Perinatal Posttraumatic Stress Disorder Diagnoses Among Commercially Insured People Increased, 2008-20.

Posttraumatic stress disorder (PTSD) is a burdensome disorder, affecting 3-4 percent of delivering people in the US, with higher rates seen among Black and Hispanic people. The extent of clinical diagnosis remains unknown. We describe the temporal and racial and ethnic trends in perinatal PTSD diagnoses among commercially insured people with live-birth deliveries during the period 2008-20, using administrative claims from Optum's Clinformatics Data Mart Database. Predicted probabilities from our logistic regression analysis showed a 394 percent increase in perinatal PTSD diagnoses, from 37.7 per 10,000 deliveries in 2008 to 186.3 per 10,000 deliveries in 2020. White people had the highest diagnosis rate at all time points (208.0 per 10,000 deliveries in 2020), followed by Black people, people with unknown race, Hispanic people, and Asian people (188.7, 171.9, 146.9, and 79.8 per 10,000 deliveries in 2020, respectively). The significant growth in perinatal PTSD diagnosis rates may reflect increased awareness, diagnosis, or prevalence of the disorder. However, these rates fall well below the estimated prevalence of PTSD in the perinatal population.

Antidepressant Prescriptions Increased For Privately Insured People With Perinatal Mood And Anxiety Disorder, 2008-20.

We aimed to determine whether antidepressant prescriptions for perinatal mood and anxiety disorder (PMAD) increased after several professional organizations issued clinical recommendations in 2015 and 2016. This serial, cross-sectional, logistic regression analysis evaluated changes in antenatal and postpartum antidepressant prescriptions among commercially insured people who had a live-birth delivery as well as a PMAD diagnosis during the period 2008-20. For people with antenatal PMAD, the odds of an antenatal antidepressant prescription decreased 3 percent annually from 2008 to 2016 and increased by 32 percent in 2017, and the annual rate of change increased 5 percent for 2017-20 compared with 2008-16. For people with postpartum PMAD, the odds of a postpartum antidepressant prescription decreased 2 percent annually from 2008 to 2016 and experienced no significant change in 2017, but the annual rate of change increased 3 percent for 2017-20 compared with 2008-16. The clinical recommendations issued in 2015 and 2016 were associated with increased antidepressant prescriptions for PMAD, particularly for antenatal PMAD. These findings indicate that clinical recommendations represent an effective tool for changing prescribing patterns.

Perinatal Mood And Anxiety Disorders Rose Among Privately Insured People, 2008-20.

Nationwide, perinatal mood and anxiety disorder (PMAD) diagnoses among privately insured people increased by 93.3 percent from 2008 to 2020, growing faster in 2015-20 than in 2008-14. Most states and demographic subgroups experienced increases, suggesting worsening morbidity in maternal mental health nationwide. PMAD-associated suicidality and psychotherapy rates also increased nationwide from 2008 to 2020. Relative to 2008-14, psychotherapy rates continued to rise in 2015-20, whereas suicidality rates declined.

The Importance of Autonomy and Performance Goals in Perceived Workload Among Behavioral Health Providers.

OBJECTIVE: The authors sought to assess workplace characteristics associated with perceived reasonable workload among behavioral health care providers in the Veterans Health Administration. METHODS: The authors evaluated perceived reasonable workload and workplace characteristics from the 2019 All Employee Survey (AES; N=14,824) and 2019 Mental Health Provider Survey (MHPS; N=10,490) and facility-level staffing ratios from Mental Health Onboard Clinical Dashboard data. Nine AES and 15 MHPS workplace predictors of perceived reasonable workload, 11 AES and six MHPS demographic predictors, and facility-level staffing ratios were included in mixed-effects logistic regression models. RESULTS: In total, 8,874 (59.9%) AES respondents and 5,915 (56.4%) MHPS respondents reported having a reasonable workload. The characteristics most strongly associated with perceived reasonable workload were having attainable performance goals (average marginal effect [AME]=0.10) in the AES and ability to schedule patients as frequently as indicated (AME=0.09) in the MHPS. Other AES characteristics significantly associated with reasonable workload included having appropriate resources, support for personal life, skill building, performance recognition, concerns being addressed, and no supervisor favoritism. MHPS characteristics included not having collateral duties that reduce care time, staffing levels not affecting care, support staff taking over some responsibilities, having spirit of teamwork, primary care-mental health integration, participation in performance discussions, well-coordinated mental health care, effective veteran programs, working at the top of licensure, and feeling involved in improving access. Facility-level staffing ratios were not significantly associated with perceived reasonable workload. CONCLUSIONS: Leadership may consider focusing resources on initiatives that support behavioral health providers' autonomy to schedule patients as clinically indicated and develop attainable performance goals.

