Peer specialist-led interventions in primary care at the Veterans Health Administration: An integrative review.

The Veterans Health Administration (VHA) currently employs over 1,300 peer specialists-veterans with lived experience of mental illness who are in recovery and have been trained to provide support to other veterans experiencing these issues. VHA peer specialists have largely been employed in behavioral health settings. In 2014, VHA began to employ peer specialists in primary care settings via the peers in Patient Aligned Care Team (PACT) program, and congressional legislation was passed to expand this program in 2022. In light of this expansion, it is important to evaluate the effectiveness of interventions provided in the Peers in PACT program. This integrative review of studies of peer specialist-led interventions in VHA primary care includes 13 articles with 11 unique studies represented in these articles. These studies targeted mental health symptoms, substance use, health/well-being, and health/treatment engagement. Seven described single-arm studies, three described two-arm studies with a treatment as usual control group, and three described two-arm studies with an active control group. The majority of these studies demonstrated statistically significant improvements on at least one main outcome. Seven studies also included qualitative interviews with veterans; several common themes emerged, including the importance of working with a veteran peer with shared lived experiences, and finding peers helpful in providing accountability, motivation, encouragement, emotional support, resources, and assistance navigating VA health care. Recommendations for future research on the peers in PACT program are discussed, including a need for more RCTs with active controls. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Associations between posttraumatic stress disorder and eating disorder symptoms among women veterans.

Recent research suggests high rates of posttraumatic stress disorder (PTSD) and eating disorder (ED) comorbidity in women veterans. This study aims to expand the literature by examining associations between PTSD and ED diagnoses and symptoms in this population. We assessed probable PTSD diagnosis and symptom clusters (intrusion, avoidance, arousal and reactivity, and negative alterations in cognition and mood [NACM]), as well as probable Binge Eating Disorder (BED) diagnosis and ED subscales (dietary restraint, shape/weight overvaluation, and body dissatisfaction) in a sample of women veterans (N = 371). We investigated significance at the standard p < .05, and the Bonferroni-corrected p < .005 cut-off to adjust for experiment-wise error. Overall, we found that probable PTSD was associated with provisional BED (p < .001) using logistic regression at both cut-offs. Probable PTSD was associated with all ED subscales (all p's < 0.003) using linear regression models also at both cut-offs. Provisional BED was associated with NACM at p < .05 (p = .046), though it did not meet significance at our conservative cut-off. NACM was also associated with shape/weight overvaluation (p = .02) and a global ED score (p = .01) at p < .05, but not at our conservative cut-off; arousal was associated with shape/weight overvaluation (p = .04) and the global ED score (p = .02) at p < .05, but not at our conservative cut-off. Our findings may further guide how ED-related topics can be integrated in PTSD treatment for women veterans with comorbid PTSD and ED.

Which veterans with PTSD are most likely to report being told of their diagnosis?

Veterans who do not know about their posttraumatic stress disorder (PTSD) diagnosis experience a fundamental barrier to accessing effective treatment. Little is known about the characteristics that influence veterans' PTSD diagnosis knowledge (i.e., report of being told they have a PTSD diagnosis by a healthcare provider). Veterans who met probable and provisional criteria for PTSD on the self-report PTSD checklist for DSM-5 were identified from the Comparative Health Assessment Interview Research Study (n = 2335). Weighted logistic regression was performed to identify demographic variables, clinical characteristics, and social determinants of health (e.g., economic instability, homelessness, healthcare coverage) associated with PTSD diagnosis knowledge among post-9/11 veterans. Approximately 62% of veterans with probable and provisional PTSD had PTSD diagnosis knowledge. Predictors with the strongest associations included another mental health diagnosis (OR = 6.10, CI95:4.58,8.12) and having Veterans Affairs (VA) healthcare coverage (OR = 2.63, CI95:1.97,3.51). Veterans with combat or sexual trauma were more likely to have PTSD diagnosis knowledge than those with different trauma types. Results suggest veterans with VA healthcare coverage and military-related trauma are more likely to be informed by a healthcare professional about a PTSD diagnosis. Further research is needed to improve PTSD diagnosis knowledge for those with non-military-related trauma and those without VA healthcare coverage.

Development and feasibility pilot of Considering PTSD Treatment: An online intervention with peer support.

