A Randomized Clinical Trial of Clinician-Supported PTSD Coach in VA Primary Care Patients.

BACKGROUND: Posttraumatic stress disorder (PTSD) is common in primary care patients; however, evidence-based treatments are typically only available in specialty mental healthcare settings and often not accessed. OBJECTIVE: To test the effectiveness of a brief primary care-based treatment, Clinician-Supported PTSD Coach (CS PTSD Coach) was compared with Primary Care Mental Health Integration-Treatment as Usual (PCMHI-TAU) in (1) reducing PTSD severity, (2) engaging veterans in specialty mental health care, and (3) patient satisfaction with care. DESIGN: Multi-site randomized pragmatic clinical trial. PARTICIPANTS: A total of 234 veterans with PTSD symptoms who were not currently accessing PTSD treatment. INTERVENTION: CS PTSD Coach was designed to be implemented in Veterans Affairs PCMHI and combines mental health clinician support with the "PTSD Coach" mobile app. Four 30-min sessions encourage daily use of symptom management strategies. MAIN MEASURES: PTSD severity was measured by clinician-rated interviews pre- and post-treatment (8 weeks). Self-report measures assessed PTSD, depression, and quality of life at pretreatment, posttreatment, and 16- and 24-week follow-ups, and patient satisfaction at post-treatment. Mental healthcare utilization was extracted from medical records. KEY RESULTS: Clinician-rated PTSD severity did not differ by condition at post-treatment. CS PTSD Coach participants improved more on patient-reported PTSD severity at post-treatment than TAU participants (D = .28, p = .021). Coach participants who continued to have problematic PTSD symptoms at post-treatment were not more likely to engage in 2 sessions of specialty mental health treatment than TAU participants. Coach participants engaged in 74% more sessions in the intervention and reported higher treatment satisfaction than TAU participants (p < .001). CONCLUSIONS: A structured 4-session intervention designed to align with patient preferences for care resulted in more patient-reported PTSD symptom relief, greater utilization of mental health treatment, and overall treatment satisfaction than TAU, but not more clinician-rated PTSD symptom relief or engagement in specialty mental health.

A Randomized Controlled Trial of Brief Skills Training in Affective and Interpersonal Regulation (STAIR) for Veterans in Primary Care.

This randomized controlled trial assessed the efficacy of a five-session version of Skills Training in Affective and Interpersonal Regulation (STAIR) among veterans obtaining treatment in primary care. Veterans who screened positive for either posttraumatic stress disorder (PTSD) or depression (N = 26) were enrolled and randomized into either five-session STAIR or treatment as usual (TAU). Assessments of PTSD symptoms (PTSD Checklist for DSM-5; PCL-5), depression (Beck Depression Inventory-II; BDI-II), emotion regulation (Difficulties in Emotion Regulation Scale; DERS), and social engagement difficulties (World Health Organization Disability Assessment 2.0; WHODAS-2) were assessed at pretreatment, posttreatment, and 3-month follow-up assessments. Participants assigned to the five-session STAIR condition reported significant improvements on all measures, whereas those assigned to TAU showed no change. Group × Treatment interactions were significant for all outcomes, and effect sizes for the interactions ranged from moderate to large, Hedge's gs = 0.81 for the PCL-5, 1.15 for the BDI-II, 0.75 for the DERS, and 0.81 for the WHODAS-2. The results indicate that five-session STAIR, a brief, skills-focused treatment, may be effective in reducing a range of symptoms and in improving social functioning among veterans treated in primary care settings.

Rethinking Violence Prevention in Rural and Underserved Communities: How Veteran Peer Support Groups Help Participants Deal with Sequelae from Violent Traumatic Experiences.

PURPOSE: Access to mental health care and programs that address violence prevention can be a challenge for veterans residing in rural and underserved areas. A growing number of trauma-affected veterans are now returning to rural areas upon completion of military service. The Palo Alto VA Health Care System has piloted a program known as the Peer Support Program (PSP) where certified peer support specialists hold group sessions for their fellow veterans in remote, community-based outpatient clinics. METHODS: A total of 29 peer-support group participants and 1 certified peer specialist were interviewed. Semistructured interviews began with open-ended questions regarding participant firsthand experiences with the support group setting. These were followed by direct questions that addressed the role of the PSP, expectations for the PSP, as well as benefits and limitations of the program. We performed a domain analysis using the Spradley ethnographic method on 325 pages of compiled narrative data focusing on violence-related themes. FINDINGS: Four key themes emerged, including: 1) Violence in Military Training Not Acceptable in Civilian Life, 2) Peer Support Creates the Trust to Speak Freely, 3) Skills Are Taught to Defuse Violence, and 4) The Veteran Peer Support Specialist Relationship Is Multi-Dimensional. CONCLUSIONS: These emergent themes illustrate how trauma-focused assistance rendered by peer support specialists as part of an interdisciplinary mental health team can be implemented to benefit trauma-affected individuals and their communities in the prevention of future violence.