Diagnosed behavioral health conditions during the perinatal period among a commercially insured population by race/ethnicity, 2008-2020.

Objective: We sought to examine trends in diagnosed behavioral health (BH) conditions [mental health (MH) disorders or substance use disorders (SUD)] among pregnant and postpartum individuals between 2008-2020. We then explored the relationship between BH conditions and race/ethnicity, acknowledging race/ethnicity as a social construct that influences health disparities. Methods: This study included delivering individuals, aged 15-44 years, and continuously enrolled in a single commercial health insurance plan for 1 year before and 1 year following delivery between 2008-2020. We used BH conditions as our outcome based on relevant ICD 9/10 codes documented during pregnancy or the postpartum year. Results: In adjusted analyses, white individuals experienced the highest rates of BH conditions, followed by Black, Hispanic, and Asian individuals, respectively. Asian individuals had the largest increase in BH rates, increasing 292%. White individuals had the smallest increase of 192%. The trend remained unchanged even after adjusting for age and Bateman comorbidity score, the trend remained unchanged. Conclusions: The prevalence of diagnosed BH conditions among individuals in the perinatal and postpartum periods increased over time. As national efforts continue to work toward improving perinatal BH, solutions must incorporate the needs of diverse populations to avert preventable morbidity and mortality.

Assessing trends and variability in outpatient dual testing for chronic kidney disease with urine albumin and serum creatinine, 2009-2018: a retrospective cohort study in the Veterans Health Administration System.

BACKGROUND: Simultaneous urine testing for albumin (UAlb) and serum creatinine (SCr), that is, 'dual testing,' is an accepted quality measure in the management of diabetes. As chronic kidney disease (CKD) is defined by both UAlb and SCr testing, this approach could be more widely adopted in kidney care. OBJECTIVE: We assessed time trends and facility-level variation in the performance of outpatient dual testing in the integrated Veterans Health Administration (VHA) system. DESIGN, SUBJECTS AND MAIN MEASURES: This retrospective cohort study included patients with any inpatient or outpatient visit to the VHA system during the period 2009-2018. Dual testing was defined as UAlb and SCr testing in the outpatient setting within a calendar year. We assessed time trends in dual testing by demographics, comorbidities, high-risk (eg, diabetes) specialty care and facilities. A generalised linear mixed-effects model was applied to explore individual and facility-level predictors of receiving dual testing. KEY RESULTS: We analysed data from approximately 6.9 million veterans per year. Dual testing increased, on average, from 17.4% to 21.2%, but varied substantially among VHA centres (0.3%-43.7% in 2018). Dual testing was strongly associated with diabetes (OR 10.4, 95% CI 10.3 to 10.5, p<0.0001) and not associated with VHA centre complexity level. However, among patients with high-risk conditions including diabetes, <50% received dual testing in any given year. As compared with white veterans, black veterans were less likely to be tested after adjusting for other individual and facility characteristics (OR 0.93, 95% CI 0.92 to 0.93, p<0.0001). CONCLUSIONS: Dual testing for CKD in high-risk specialties is increasing but remains low. This appears primarily due to low rates of testing for albuminuria. Promoting dual testing in high-risk patients will help to improve disease management and patient outcomes.

Societal costs of untreated perinatal mood and anxiety disorders in Vermont.

PURPOSE: To estimate the societal costs of untreated perinatal mood and anxiety disorders (PMADs) in Vermont for the 2018-2020 average annual birth cohort from conception through five years postpartum. METHODS: We developed a cost analysis model to calculate the excess cases of outcomes attributed to PMADs in the state of Vermont. Then, we modeled the associated costs of each outcome incurred by birthing parents and their children, projected five years for birthing parents who do not achieve remission by the end of the first year postpartum. RESULTS: We estimated that the total societal cost of untreated PMADs in Vermont could reach $48 million for an annual birth cohort from conception to five years postpartum, amounting to $35,910 in excess societal costs per birthing parent with an untreated PMAD and their child. CONCLUSION: Our model provides evidence of the high costs of untreated PMADs for birthing parents and their children in Vermont. Our estimates for Vermont are slightly higher but comparable to national estimates, which are $35,500 per birthing parent-child pair, adjusted to 2021 US dollars. Investing in perinatal mental health prevention and treatment could improve health outcomes and reduce economic burden of PMADs on individuals, families, employers, and the state.

