ethnic differences in psychotherapy receipt were due to factors occurring between VA health care networks as well as factors occurring within networks. Drivers of disparities differed across racial and ethnic groups. CONCLUSIONS: Inequity in psychotherapy services for some veterans from racial and ethnic minority groups with PTSD were due to factors operating both within and between health care networks.

Treatment initiation and dropout from prolonged exposure and cognitive processing therapy in a VA outpatient clinic.

Emerging data suggest that few veterans are initiating prolonged exposure (PE) and cognitive processing therapy (CPT) and dropout levels are high among those who do start the therapies. The goal of this study was to use a large sample of veterans seen in routine clinical care to 1) report the percent of eligible and referred veterans who (a) initiated PE/CPT, (b) dropped out of PE/CPT, (c) were early PE/CPT dropouts, 2) examine predictors of PE/CPT initiation, and 3) examine predictors of early and late PE/CPT dropout. We extracted data from the medical records of 427 veterans who were offered PE/CPT following an intake at a Veterans Health Administration (VHA) PTSD Clinical Team. Eighty-two percent (n = 351) of veterans initiated treatment by attending Session 1 of PE/CPT; among those veterans, 38.5% (n = 135) dropped out of treatment. About one quarter of veterans who dropped out were categorized as early dropouts (dropout before Session 3). No significant predictors of initiation were identified. Age was a significant predictor of treatment dropout; younger veterans were more likely to drop out of treatment than older veterans. Therapy type was also a significant predictor of dropout; veterans receiving PE were more likely to drop out late than veterans receiving CPT. Findings demonstrate that dropout from PE/CPT is a serious problem and highlight the need for additional research that can guide the development of interventions to improve PE/CPT engagement and adherence.

Does This Patient Have Posttraumatic Stress Disorder?: Rational Clinical Examination Systematic Review.

IMPORTANCE: Posttraumatic stress disorder (PTSD) is a relatively common mental health condition frequently seen, though often unrecognized, in primary care settings. Identifying and treating PTSD can greatly improve patient health and well-being. OBJECTIVE: To systematically review the utility of self-report screening instruments for PTSD among primary care and high-risk populations. EVIDENCE REVIEW: We searched MEDLINE and the National Center for PTSD's Published International Literature on Traumatic Stress (PILOTS) databases for articles published on screening instruments for PTSD published from January 1981 through March 2015. Study quality was rated using Quality Assessment of Diagnostic Accuracy Studies (QUADAS) criteria. STUDY SELECTION: Studies of screening instruments for PTSD evaluated using gold standard structured clinical diagnostic interviews that had interview samples of at least 50 individuals. FINDINGS: We identified 2522 citations, retrieved 318 for further review, and retained 23 cohort studies that evaluated 15 screening instruments for PTSD. Of the 23 studies, 15 were conducted in primary care settings in the United States (n = 14,707 were screened, n = 5374 given diagnostic interview, n = 814 had PTSD) and 8 were conducted in community settings following probable trauma exposure (ie, natural disaster, terrorism, and military deployment; n = 5302 were screened, n = 4263 given diagnostic interview, n = 393 were known to have PTSD with an additional 50 inferred by rates reported by authors). Two screens, the Primary Care PTSD Screen (PC-PTSD) and the PTSD Checklist were the best performing instruments. The 4-item PC-PTSD has a positive likelihood ratio of 6.9 (95% CI, 5.5-8.8) and a negative likelihood ratio of 0.30 (95% CI, 0.21-0.44) using the same score indicating a positive screen as used by the Department of Veterans Affairs in all of its primary care clinics. The 17-item PTSD Checklist has a positive likelihood ratio of 5.2 (95% CI, 3.6-7.5) and a negative likelihood ratio of 0.33 (95% CI, 0.29-0.37) using scores of around 40 as indicating a positive screen. Using the same score employed by primary care clinics in the Department of Veterans Affairs to indicate a positive screen, the 4-item PC-PTSD has a sensitivity of 0.69 (95% CI, 0.55-0.81), a specificity of 0.92 (95% CI, 0.86-0.95), a positive likelihood ratio of 8.49 (95% CI, 5.56-12.96) and a negative likelihood ratio of 0.34 (95% CI, 0.22-0.48). For the 17-item PTSD Checklist, scores around 40 as indicating a positive screen, have a sensitivity of 0.70 (95% CI, 0.64-0.77), a specificity of 0.90 (95% CI, 0.84-0.93), a positive likelihood ratio of 6.8 (95% CI, 4.7-9.9) and a negative likelihood ratio of 0.33 (95% CI, 0.27-0.40). CONCLUSIONS AND RELEVANCE: Two screening instruments, the PC-PTSD and the PTSD Checklist, show reasonable performance characteristics for use in primary care clinics or in community settings with high-risk populations. Both are easy to administer and interpret and can readily be incorporated into a busy practice setting.