Peer support in an outpatient program for veterans with posttraumatic stress disorder: Translating participant experiences into a recovery model.

Veterans returning from recent conflicts present with increased rates of posttraumatic stress disorder (PTSD), and veterans from prior service eras continue to seek trauma-based services. Peer support for veterans with PTSD has the potential to resolve ongoing challenges in access and engagement in mental health care. Assessing the value of peer support services requires a thorough understanding of the expected role and the empirical mechanisms of peer support participation in PTSD recovery. To better understand these mechanisms, this study interviewed 29 veteran participants from an established peer support program (PSP), located in the Central Valley of the Veterans Affairs (VA) Palo Alto Health Care System (VAPAHCS) in Northern California. A domain analysis of narrative transcripts generated 34 codes through a grounded theory method. Codes were organized into the following thematic categories: the perceived role of the PSP, supportive experiences of the PSP, global gains from the PSP, and limitations to PSP and further mental health engagement. These results were synthesized into a theoretical model that identifies improved functioning and reduced distress as the expected outcomes of PSP-mediated recovery and illustrates the continuum from in-group experiences to these outcomes. Our results suggest that PSP-mediated recovery is defined as acceptance of PTSD into daily life and identity, rather than resolution of symptoms. This conceptualization has implications for peer support provider training, PSP integration into health care settings, and future outcome analyses on the effectiveness of PSPs. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Peer Support and Outcome for Veterans with Posttraumatic Stress Disorder (PTSD) in a Residential Rehabilitation Program.

This observational study aims to determine the characteristics of peer support that change attitudes toward recovery and PTSD symptom severity. The study respondents were a sample of 55 VA patients who were residents at a residential rehabilitation program for PTSD where they were the recipients of peer support. Veterans perceived greater support from other veterans (mean = 4.04 on 1-5 scale, SD = 0.78) than from any other source. Greater perceived support from the peer support provider, other veterans and mental health staff was associated with improvements from intake to discharge in recovery attitudes. Greater perceived support from other veterans and mental health staff was associated with an improvement in PTSD symptoms. Results from this study suggest that positive perceptions of peer support favorably influences attitudes toward recovery, from PTSD, in veterans who are the recipients of such support.

Associations of psychotherapy dose and SSRI or SNRI refills with mental health outcomes among veterans with PTSD.

OBJECTIVE: This study assessed associations between psychotherapy and pharmacotherapy for posttraumatic stress disorder (PTSD) and longitudinal changes in PTSD, depression, and mental health functioning among U.S. veterans diagnosed as having PTSD. METHODS: Information about self-reported symptoms experienced from .5 to over three years was collected from 482 veterans diagnosed as having PTSD. Administrative data from the U.S. Department of Veterans Affairs (VA) were used to calculate initiation of a course of selective serotonin reuptake inhibitors (SSRIs) or serotonin norepinephrine reuptake inhibitors (SNRIs), days of medication coverage, and number of PTSD-related psychotherapy visits during the year after a baseline survey. Hierarchical linear modeling was used to analyze the effects of psychotherapy dose, initiation of an SSRI or SNRI, and medication coverage on symptoms over one year. RESULTS: In the year after baseline, over half of the sample (55%) received no psychotherapy for PTSD, and only 8% met the VA's proposed standard of eight PTSD-related sessions within 14 weeks. Nearly half of the participants (47%) were prescribed an SSRI or SNRI and 37% completed a 90-day trial in the year after baseline. Participants' symptoms improved slightly over time. Participants who received eight or more psychotherapy sessions in 14 weeks, completed a 90-day course of SSRIs or SNRIs, or had more days of medication coverage did not improve more than participants who received less treatment. CONCLUSIONS: These dose-of-care benchmarks were not related to symptom improvement, highlighting the importance of directly assessing the impact of particular treatments on patient outcomes rather than solely relying on process measures.

