Prevalence of Sexual Violence and Intimate Partner Violence Among US Military Veterans: Findings from Surveys with Two National Samples.

BACKGROUND: Sexual violence (SV) and intimate partner violence (IPV) experiences are major social determinants of adverse health. There is limited prevalence data on these experiences for veterans, particularly across sociodemographic groups. OBJECTIVE: To estimate the prevalence of SV before, during, and after military service and lifetime and past-year IPV for women and men, and explore differences across sociodemographic groups. DESIGN: Data are from two national cross-sectional surveys conducted in 2020. Weighted prevalence estimates of SV and IPV experiences were computed, and weighted logistic regression models were used for comparisons across gender, race, ethnicity, sexual orientation, and age. PARTICIPANTS: Study 1 included veterans of all service eras (N = 1187; 50.0% women; 29% response rate). Study 2 included recently separated post-9/11 veterans (N = 1494; 55.2% women; 19.4% response rate). MAIN MEASURES: SV was assessed with the Deployment Risk and Resilience Inventory-2 (DRRI-2). IPV was assessed with the extended Hurt-Insult-Threaten-Scream Tool. KEY RESULTS: Women were more likely than men to experience pre-military SV (study 1: 39.9% vs. 8.7%, OR = 6.96, CIs: 4.71-10.28; study 2: 36.2% vs. 8.6%, OR = 6.04, CIs: 4.18-8.71), sexual harassment and/or assault during military service (study 1: 55.0% vs. 16.8%, OR = 6.30, CIs: 4.57-8.58; study 2: 52.9% vs. 26.9%, OR = 3.08, CIs: 2.38-3.98), and post-military SV (study 1: 12.4% vs. 0.9%, OR = 15.49, CIs: 6.42-36.97; study 2: 7.5% vs. 1.5%, OR = 5.20, CIs: 2.26-11.99). Women were more likely than men to experience lifetime IPV (study 1: 45.7% vs. 37.1%, OR = 1.38, CIs: 1.04-1.82; study 2: 45.4% and 34.8%, OR = 1.60, CIs: 1.25-2.04) but not past-year IPV (study 1: 27.9% vs. 28.3%, OR = 0.95, CIs: 0.70-1.28; study 2: 33.1% vs. 28.5%, OR = 1.24, CIs: 0.95-1.61). When controlling for gender, there were few differences across other sociodemographic groups, with the exception of sexual orientation. CONCLUSIONS: Understanding veterans' experiences of SV and IPV can inform identification and intervention efforts, especially for women and sexual minorities.

Using brief reflections to capture and evaluate end-user engagement: a case example using the COMPASS study.

BACKGROUND: Use of participatory research methods is increasing in research trials. Once partnerships are established with end-users, there is less guidance about processes research teams can use to successfully incorporate end-user feedback. The current study describes the use of a brief reflections process to systematically examine and evaluate the impact of end-user feedback on study conduct. METHODS: The Comparative Effectiveness of Trauma-Focused and Non-Trauma- Focused Treatment Strategies for PTSD among those with Co-Occurring SUD (COMPASS) study was a randomized controlled trial to determine the effectiveness of trauma-focused psychotherapy versus non-trauma-focused psychotherapy for Veterans with co-occurring posttraumatic stress disorder and substance use disorder who were entering substance use treatment within the Department of Veterans Affairs. We developed and paired a process of "brief reflections" with our end-user engagement methods as part of a supplemental evaluation of the COMPASS study engagement plan. Brief reflections were 30-minute semi-structured discussions with the COMPASS Team following meetings with three study engagement panels about feedback received regarding study issues. To evaluate the impact of panel feedback, 16 reflections were audio-recorded, transcribed, rapidly analyzed, and integrated with other study data sources. RESULTS: Brief reflections revealed that the engagement panels made recommended changes in eight areas: enhancing recruitment; study assessment completion; creating uniformity across Study Coordinators; building Study Coordinator connection to Veteran participants; mismatch between study procedures and clinical practice; therapist skill with patients with active substance use; therapist burnout; and dissemination of study findings. Some recommendations positively impact study conduct while others had mixed impact. Reflections were iterative and led to emergent processes that included revisiting previously discussed topics, cross-pollination of ideas across panels, and sparking solutions amongst the Team when the panels did not make any recommendations or recommendations were not feasible. CONCLUSIONS: When paired with end-user engagement methods, brief reflections can facilitate systematic examination of end-user input, particularly when the engagement strategy is robust. Reflections offer a forum of accountability for researchers to give careful thought to end-user recommendations and make timely improvements to the study conduct. Reflections can also facilitate evaluation of these recommendations and reveal end-user-driven strategies that can effectively improve study conduct. TRIAL REGISTRATION: ClinicalTrials.gov (NCT04581434) on October 9, 2020; https://clinicaltrials.gov/ct2/show/study/NCT04581434?term=NCT04581434&draw=2&rank=1 .