Are there racial/ethnic disparities in VA PTSD treatment retention?

BACKGROUND: Chronic posttraumatic stress disorder (PTSD) can result in significant social and physical impairments. Despite the Department of Veterans Affairs' (VA) expansion of mental health services into primary care clinics to reach larger numbers of Veterans with PTSD, many do not receive sufficient treatment to clinically benefit. This study explored whether the odds of premature mental health treatment termination varies by patient race/ethnicity and, if so, whether such variation is associated with differential access to services or beliefs about mental health treatments. METHODS: Prospective national cohort study of VA patients who were recently diagnosed with PTSD (n = 6,788). Self-administered surveys and electronic VA databases were utilized to examine mental health treatment retention across racial/ethnic groups in the 6 months following the PTSD diagnosis controlling for treatment need, access factors, age, gender, treatment beliefs, and facility factors. RESULTS: African American and Latino Veterans were less likely to receive a minimal trial of pharmacotherapy and African American Veterans were less likely to receive a minimal trial of any treatment in the 6 months after being diagnosed with PTSD. Controlling for beliefs about mental health treatments diminished the lower odds of pharmacotherapy retention among Latino but not African American Veterans. Access factors did not contribute to treatment retention disparities. CONCLUSIONS: Even in safety-net healthcare systems like VA, racial and ethnic disparities in mental health treatment occur. To improve treatment equity, clinicians may need to more directly address patients' treatment beliefs. More understanding is needed to address the treatment disparity for African American Veterans.

Gender differences in VA disability status for PTSD over time.

OBJECTIVE: Posttraumatic stress disorder (PTSD) is the most prevalent psychiatric condition for which veterans receive service-connected disability benefits from the U.S. Department of Veterans Affairs (VA). Historically, women have been less likely than men to obtain PTSD disability benefits. The authors examined whether these gender disparities have been redressed over time and, if not, whether appropriate clinical factors account for persisting differences. METHODS: This longitudinal, observational study was based on a gender-stratified, nationally representative sample of 2,998 U.S. veterans who applied for VA disability benefits for PTSD between 1994 and 1998. The primary outcome was change in PTSD service connection over a ten-year period. RESULTS: Forty-two percent (95% confidence interval [CI]=38%-45%) of the women and 50% (CI=45%-55%) of the men originally denied service connection for PTSD eventually received such benefits. Only 8% (CI=7%-10%) of women and 5% (CI=4%-6%) of men lost PTSD disability status. Compared with men, women had lower unadjusted odds of gaining PTSD service connection (odds ratio [OR]=.70, CI=.55-.90) and greater unadjusted odds of losing PTSD service connection (OR=1.76, CI=1.21-2.57). Adjusting for clinical factors accounted for the gender difference in gaining PTSD service connection; adjusting for clinical factors and demographic characteristics eliminated the gender difference in loss of PTSD service connection. CONCLUSIONS: Gender-based differences in receipt of PTSD service connection persisted in this cohort over a ten-year period but were explained by appropriate sources of variation. Further research on possible disparities in loss of PTSD disability benefits is warranted.

Impact of treatment beliefs and social network encouragement on initiation of care by VA service users with PTSD.

OBJECTIVES: Despite the U.S. Department of Veterans Affairs' (VA) expansion of mental health services to treat VA service users with posttraumatic stress disorder (PTSD), many with PTSD do not engage in treatment. Numerous studies suggest that beliefs about treatment and social network factors, such as encouragement to seek treatment by others, affect engagement; however, prospective studies examining these factors are largely absent in this population. This study sought to understand social and attitudinal factors influencing treatment initiation, which may help to inform outreach interventions for VA service users with PTSD. METHODS: A prospective, national cohort study of mental health care use among veterans recently diagnosed as having PTSD (N=7,645) was undertaken. Data from self-administered surveys and administrative databases were analyzed to assess contributions of treatment-related beliefs and social network encouragement to subsequent mental health care use, after facility, demographic, need, and access factors were controlled. RESULTS: After the analysis controlled for treatment need and accessibility, the odds of initiating mental health care were greater for veterans who believed that they needed help for PTSD or other emotional problems and those who were encouraged to seek help by friends and family. Beliefs about the effectiveness of PTSD treatments were associated with the type of treatment received. Negative illness identity was not a barrier to treatment initiation. CONCLUSIONS: VA service users' social networks, veterans' perceptions of their need for mental health care, and their beliefs about PTSD treatment effectiveness may be fruitful targets for future treatment engagement interventions.