Considering PTSD Treatment is an online program adapted from the National Center for PTSD's AboutFace website. Developed to help veterans overcome barriers to seeking treatment for posttraumatic stress disorder (PTSD), the program features videos of veterans describing PTSD and what treatment was like. Peer specialists are available at the beginning and end to chat with participants. We describe initial pilot feasibility data in 50 veterans recruited through online ads who screened positive for PTSD and were not currently in treatment. Eighty percent of participants who consented enrolled in the program and 64.0 % completed all modules. On average, participants rated the program at least "moderately" helpful and over 90 % reported feeling more knowledgeable about PTSD and PTSD treatment. Of the 21 participants who completed the one month follow-up, 52.4 % said they had talked to or were assessed by a provider and 61.9 % said they started treatment. There was not a significant change in stigma scores from baseline to follow-up. Results provide initial support for the feasibility, acceptability, and effectiveness of Considering PTSD Treatment for increasing treatment seeking readiness and support the need for a larger randomized controlled trial.

Factors associated with receipt of minimally adequate psychotherapy for PTSD at the Veterans Health Administration.

BACKGROUND: Despite Veterans Health Administration (VHA) efforts, many Veterans do not receive minimally adequate psychotherapy (MAP) for posttraumatic stress disorder (PTSD). It is important to understand factors associated with receipt of PTSD MAP (at least eight sessions) so that we may tailor efforts to increase treatment utilization for those who experience the greatest barriers to care. METHODS: Participants were 2008 post-9/11 Veterans who participated in a nationwide survey and had a PTSD diagnosis documented in the VHA electronic health record (EHR) before 2018. Participants self-reported sociodemographic information and trauma history. Service utilization data (e.g., PTSD MAP) were obtained from EHR. Logistic regression was used to model factors associated with PTSD MAP. RESULTS: Only 24% of Veterans (n = 479) received PTSD MAP. Veterans who reported that they were not employed and had reported history of military sexual trauma were more likely to have received PTSD MAP. CONCLUSIONS: Understanding and addressing barriers to PTSD care for Veterans who are employed could help improve PTSD treatment utilization for this group.

Relationship of social determinants of health with symptom severity among Veterans and non-Veterans with probable posttraumatic stress disorder or depression.

PURPOSE: Social determinants of health (SDoH) refer to the conditions in the environments in which people live that affect health outcomes and risks. SDoH may provide proximal, actionable targets for interventions. This study examined how SDoH are associated with posttraumatic stress disorder (PTSD) and depression symptoms among Veterans and non-Veterans with probable PTSD or depression. METHODS: Four multiple regressions were conducted. Two multiple regressions with Veterans examined the impact of SDoH on PTSD symptoms and on depression symptoms. Two multiple regressions with non-Veterans examined the impact of SDoH on PTSD symptoms and on depression symptoms. Independent variables included demographic characteristics, adverse experiences (in childhood and adulthood), and SDoH (discrimination, education, employment, economic instability, homelessness, justice involvement, and social support). Correlates that were statistically significant (p < 0.05) and clinically meaningful (rpart >|0.10|) were interpreted. RESULTS: For Veterans, lower social support (rpart = - 0.14) and unemployment (rpart = 0.12) were associated with greater PTSD symptoms. Among non-Veterans, greater economic instability (rpart = 0.19) was associated with greater PTSD symptoms. In the depression models, lower social support (rpart = - 0.23) and greater economic instability (rpart = 0.12) were associated with greater depression for Veterans, while only lower social support was associated with greater depression for non-Veterans (rpart = - 0.14). CONCLUSION: Among Veterans and non-Veterans with probable PTSD or depression, SDoH were associated with PTSD and depression symptoms, particularly social support, economic instability, and employment. Beyond direct treatment of mental health symptoms, addressing social support and economic factors such as instability and employment in the context of PTSD and depression are potential intervention targets that would benefit from future research.

Alcohol use and treatment utilization in a national sample of veterans and nonveterans.