Walking the line between fidelity and flexibility: A conceptual review of personalized approaches to manualized treatments for posttraumatic stress disorder.

The heterogeneity of the core symptoms of posttraumatic stress disorder (PTSD), high rates of comorbid mental and physical health conditions, and substantial impact of the disorder on functioning and well-being contribute to complex clinical presentations that can be challenging to treat. Despite these challenges, there are excellent manualized treatments for PTSD with significant empirical support. Although the success of frontline treatments for PTSD is evident, there remains room for improvement as indicated by suboptimal response and attrition rates. To address challenges to optimal therapy outcomes (COTOs), researchers have conducted numerous clinical trials designed to (a) enhance the core structure of treatment protocols to increase flexibility or (b) expand the protocols to address comorbid conditions that inhibit recovery. However, it is implausible to ever conduct the number of enhancement and expansion clinical trials necessary to test manual modifications for the universe of possible COTOs. This conceptual review describes the concept of a personalized model of therapy that leverages a case formulation approach to implementing an evidence-based treatment for PTSD. This personalized approach provides guidance for the clinician in assessing the patient's COTOs, monitoring them throughout treatment, and relying on the patient's idiosyncratic data to inform treatment decisions, including how and when to diverge from treatment when clinically indicated and ensuring a clear path to return to trauma-focused work when the COTO is stabilized. This personalized, case formulation approach to treating PTSD provides guidance for adopting a more flexible approach to treating clinically complex patients while ensuring fidelity to the protocol.

"Pitching" posttraumatic stress disorder treatment: A qualitative study of how providers discuss evidence-based psychotherapies with patients.

The two widely available evidence-based psychotherapies (EBPs) for posttraumatic stress disorder (PTSD) are cognitive processing therapy and prolonged exposure. Although the U.S. Department of Veterans Affairs (VA) has invested in intensive clinical training to provide these first-line treatments, most military veterans do not receive these therapies. Prior research indicates that patient interest and motivation depend on how patients are educated, and differences in how information is presented shape their decision-making. To our knowledge, no studies have addressed how clinicians "pitch" EBPs for PTSD and examined whether certain approaches are more effective than others. We recorded and thematically analyzed 25 treatment planning sessions across 10 VA sites in the United States to better understand how providers talk to patients about treatment options. Five themes were identified: using rich description, integrating various forms of questioning to engage the patient, sharing prior patient success stories, using inviting and direct language, and tailoring therapy talk to fit patient needs. Providers learning to offer EBPs can use these strategies to serve as a "menu" of options that will allow them to present EBPs in a way that appeals to a particular patient.

The impact of substance use on posttraumatic stress disorder symptoms and treatment discontinuation.