Long-term outcomes of disability benefits in US veterans with posttraumatic stress disorder.

CONTEXT: Most studies examining the clinical impact of disability benefits have compared aid recipients with people who never applied for benefits. Such practices may bias findings against recipients because disability applicants tend to be much sicker than never-applicants. Furthermore, these studies ignore the outcomes of denied claimants. OBJECTIVE: To examine long-term outcomes associated with receiving or not receiving Department of Veterans Affairs (VA) disability benefits for posttraumatic stress disorder (PTSD), the most common mental disorder for which veterans seek such benefits. DESIGN: Comparison of outcomes between successful and unsuccessful applicants for VA disability payments. Because we could not randomize the receipt of benefits, we used exact matching by propensity scores to control for potential baseline differences. We examined clinical outcomes approximately 10 years later. SETTING AND PARTICIPANTS: Stratified, nationally representative cohort of 3337 veterans who applied for VA PTSD disability benefits between January 1, 1994, and December 31, 1998. MAIN OUTCOME MEASURES: Assessment on validated survey measures of PTSD; work, role, social, and physical functioning; employment; and poverty. We compared outcomes with earlier scores. Homelessness and mortality were assessed using administrative data. RESULTS: Of still-living cohort members, 85.1% returned usable surveys. Symptoms of PTSD were elevated in both groups. After adjustment, awardees had more severe PTSD symptoms than denied claimants but were nonetheless more likely to have had a meaningful symptom reduction since their last assessment (-6.1 vs -4.4; SE, 0.1; P = .01). Both groups had meaningful improvements of similar magnitude in work, role, and social functioning (-0.15 vs -0.19; SE, 0.01; P = .94), but functioning remained poor nonetheless. Comparing awardees with denied claimants after adjustment, 13.2% vs 19.0% were employed (P = .11); 15.2% vs 44.8% reported poverty (P < .001); 12.0% vs 20.0% had been homeless (P = .02); and 10.4% vs 9.7% had died (P = .66). CONCLUSIONS: Regardless of claim outcome, veterans who apply for PTSD disability benefits are highly impaired. However, receiving PTSD benefits was associated with clinically meaningful reductions in PTSD symptoms and less poverty and homelessness.

Autobiographical memories of anger in violent and non-violent individuals: a script-driven imagery study.

Numerous studies have implicated frontal lobe dysfunction in anger-related impulsive violent behavior; however, few studies have looked at frontal activity during angry states in violent individuals. Using PET and a script-driven imagery paradigm, we report on autobiographical memories of angry vs. neutral memories in violent patients and psychiatric matched controls. Relative to recall of neutral memories, recall of anger-laden memories was associated with an activation of frontal regions among control subjects but not violent subjects. Violent subjects demonstrated relatively greater activations in the left amygdala, pontine, and cerebellar regions compared to control subjects.

Treatment receipt by veterans after a PTSD diagnosis in PTSD, mental health, or general medical clinics.

OBJECTIVE: Despite the high prevalence of posttraumatic stress disorder (PTSD) among veterans treated at Department of Veterans Affairs (VA) facilities, rates of initiation of mental health treatment and persistence in treatment are unknown. This study examined outpatient treatment participation among veterans with a recent PTSD diagnosis and treatment differences according to the VA sector in which they received the diagnosis (PTSD specialty treatment program, general mental health clinic, and general medical clinic). METHODS: Administrative data for 20,284 veterans who had received a diagnosis of PTSD at VA facilities were analyzed to determine rates of treatment initiation (any psychotropic prescription, an antidepressant prescription, behavioral counseling, and either a prescription or counseling) and maintenance of pharmacotherapy (at least four 30-day supplies), and counseling (at least eight visits) for the six months after diagnosis. RESULTS: Approximately two-thirds of the sample initiated treatment: 50% received a psychotropic medication and 39% received some counseling; 64% received either medication or counseling. About half of those given medication (54%) received at least a four-month supply, and 24% of those given counseling had at least eight sessions. Overall, 33% received minimally adequate treatment. Initiation, type, and duration varied by treatment sector: receipt of a diagnosis in a PTSD specialty program or a mental health clinic conferred small but significant benefits over receipt in a general medical clinic. CONCLUSIONS: Greater availability of mental health specialty services, particularly PTSD services, may be needed to ensure that veterans receive minimally adequate treatment after a PTSD diagnosis.