Longitudinal correlates of aggressive behavior in help-seeking U.S. veterans with PTSD.

The current study examined the longitudinal effects of clinical and treatment utilization factors on aggressive behavior among 376 help-seeking U.S. veterans recently diagnosed with posttraumatic stress disorder (PTSD) who were followed for 5-12 months. Participants were sampled from 4 strata: male Iraq/Afghanistan veterans, female Iraq/Afghanistan veterans, male prior-era veterans, and female prior-era veterans. Hierarchical regression analyses indicated that changes in PTSD severity were significantly associated with changes in aggressive behavior among veterans who reported any aggression at baseline (ß = .15). Changes in days of alcohol intoxication also were positively associated with changes in aggressive behavior (ß = .16). Participants with both a benzodiazepine prescription and any baseline aggression were significantly more likely to increase in aggressive behavior over time (ß = .14). Contrary to our hypotheses, reductions in aggressive behavior were not related to the number of outpatient mental health visits or to first-line recommended psychotropic medications. Results inform assessment and clinical research on changes in aggressive behavior among veterans with PTSD.

Do veterans with posttraumatic stress disorder receive first-line pharmacotherapy? Results from the longitudinal veterans health survey.

OBJECTIVE: Guidelines addressing the treatment of veterans with posttraumatic stress disorder (PTSD) strongly recommend a therapeutic trial of selective serotonin reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors (SNRIs). This study examined veteran characteristics associated with receiving such first-line pharmacotherapy, as well as how being a veteran of the recent conflicts in Afghanistan and Iraq impact receipt of pharmacotherapy for PTSD. METHOD: This was a national study of 482 Veterans Affairs (VA) outpatients between the ages of 18 and 69 years who had been newly diagnosed with PTSD (DSM-IV criteria: 309.81) during a VA outpatient visit between May 31, 2006, and December 7, 2007. Participants completed a mailed survey between August 11, 2006, and April 6, 2008. Veterans from the Afghanistan and Iraq conflicts and female veterans were intentionally oversampled. Logistic regression models were developed to predict 2 dependent variables: odds of initiating an SSRI/SNRI and, among veterans who initiated an SSRI/SNRI, odds of receiving an adequate therapeutic trial. Each dependent variable was regressed on a variety of sociodemographic and survey characteristics. RESULTS: Of the 377 veterans prescribed a psychotropic medication, 73% (n = 276) received an SSRI/SNRI, of whom 61% (n = 168) received a therapeutic trial. Afghanistan and Iraq veterans were less likely to receive a therapeutic trial (odds ratio [OR] = 0.45; 95% CI, 0.27-0.75; P < .01), with presence of a comorbid depression diagnosis in the year after the index episode moderating this relationship, which further decreased the odds of completing a therapeutic trial (OR = 0.29; 95% CI, 0.09-0.95; P < .05). CONCLUSIONS: Reduced levels of receipt of first-line pharmacotherapy among recent veteran returnees parallel previous findings of less mental health treatment utilization in this population and warrant investigation.

Concordance between psychotropic prescribing for veterans with PTSD and clinical practice guidelines.

OBJECTIVE: Clinical practice guidelines for the pharmacological treatment of posttraumatic stress disorder (PTSD) do not support the use of benzodiazepines and cite insufficient evidence to recommend mood stabilizers. Although guidelines previously recommended second-generation antipsychotics as adjunct medication, recent research findings have also brought this recommendation into question. This study aimed to determine which characteristics of veterans with diagnosed PTSD were associated with receiving prescriptions for benzodiazepines and mood stabilizers and second-generation antipsychotics. METHODS: The survey responses of 482 veterans with PTSD were combined with prescription information from Veterans Affairs national pharmacy databases. The researchers assessed the use of eight classes of psychotropics prescribed for patients with PTSD in the year after a new PTSD diagnosis. Multivariate logistic regressions identified demographic characteristics, symptom severity, co-occurring psychiatric diagnoses, health service use, and attitudinal characteristics associated with prescribing of benzodiazepines, second-generation antipsychotics, and mood stabilizers. RESULTS: In the absence of a clearly indicated co-occurring psychiatric diagnosis, long-term benzodiazepines were prescribed to 14%, second-generation antipsychotics to 15%, and mood stabilizers to 18% of veterans with PTSD. Benzodiazepine prescribing was associated with symptoms of insomnia. Having a mental health inpatient stay (odds ratio [OR]=8.01, p<.001) and at least one psychotherapy visit (OR=5.37, p<.001) were predictors of being prescribed a second-generation antipsychotic. Reporting more symptom severity (OR=1.84, p<.001) and fewer alcohol use problems (OR=.36, p<.03) predicted being prescribed a mood stabilizer. CONCLUSIONS: Prescribing patterns appeared generally consistent with treatment guidelines. Notable exceptions and areas worthy of future attention are discussed.