This study examined the impact of ongoing substance use during posttraumatic stress disorder (PTSD) and substance use disorder (SUD) treatment on PTSD symptoms and treatment discontinuation. The study represents a secondary analysis of U.S. military veterans (N = 183) who participated in a randomized clinical trial for the treatment of both PTSD and SUD. Veterans mostly identified as Black (53.8%) or White (41.9%) and male (92.4%). Substance use, PTSD symptoms, and treatment discontinuation were measured at 4-week intervals throughout treatment. Predictors were the percentage of days with alcohol, cannabis, and other substance use (primarily cocaine and opioids) and the average number of alcoholic drinks per drinking day. Outcomes were PTSD symptoms and treatment discontinuation at concurrent and prospective assessments. Multilevel models accounted for the nested structure of the longitudinal data. Alcohol, cannabis, and other substance use did not predict PTSD symptoms or treatment discontinuation prospectively. Concurrently, we observed that as a participant's percentage of drinking days increased by 34.7% (i.e., 1 standard deviation), PTSD symptoms during the same period were 0.07 standard deviations higher (i.e., 1 point on the PCL), B = 0.03, p = .033. No other substances were related to PTSD symptoms concurrently. The findings demonstrate that PTSD symptoms improved regardless of substance use during exposure-based PTSD and SUD treatment, and treatment discontinuation was not associated with substance use. This study suggests that substance use during treatment cannot directly explain the poorer treatment outcomes observed in the literature on comorbid PTSD/SUD compared to PTSD-only populations.

"It made me feel more alive": A qualitative analysis of quality of life improvements following completion of trauma-focused therapy for posttraumatic stress disorder.

Posttraumatic stress disorder (PTSD) is associated with poor quality of life. Although randomized clinical trial data show improvements in quality of life following trauma-focused therapies (TFTs), including prolonged exposure therapy (PE) and cognitive processing therapy (CPT), less is known about how these improvements are experienced from the trauma survivor's perspective. A national sample of 60 veterans who recently completed TFT as part of routine care at U.S. Department of Veterans Affairs facilities participated in semistructured qualitative interviews during which the impact of treatment on quality of life was explored. Following a mixed deductive/inductive approach, six interrelated themes describing changes in quality of life emerged: full participation in social activities, greater emotional intimacy in relationships, improvements in parenting, expanded engagement in hobbies and community, increased occupational commitment and confidence, and more joy in life. The data highlight the positive impact of treatment on quality of life and provide depth to quantitative findings demonstrating improvements in quality of life following TFT.

Clusters Based on Within-Treatment Symptom Trajectories as Predictors of Dropout in Treatment for Posttraumatic Stress Disorder and Substance Use Disorder.

Objective: Dropout rates are high in treatments for co-occurring posttraumatic stress disorder (PTSD) and substance use disorders (SUDs). We examined dropout predictors in PTSD-SUD treatment. Methods: Participants were 183 veterans receiving integrated or phased motivational enhancement therapy and prolonged exposure. Using survival models, we examined demographics and symptom trajectories as dropout predictors. Using latent trajectory analysis, we incorporated clusters based on symptom trajectories to improve dropout prediction. Results: Hispanic ethnicity (integrated arm), Black or African American race (phased arm), and younger age (phased arm) predicted dropout. Clusters based on PTSD and substance use trajectories improved dropout prediction. In integrated treatment, participants with consistently-high use and low-and-improving use had the highest dropout. In phased treatment, participants with the highest and lowest PTSD symptoms had lower dropout; participants with the lowest substance use had higher dropout. Conclusions: Identifying within-treatment symptom trajectories associated with dropout can help clinicians intervene to maximize outcomes. ClinicalTrials.gov Identifier: NCT01211106.

Associations between DSM-5 posttraumatic stress disorder Criterion E2 endorsement and selected self-destructive behaviors in recent-era veterans: A focus on disordered eating.