BACKGROUND: Research comparing prevalence of alcohol use problems and alcohol treatment utilization between veterans and nonveterans is lacking. Whether predictors of alcohol use problems and alcohol treatment utilization differ in veterans vs. nonveterans is also unclear. METHODS: Using survey data from national samples of post-9/11 veterans and nonveterans (N = 17,298; 13,451 veterans, 3847 nonveterans), we investigated associations between veteran status and 1) alcohol consumption, 2) need for intensive alcohol treatment, and 3) past-year and lifetime alcohol treatment utilization. We also investigated associations between predictors and these three outcomes in separate models for veterans and nonveterans. Predictors included age, gender, racial/ethnic identity, sexual orientation, marital status, education, health coverage, financial difficulty, social support, adverse childhood experiences (ACEs), and adult sexual trauma. RESULTS: Population weighted regression models demonstrated that veterans reported modestly higher alcohol consumption than nonveterans, but were not significantly more likely to need intensive alcohol treatment. Veterans and nonveterans did not differ in past-year alcohol treatment utilization, but veterans were 2.8 times more likely to utilize lifetime treatment than nonveterans. We found several differences between veterans and nonveterans in associations between predictors and outcomes. For veterans, being male, having higher financial difficulty, and lower social support were associated with need for intensive treatment, but for nonveterans, only ACEs were associated with need for intensive treatment. CONCLUSIONS: Veterans may benefit from interventions with social and financial support to reduce alcohol problems. These findings can help to identify veterans and nonveterans who are more likely to need treatment.

Treatment Utilization for Posttraumatic Stress Disorder in a National Sample of Veterans and Nonveterans.

OBJECTIVE: The current study sought to compare rates of posttraumatic stress disorder (PTSD) treatment utilization (medication and psychotherapy) among veterans and nonveterans-and to investigate which factors are associated with treatment utilization among veterans versus nonveterans. METHODS: Participants were 2775 individuals (veteran, n=2508; nonveteran, n=267) meeting criteria for probable PTSD (determined by the PTSD Checklist) drawn from a nationwide, population-based survey. Participants reported demographic information, trauma history, mental health symptoms, insurance coverage, and treatment history. RESULTS: Analyses revealed that the majority of veterans and nonveterans with probable PTSD had not received any PTSD treatment (56% of veterans and 86% of nonveterans). Population-weighted logistic regression models demonstrated that veterans with probable PTSD were substantially more likely to receive medication and psychotherapy for PTSD than nonveterans with probable PTSD. Logistic regression models demonstrated that, among veterans, having Veterans Affairs health care coverage was most strongly associated with receiving PTSD medication and psychotherapy. Black (vs. White) veterans were less likely to have received PTSD medication and psychotherapy. In contrast, among nonveterans, being married or divorced (vs. never married) was most strongly associated with receiving PTSD medication, and reporting a history of sexual trauma was most strongly associated with receiving PTSD psychotherapy. CONCLUSION: Given that most individuals do not receive PTSD treatment, additional understanding of treatment barriers and facilitators for both veterans and nonveterans is needed to improve intervention reach.

Moral injury and chronic pain in veterans.

Posttraumatic stress disorder (PTSD) and chronic pain are highly prevalent and co-morbid among veterans. Moral injury (MI), which results from traumatic experiences that conflict with deeply held moral beliefs, is also associated with pain. However, relationships between different types of exposures to potentially morally injurious events (PMIEs) and pain have not yet been investigated. In the current study, we investigated these relationships between exposure to PMIEs (betrayal, witnessing, and perpetration) and different types of pain (joint pain, muscle pain, and overall pain intensity), while controlling for other relevant variables (including PTSD symptoms, combat exposure, adverse childhood experiences, age, gender, and race/ethnicity). We also examined gender differences in these associations. Participants were 11,871 veterans drawn from a nationwide, population-based survey who self-reported exposure to PMIEs, PTSD symptoms, frequency of adverse childhood experiences, combat exposure, sociodemographic information, past six-month joint pain, past six-month muscle pain, and past week overall pain intensity. Population weighted regression models demonstrated that PMIEs were not significantly associated with joint or muscle pain, but that betrayal was associated with past week overall pain intensity, even when controlling for all other variables. Models investigating men and women separately found that for women, betrayal was associated with joint pain and pain intensity, but for men, betrayal was not associated with any pain outcome. These findings suggest that it may be especially important to assess betrayal when treating patients with a history of trauma and chronic pain.

Intolerance of uncertainty and information-seeking behavior: Experimental manipulation of threat relevance.