Results of a multisite survey of U.S. psychiatry residents on education in professionalism and ethics.

OBJECTIVE: The authors assess the perspectives of psychiatry residents about the goals of receiving education in professionalism and ethics, how topics should be taught, and on what ethical principles the curriculum should be based. METHOD: A written survey was sent to psychiatry residents (N=249) at seven U.S. residency programs in Spring 2005. The survey was based on an instrument originally developed at the University of New Mexico, consisting of 149 questions in 10 content domains, with 6 questions regarding ethics experiences during training and 5 demographic questions. RESULTS: A total of 151 psychiatry residents (61%) returned usable responses to our survey. Residents reported receiving a moderate amount of ethics training during medical school (mean: 5.20; scale: 1: None to 9: Very Much) and some ethics training during residency (mean: 4.60). Residents endorsed moderate to moderately-strong agreement with all 11 goals of medical education in professionalism and ethics (means: 5.29 to 7.49; scale: 1: Strongly Disagree to 9: Strongly Agree). Respondents were more likely to endorse the value of clinically- and expert-oriented learning methods over web-based educational approaches. CONCLUSION: U.S. psychiatry residents endorse a range of goals for education in professionalism and ethics. At the same time, they prefer that these topics be taught in clinically relevant ways and through expert instruction. The value of web-based approaches warrants further investigation.

Psychiatric residents' needs for education about informed consent, principles of ethics and professionalism, and caring for vulnerable populations: results of a multisite survey.

OBJECTIVE: The authors examined psychiatric residents' perceived needs for education in informed consent, principles of ethics and professionalism, and treating vulnerable populations. METHOD: A written survey was distributed to psychiatric residents (N=249) at seven U.S. residency programs in 2005. The survey contained 149 questions in 10 content domains, 6 questions regarding personal ethics experiences during training, and 5 demographic questions. Here, the authors report responses to items regarding informed consent, professional principles, and care of vulnerable populations. RESULTS: A total of 151 psychiatric residents responded to the survey (61% overall response rate). On a scale of 1: Much Less, to 5: Same, to 9: Much More Education Desired, psychiatric residents indicated that 9 topics relating to informed consent, 10 issues surrounding professional principles, and 25 topics relating to care of vulnerable populations should receive more educational attention than currently provided. No topics were rated as needing less education. Higher ratings of the need for additional educational attention were associated with more reported ethical conflicts encountered during training. CONCLUSION: Psychiatric residents at seven diverse U.S. training programs expressed the need for greater educational attention to issues around informed consent, ethical and professional principles, and treating vulnerable populations. These findings reflect the ongoing need for educators to devote curricular attention to these areas so that trainees can incorporate such knowledge effectively into their daily clinical practice in an always-complex, highly fragmented medical care environment.

Ethics in psychotherapy: a focus on professional boundaries and confidentiality practices.

The practice of psychotherapy gives rise to many ethical dilemmas. In this article we offered a "primer" on the most commonly cited ethical concerns in psychotherapy related to professionalism and therapeutic boundaries and confidentiality. There is no single answer to the varied and complex ethical issues that therapists may encounter in their treatment of patients. Such dilemmas are dynamic, nuanced, complex, and highly context dependent. Although professional codes offer guidance on optimal standards of conduct, they do not always offer clear answers; hence, therapists need to be able to critically evaluate and interpret such codes in relation to their daily practice. The contemporary therapist continues to face new dilemmas in an ever-evolving and dynamic twenty-first-century practice environment. Ethical therapists serve the well-being of their patients above all other interests or commitments. Therapists who are attentive to the professional obligations they possess can adopt several strategies to increase their ethical competence, including constantly evaluating their own attitudes and behaviors in addition to those of their patients, engaging in dialog and developing expertise in relation to ethics issues, having a solid grasp of relevant professional codes of conduct, and demonstrating an openness to consultation with peers and exposure of their work to peer review.