Revisions to the posttraumatic stress disorder (PTSD) criteria in the DSM-5 included a new criterion in the alterations in arousal and reactivity cluster (i.e., engagement in reckless and self-destructive behaviors; Criterion E2). Despite its clinical significance, little is known about how this symptom corresponds to engagement in specific direct and indirect self-harm behaviors. We examined associations between E2 and self-reported recent engagement in direct and indirect self-harm behaviors, including disordered eating, which is not included in the prototypical E2 symptom scope, in a trauma-exposed sample of 1,010 recent-era veterans (61.5% self-identified women, 38.5% self-identified men). We also tested whether gender moderated these associations. We repeated analyses in a subsample of participants with clinically elevated PTSD symptoms. Participants self-reported past-month PTSD symptoms (PCL-5) as well as past-month nonsuicidal self-injury, suicidal ideation, suicide planning, fasting, purging, binge eating, compulsive exercise, and problematic alcohol and drug use. We found no evidence for moderation by gender for any of the behaviors examined in the main sample. However, after controlling for gender and demographic covariates, weighted logistic regressions showed small, significant associations between E2 score and direct self-harm behaviors, substance use, purging, and binge eating, aORs = 1.30-1.91. Criterion E2 was linked to behaviors included in the typical symptom scope (self-directed violence, substance use) and those that are not (disordered eating behaviors). Comprehensive screening for self-destructive behaviors, including disordered eating, among veteran men and women who endorse Criterion E2 is indicated.

Leveraging observational data to identify in-session patient and therapist predictors of cognitive processing therapy response and completion.

Cognitive processing therapy (CPT) is an evidence-based treatment for posttraumatic stress disorder (PTSD), but little is known about in-session process variables that predict symptom reduction and treatment completion during CPT. Examining potentially malleable factors that may promote or impede recovery can inform care delivery and enhance outcomes. The current study used observational ratings of CPT session recordings to examine in-session patient and therapist factors in cognitive, affective, and interpersonal domains to identify their relative contributions to predicting symptom outcomes and treatment completion. Participants were 70 adult survivors of interpersonal violence who received CPT. Predictors of better posttreatment PTSD outcomes included less patient fear, ß = .32, and less patient avoidance of engaging with the therapist, ß = .35. When using the last available PTSD score, less fear, ß = .23, and avoidance, ß = .28, continued to predict better outcomes, and more patient cognitive flexibility emerged as a stronger predictor of outcome, ß = -.33. Predictors of a higher likelihood of treatment completion included more therapist use of Socratic dialogue, OR = 6.75, and less therapist encouragement of patient affect, OR = 0.11. Patient sadness and anger and therapist expression of empathy did not predict symptom outcomes or treatment completion versus dropout. The results highlight the importance of patients' cognitions, emotions, and engagement with their therapist in CPT as well as the role of therapist behaviors in patient completion of treatment.

Impact of different cover letter information and incentives on Veterans' emotional responses to an unsolicited mailed survey about military traumas: a randomized, 3x2x2 factorial trial.

BACKGROUND: Altering cover letter information to reduce non-response bias in trauma research could inadvertently leave survey participants unprepared for potentially upsetting questions. In an unsolicited, mailed survey, we assessed participants' change in affect post-survey after altering key cover letter information and promising different incentives. We tested direct and indirect effects of participants carefully reading the cover letter on changes in their affect post-survey. METHODS: In a 3X2X2 randomized, factorial trial, 480 male and 480 female, nationally representative Veterans who were applying for posttraumatic stress disorder disability benefits were randomized to receive one of 12 different cover letters. The cover letters provided general versus more explicit information about the survey's trauma content and how their names were selected for study; we also promised different incentives for returning the survey. The main outcome was change in affect post-survey. We examined five potential moderators: combat or military sexual trauma exposure, posttraumatic stress disorder or serious mental illness diagnosis, and recency of military service. Mediators between reading the cover letter carefully and post-survey affect included how participants rated the cover letters' information and whether they thought the cover letters prepared them for the survey's content. A Bonferroni corrected alpha of 0.003 was the threshold for statistical significance. RESULTS: One hundred ninety men and 193 women reported their pre-and post-survey affect. Across all study conditions, out of 16 possible points, the net change in affect post-survey was less than a quarter-point for men and women. Mean changes in post-survey affect did not differ statistically significantly across any of the study factors (ps > 0.06); nor were there statistically significant interactions between any of the study factors and the 5 moderators after accounting for multiple comparisons (ps > 0.02). After controlling for pre-survey affect, reading the cover letter carefully had small effects on changes in post-survey affect, with larger associations seen in the women compared to men. Mediators' effects were often in opposite directions for men and women. CONCLUSION: General descriptions of a survey's trauma content appear ethically defensible. Research on cover letters' impacts on survey participants' emotional reactions and how those impacts differ by gender is needed.