Prospective intolerance of uncertainty (IU) involves fear and anxiety in anticipation of future uncertainty and is especially related to worry and generalized anxiety disorder (GAD). Individuals high in IU appraise uncertain situations as threatening and thus may engage in excessive information-seeking behavior to decrease uncertainty. This study aimed to examine the links between prospective IU and information-seeking. Participants (N = 174) high and low in prospective IU completed an ostensible aptitude test (threat stimulus), which was supposedly either excellent (high relevance condition) or poor (low relevance condition) at predicting future outcomes. Thus, the test itself presented an immediate threat, and the awaited test results generated uncertainty. Following the relevance manipulation, participants were given the opportunity to engage in information-seeking behavior by asking questions about the ostensible test and by requesting feedback about the test results. Results indicated that in the high-relevance condition, individuals high and low in IU evidenced similar levels of information-seeking behavior. Conversely, in the low-relevance condition, individuals low in IU evidenced less information-seeking than did individuals high in IU. Furthermore, cognitive appraisals of ambiguous situations were associated with the extent of information-seeking behavior. The implications of these findings for the treatment of GAD are discussed.

Brief behavioral treatment for insomnia decreases trauma-related nightmare frequency in veterans.

STUDY OBJECTIVES: Trauma-related nightmares are highly prevalent among veterans and are associated with higher-severity insomnia and posttraumatic stress disorder. Cognitive behavioral therapy for insomnia (typically 6-8 sessions) has been shown to reduce trauma-related nightmares. Brief behavioral treatment for insomnia (BBTI, 4 sessions) has been found to be comparable to CBT-I in decreasing insomnia severity; however, the effects of BBTI on nightmares have not been investigated. The current study tested the effects of BBTI on both trauma-related nightmares and nontrauma-related bad dreams using an active control group treated using progressive muscle relaxation therapy. In addition, we tested whether baseline trauma-related nightmare frequency and baseline nontrauma-related bad dream frequency moderated changes in insomnia severity. METHODS: Participants were 91 military veterans with insomnia disorder randomized to BBTI or progressive muscle relaxation therapy. Participants reported insomnia severity on the Insomnia Severity Index and reported trauma-related nightmare frequency and nontrauma-related bad dream frequency on the Pittsburgh Sleep Quality Index-PTSD Addendum. RESULTS: We found that BBTI significantly reduced trauma-related nightmares from baseline to posttreatment, whereas progressive muscle relaxation therapy did not. However, reductions in trauma-related nightmares were not maintained at the 6-month follow up. Neither BBTI nor progressive muscle relaxation therapy reduced nontrauma-related bad dreams from baseline to posttreatment. We also found that neither baseline trauma-related nightmare frequency nor baseline nontrauma-related bad dream frequency moderated changes in insomnia symptom severity. CONCLUSIONS: Findings from the current study suggest that BBTI may help reduce trauma-related nightmares. Further research is needed to better understand the potential mechanisms underlying how improved sleep may reduce trauma-related nightmares. CLINICAL TRIAL REGISTRATION: Registry: ClinicalTrials.gov; Name: Brief Behavioral Insomnia Treatment Study (BBTI); URL: https://clinicaltrials.gov/ct2/show/NCT02571452; Identifier: NCT02571452. CITATION: Ranney RM, Gloria R, Metzler TJ, Huggins J, Neylan TC, Maguen S. Brief behavioral treatment for insomnia decreases trauma-related nightmare frequency in veterans. J Clin Sleep Med. 2022:18(7):1831-1839.

Lifetime trauma endorsement, posttraumatic stress disorder, and alcohol dependence as a function of sexual minority status.