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.

Reversals in initially denied Department of Veterans Affairs' PTSD disability claims after 17 years: a cohort study of gender differences.

BACKGROUND: In 2011, the Department of Veterans Affairs (VA) strengthened its disability claims processes for military sexual trauma, hoping to reduce gender differences in initial posttraumatic stress disorder (PTSD) disability awards. These process improvements should also have helped women reverse previously denied claims and, potentially, diminished gender discrepancies in appealed claims' outcomes. Our objectives were to examine gender differences in reversals of denied PTSD claims' outcomes after 2011, determine whether disability awards (also known as "service connection") for other disorders offset any PTSD gender discrepancy, and identify mediating confounders that could explain any persisting discrepancy. METHODS: From a nationally representative cohort created in 1998, we examined service connection outcomes in 253 men and 663 women whose initial PTSD claims were denied. The primary outcome was PTSD service connection as of August 24, 2016. Secondary outcomes were service connection for any disorder and total disability rating. The total disability rating determines the generosity of Veterans' benefits. RESULTS: 51.4% of men and 31.3% of women were service connected for PTSD by study's end (p < 0.001). At inception, 54.2% of men and 63.2% of women had any service connection-i.e., service connection for disorders other than PTSD (p = 0.01) and similar total disability ratings (p = 0.50). However, by study's end, more men than women had any service connection (88.5% versus 83.5%, p = 0.05), and men's mean total disability rating was substantially greater than women's (77.1 ± 26.2 versus 66.8 ± 30.7, p < 0.001). History of military sexual assault had the largest effect modification on men's versus women's odds of PTSD service connection. CONCLUSION: Even after 2011, cohort men were more likely than the women to reverse initially denied PTSD claims, and military sexual assault history accounted for much of this difference. Service connection for other disorders initially offset women's lower rate of PTSD service connection, but, ultimately, men's total disability ratings exceeded women's. Gender discrepancies in service connection should be monitored beyond the initial claims period.

Evaluation of an Implementation Intervention to Increase Reach of Evidence-Based Psychotherapies for PTSD in US Veterans Health Administration PTSD Clinics.

To evaluate an implementation intervention to increase the uptake, referred to as reach, of two evidence-based psychotherapies (EBP) for posttraumatic stress disorder (PTSD) in Veterans Health Administration (VHA) PTSD specialty clinics. The implementation intervention was external facilitation guided by a toolkit that bundled strategies associated with high EBP reach in prior research. We used a prospective quasi-experimental design. The facilitator worked with local champions at two low-reach PTSD clinics. Each intervention PTSD clinic was matched to three control clinics. We compared the change in EBP reach from 6-months pre- to post-intervention using Difference-in-Difference (DID) effect estimation. To incorporate possible clustering effects and adjust for imbalanced covariates, we used mixed effects logistic regression to model the probability of EBP receipt. Analyses were conducted separately for PTSD and other mental health clinics. 29,446 veterans diagnosed with PTSD received psychotherapy in the two intervention and six control sites in the two 6-month evaluation periods. The proportion of therapy patients with PTSD receiving an EBP increased by 16.98 percentage points in the intervention PTSD clinics compared with .45 percentage points in the control PTSD clinics (DID = 16.53%; SE = 2.26%). The adjusted odd ratio of a patient receiving an EBP from pre to post intervention was almost three times larger in the intervention than in the control PTSD clinics (RoR 2.90; 95% CI 2.22-3.80). EBP reach was largely unchanged in other (not PTSD specialty) mental health clinics within the same medical centers. Toolkit-guided external facilitation is a promising intervention to improve uptake of EBPs in VHA. Toolkits that pre-specify targets for clinic change based on prior research may enhance the efficiency and effectiveness of external facilitation. Trial registration ISRCTN registry identifier: ISRCTN65119065. Available at https://www.isrctn.com/search?q=ISRCTN65119065 .