OBJECTIVE: Posttraumatic stress disorder (PTSD) and alcohol use disorder (AUD) frequently co-occur, with elevated rates of both disorders in lesbian, gay, or bisexual (LGB) samples. Few studies have compared the strength of PTSD-AUD associations between LGB and heterosexual individuals or evaluated the role of nontraumatic LGB discrimination in these relationships among sexual minorities. METHOD: The current study utilized nationally representative epidemiological data (N = 29,646) to (a) examine whether associations between lifetime trauma endorsement/PTSD and lifetime alcohol dependence (AD) differ as a function of sexual minority status and (b) evaluate the role of LGB-specific discrimination in trauma/PTSD and AD associations among LGB individuals. RESULTS: Logistic regression analyses showed the association between lifetime trauma endorsement and lifetime AD was significantly greater in magnitude for LGB individuals (odds ratio [OR] = 2.17) compared to heterosexual individuals (OR = 1.32; Z = 2.51, p < .05). The magnitude of the association between lifetime PTSD and lifetime AD was not greater in the LGB subsample (OR = 2.11) than the heterosexual subsample (OR = 1.71; Z = 0.63, p > .05), after controlling for trauma endorsement. Among the LGB subsample, logistic regression analyses did not support a significant main effect for LGB discrimination nor an interaction between trauma endorsement and nontraumatic LGB discrimination, nor between PTSD and nontraumatic LGB discrimination, on lifetime AD (ps > .05). CONCLUSIONS: LGB individuals demonstrate stronger associations between lifetime trauma endorsement and AD, relative to heterosexual counterparts; however, this association may not be accounted for or moderated by nontraumatic LGB discrimination. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Effortful control moderates relationships between worry and symptoms of depression and anxious arousal.

OBJECTIVES: Findings are inconsistent regarding the relationship between worry and anxious arousal (AA). Effortful control (EC) capacity may explain these inconsistent findings, such that only high worriers with higher EC are able to suppress autonomic arousal through worrying. The current study investigated these main and interactive effects of worry and EC on AA as well as depression. METHODS: Participants (N = 1210, 779 females) were recruited from Amazon's Mechanical Turk website and completed self-report measures assessing worry, EC, AA, depression, and negative affect intensity. RESULTS: Regression models revealed that EC moderated the relationship between worry and AA, with individuals lower in EC demonstrating a stronger positive relationship between worry and AA. EC also moderated the relationship between worry and depression, with individuals lower in EC demonstrating a stronger positive relationship between worry and depression. Results remained the same when controlling for age, gender, and negative affect intensity. CONCLUSIONS: Results support the idea that low EC may help to explain a range of comorbid psychiatric symptoms. PRACTITIONER POINTS: Individuals low in effortful control demonstrate a stronger association between worry and anxious arousal, as well as between worry and depression Those low in effortful control may be especially vulnerable to comorbid worry and depression High worriers who are high in effortful control may be motivated to continue worrying due to their ability to reduce anxious arousal during worry.

Cardiovascular risk as a moderator of associations among anxiety sensitivity, distress tolerance, PTSD and depression symptoms among trauma-exposed firefighters.

BACKGROUND: Firefighters experience frequent and severe trauma exposure, which places them at elevated risk for posttraumatic stress disorder (PTSD) and major depression. Cardiovascular issues may exacerbate the effects of mental health risk factors, such as anxiety sensitivity (AS) and distress tolerance (DT), on PTSD and depression. The current study investigated cardiovascular risk as a moderator of associations between risk factors (AS and DT) and psychiatric symptoms (PTSD and depression) among firefighters. METHODS: Participants were 836 trauma-exposed active duty firefighters (93.90% men; with mean age 38 years, [SD = 9]). Participants endorsing at least one of three cardiovascular risk items-experiencing current high blood pressure, history of heart problems, and experiencing chest pains in the past 2 years-were considered high in cardiovascular risk. RESULTS: A structural equation model indicated that higher AS was associated with greater PTSD (ß = 0.38, p < .01) and depression symptoms (ß = 0.32, p < .01); lower DT was associated with greater PTSD (ß = -0.18, p < .01) and depression symptoms (ß = -0.31, p < .01). Multigroup analyses showed that cardiovascular risk moderated the association between 1) AS and PTSD symptoms, but not 2) AS and depression symptoms, 3) DT and PTSD symptoms, or 4) DT and depression symptoms. For those high in cardiovascular risk, higher AS was associated more strongly with greater PTSD symptoms (high cardiovascular risk group: ß = 0.46, p < .01]; low cardiovascular risk group: ß = 0.33, p < .01). CONCLUSIONS: High cardiovascular risk may contribute to PTSD symptoms among trauma-exposed firefighters with high AS. These results highlight the importance of considering physical and mental health vulnerabilities in first responder populations.

Affect variability and emotional reactivity in generalized anxiety disorder.