Yoga Practice Among Veterans With and Without Chronic Pain: A Mixed Methods Study.

OBJECTIVES: The primary aim of this study was to examine differences in yoga practice between persons with and without chronic pain. Secondarily, we describe use of the Essential Properties of Yoga Questionnaire, Short Form (EPYQ-SF) for self-report. DESIGN: Participants were members of an existing cohort of veterans who completed a 2015-2016 survey focused on pain and nonpharmacological health practices. Cohort members who reported yoga in the past year [n=174 (9.4%) of 1850] were eligible for the present study, which used multiple-contact mixed-mode survey methodology to collect data on yoga practices. The EPYQ-SF was used to assess properties and context of yoga practice. Practice patterns were compared for participants with and without chronic pain. To explore potential reasons for reported yoga practice patterns, focused semistructured interviews were conducted with a subset of participants. RESULTS: Of 174 participants contacted, 141 (82%) returned the yoga questionnaire and 110 (78% of respondents) were still practicing yoga. Among yoga practitioners, 41 (37%) had chronic pain. Practitioners with chronic pain reported gentler (2.8 vs. 3.1, 5-point scale) and less active (2.9 vs. 3.3) yoga practice than those without. Those with chronic pain attended yoga studios less frequently and reported shorter yoga practices than those without. Most yoga practice was self-directed and at home. CONCLUSIONS: Differences in yoga practice of persons with and without chronic pain have implications for implementation of yoga interventions for chronic pain. Future interventions should focus on alternative individual delivery formats or addressing barriers to group practice among people with chronic pain.

Changes in affect after completing a mailed survey about trauma: two pre- and post-test studies in former disability applicants for posttraumatic stress disorder.

BACKGROUND: One potential concern with using mailed surveys containing trauma-related content is the possibility of re-traumatizing survivors without a trained mental health professional present. Prior research provides insufficient guidance regarding the prevalence and magnitude of this risk because the psychological harms of trauma-related surveys have typically been estimated using single post-test observations. Post-test observations cannot quantify magnitude of change in participants' emotional states and may over or under estimate associations between participants' characteristics (risk factors) and post-survey upset. METHODS: We conducted two pre- and post-test studies in samples of former applicants for posttraumatic stress disorder disability benefits: 191 males who served during Gulf War I plus 639 male and 921 female Veterans who served sometime between 1955 and 1998. We used two 9-point items from the Self-Assessment Manikins to measure participants' valence (sadness/happiness) and arousal (tenseness/calmness) before and after they completed mailed surveys asking about trauma-related symptoms or experiences. We examined the following potential predictors for post-survey sadness and tenseness: screening positive for posttraumatic stress disorder, having a serious mental illness, and history of military sexual assault or combat. RESULTS: After the survey, across the groups, 29.3-41.8% were sadder, 45.3-52.2% had no change in valence, and 12.9-22.5% were happier; 31.7-40.2% were tenser, 40.6-48.2% had no change in arousal, and 17.3-24.0% were calmer. The mean increase in sadness or tenseness post-survey was less than one point in all groups (SD's < 1.7). Cohen's d ranged from 0.07 to 0.30. Most hypothesized predictors were associated with greater baseline sadness or tenseness, but not necessarily with larger post-survey changes. Women with a history of military sexual assault had the largest net post-survey changes in sadness (mean = 0.7, SD = 1.4) and tenseness (mean = 0.6, SD = 1.6). CONCLUSION: While a substantial minority of Veterans reported more sadness or tenseness post-survey, the net change in affect was small. Most hypothesized risk factors were actually associated with higher baseline sadness or tenseness scores. When receiving unsolicited, trauma-related surveys by mail, separate protections for Veterans with the risk factors studied here do not seem necessary.

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.

Does Co-Occurring Traumatic Brain Injury Affect VHA Outpatient Health Service Utilization and Associated Costs Among Veterans With Posttraumatic Stress Disorder? An Examination Based on VHA Administrative Data.

OBJECTIVE: To examine whether a traumatic brain injury (TBI) diagnosis was associated with increased outpatient service utilization and associated costs among Iraq and Afghanistan (Operation Enduring Freedom [OEF]/Operation Iraqi Freedom [OIF]/Operation New Dawn [OND]) War veterans with posttraumatic stress disorder (PTSD) who used Veterans Health Affairs (VHA) care in a 1-year period. SETTING: N/A. PARTICIPANTS: OEF/OIF/OND veterans with a diagnosis of PTSD and/or TBI who utilized VHA services during fiscal year 2012 (N = 164 644). DESIGN: Observational study using VHA administrative data. MAIN MEASURES: Outpatient VHA utilization (total and by category of care) and associated costs (total and by VA Health Economic Resource Center cost category). RESULTS: Veterans in the comorbid PTSD/TBI group had significantly more total outpatient appointment than veterans with PTSD but no TBI. This pattern held for all categories of care except orthopedics. The comorbid TBI/PTSD group ($5769) incurred greater median outpatient healthcare costs than the PTSD ($3168) or TBI-alone ($2815) group. CONCLUSIONS: Co-occurring TBI increases the already high level of healthcare utilization by veterans with PTSD, suggesting that OEF/OIF/OND veterans with comorbid PTSD/TBI have complex and wide-ranging healthcare needs.

Persistent Serious Mental Illness Among Former Applicants for VA PTSD Disability Benefits and Long-Term Outcomes: Symptoms, Functioning, and Employment.

Millions of U.S. veterans have returned from military service with posttraumatic stress disorder (PTSD), for which a substantial number receive U.S. Department of Veterans Affairs (VA) disability benefits. Although PTSD is treatable, comorbid serious mental illness (defined here as schizophrenia, schizoaffective disorder, and bipolar spectrum disorders) could complicate these veterans' recovery. Using VA administrative data, we examined the burden of persistent serious mental illness in a nationally representative cohort of 1,067 men and 1,513 women who applied for VA PTSD disability benefits between 1994 and 1998 and served during or after the Vietnam conflict. Self-reported outcomes were restricted to the 713 men and 1,015 women who returned surveys at each of 3 collection points. More than 10.0% of men and 20.0% of women had persistent serious mental illness; of these, more than 80.0% also had persistent PTSD. On repeated measures modeling, those with persistent serious mental illness consistently reported more severe PTSD symptoms and poorer functioning in comparison to other participants (ps < .001); their employment rate did not exceed 21.0%. Interactions between persistent serious mental illness and PTSD were significant only for employment (p = .002). Persistent serious mental illness in this population was almost 2 to 19 times higher than in the general U.S. POPULATION: The implications of these findings are discussed.

Context Matters: Team and Organizational Factors Associated with Reach of Evidence-Based Psychotherapies for PTSD in the Veterans Health Administration.

Evidence-based psychotherapies for PTSD are often underused. The objective of this mixed-method study was to identify organizational and clinic factors that promote high levels of reach of evidence-based psychotherapies for PTSD 10 years into their dissemination throughout the Veterans Health Administration. We conducted 96 individual interviews with staff from ten outpatient PTSD teams at nine sites that differed in reach of evidence-based psychotherapies for PTSD. Major themes associated with reach included clinic mission, clinic leader and staff engagement, clinic operations, staff perceptions, and the practice environment. Strategies to improve reach of evidence-based psychotherapies should attend to organizational and team-level factors.