BACKGROUND AND OBJECTIVES: Research indicates that greater variability in affect and emotion over time is associated with depression and anxiety. However, it remains unclear whether individuals with generalized anxiety disorder (GAD) experience greater affect variability due to individual differences or differences in the stimuli they encounter. The current study investigated whether individuals with analogue GAD demonstrate greater affect variability in response to a standardized set of stimuli. METHODS: Participants were 134 (95 female) undergraduate participants with analogue GAD (endorsing DSM-IV criteria A, B, C, and E on the GAD-Q-IV; n = 66) or with no symptoms of GAD (n = 68). Participants reported affective reactions (positive affect, negative affect, affective arousal, and affective dominance) to each of nine sets of standardized images varying in valence (positive, neutral, or negative) and arousal (low, medium, or high). RESULTS: In a logistic regression model controlling for baseline measurements, higher variability of affective arousal across the nine sets of images uniquely predicted analogue GAD status, whereas variability in positive affect, negative affect, and affective dominance did not. Additional analyses revealed that lower mean affective arousal also uniquely predicted analogue GAD. LIMITATIONS: Limitations include using self-report measures to determine analogue GAD status; using a short laboratory session for the assessment of affect variability; and potential repeated testing effects. CONCLUSIONS: These findings suggest that individuals with GAD symptoms experience higher levels of affective arousal variability, even when the stimuli presented are held constant. Assessing variability in affective arousal may be helpful in both conceptualizing and treating individuals with GAD symptoms.

Individuals Intolerant of Uncertainty: The Maintenance of Worry and Distress Despite Reduced Uncertainty.

The intolerance of uncertainty model of worry posits that individuals worry as a means to cope with the discomfort they feel when outcomes are uncertain, but few experimental studies have investigated the causal relationships between intolerance of uncertainty, situational uncertainty, and state worry. Furthermore, existing studies have failed to control for the likelihood of future negative events occurring, introducing an important rival hypothesis to explain past findings. In the present study, we examined how individuals with high and low trait intolerance of uncertainty differ in their behavioral, cognitive, and emotional reactions to situational uncertainty about an upcoming negative event (watching emotionally upsetting film clips), holding constant the likelihood of that negative event taking place. We found that although individuals high in trait prospective intolerance of uncertainty reported a higher degree of belief that being provided with detailed information about the upcoming stressor would make them feel more at ease, they did not experience an actual decrease in distress or state worry upon being provided with more information, during anticipation of the film clips, or during the film clips themselves. Our results suggest that heightened distress regarding negative events may be more central than intolerance of uncertainty to the maintenance of worry.

Alcohol Use Problems, Posttraumatic Stress Disorder, and Suicide Risk Among Trauma-Exposed Firefighters.

Alcohol use problems are associated with suicidal desire and may provide an avenue to suicidal ideation and behavior. However, the influence of posttraumatic stress disorder (PTSD) on the nature of the relationship between alcohol use problems and suicide risk is not well understood. In particular, the potential for PTSD to moderate the association between alcohol use problems and suicide risk remains unexplored. The present study investigated the main and interactive effects of alcohol use problems (Alcohol Use Disorders Identification Test) and PTSD symptoms (PTSD Checklist for DSM-5) on suicide risk (Suicide Behaviors Questionnaire-Revised) in a sample of 632 trauma-exposed firefighters (93.5% men; Mage = 38.44 years, SD = 8.59). Hierarchical logistic regression analyses evaluated whether the main and interactive effects of PTSD symptom severity and alcohol use disorders were significantly related to suicide risk, above and beyond age and cumulative trauma. The main effects of PTSD symptom severity (odds ratio, 1.76; p < 0.001) and alcohol use problems (odds ratio, 1.37; p = 0.391) significantly positively predicted suicide risk; however, PTSD symptoms did not moderate an association between alcohol use problems and suicide risk after accounting for these main effects (p > 0.05). A secondary, exploratory aim demonstrated that all PTSD symptom clusters significantly positively predicted suicide risk (p's < 0.001), although none of these clusters interacted with alcohol use problems to predict suicide risk (p's > 0.05). Theoretical and clinical implications are discussed as they relate to the importance of screening for PTSD and alcohol use disorder among firefighter populations.