Burnout and Perceived Workload Among Behavioral Health Providers During the COVID-19 Pandemic: Importance of Supervisory, Leadership, and Organizational Support.

PURPOSE: To assess the relationship between behavioral health provider (BHP) perceptions of support during COVID-19 and burnout and self-reported workload. DESIGN: We conducted a cross-sectional analysis of provider-level data collected from the 2020 and 2021 All Employee Survey (AES). SETTING: The Veterans Health Administration. SUBJECTS: 36,541 (10,332 [28.28%] with missing data) respondents in 2020 and 2021 combined. MEASURES: Main outcomes were self-reported burnout and self-reported workload. Main predictors were 6 COVID-19-related provider-perceived support domains. Covariates were 11 AES demographic predictors. ANALYSIS: We conducted mixed-effects logistic regression modeling for each domain and outcome pairing. We summarized our results using average marginal effects (AMEs) and odds ratios (ORs). RESULTS: All 6 domains of feeling prepared, heard, protected, cared for, honored, and having flexible policies were significantly negatively associated with burnout (AMEs -.20 to -.10, ORs .38-.63, P < .001) and positively associated with reasonable workload (AMEs .11-.20, ORs 1.63-2.59, P < .001). Feeling prepared had the largest associations with burnout (OR .38) and reasonable workload (OR 2.59). CONCLUSION: Creating a work environment with flexible policies and where staff feel prepared, heard, protected, cared for, and honored could support BHPs in feeling less burned out and that their workload is reasonable.

Relationship between facility number of clinicians and prescribing intensity of psychotropic medications, opioids, and antibiotics in ambulatory practice.

BACKGROUND: Promoting appropriate pharmacotherapy requires understanding the factors that influence how clinicians prescribe medications. While prior work has focused on patient and clinician factors, features of the organizational setting have received less attention, though identifying sources of variation in prescribing may help identify opportunities to improve patient safety and outcomes. OBJECTIVE: To evaluate the relationship between the number of clinicians who prescribe medications in a facility and facility prescribing intensity of six individual medication classes by clinician specialty: benzodiazepines, antipsychotics, antiepileptics, and antidepressants by psychiatrists and antibiotics, opioids, antiepileptics, and antidepressants by primary care clinicians (PCPs). DESIGN: We used 2017 Veterans Health Administration (VHA) administrative data. SUBJECTS: We included patient-clinician dyads of older patients (> 55 years) with an outpatient encounter with a clinician in 2017. Patient-clinician data from 140 VHA facilities were included (n = 13,347,658). Analysis was repeated for years 2014 to 2016. MAIN MEASURES: For each medication, facility prescribing intensity measures were calculated as clinician prescribing intensity averaged over all clinicians at each facility. Clinician prescribing intensity measures included percentage of each clinician's patients prescribed the medication and mean number of days supply per patient among all patients of each clinician. KEY RESULTS: As the number of prescribing clinicians in a facility increased, the intensity of prescribing decreased. Every increase of 10 facility clinicians was associated with a significant decline in prescribing intensity for both specialties for different medication classes: for psychiatrists, declines ranged from 6 to 11%, and for PCPs, from 2 to 3%. The pattern of more clinicians less prescribing was significant across all years. CONCLUSION: Future work should explore the mechanisms that link the number of facility clinicians with prescribing intensity for benzodiazepines, antipsychotics, antiepileptics, antidepressants, antibiotics, and opioids. Facilities with fewer clinicians may need additional resources to avoid unwanted prescribing of potentially harmful or unnecessary medications.

The impact of the affordable care act on perinatal mood and anxiety disorder diagnosis and treatment rates among Michigan Medicaid enrollees 2012-2018.

BACKGROUND: Perinatal Mood and Anxiety Disorders (PMADs) affect one in five birthing individuals and represent a leading cause of maternal mortality. While these disorders are associated with a variety of poor outcomes and generate significant societal burden, underdiagnosis and undertreatment remain significant barriers to improved outcomes. We aimed to quantify whether the Patient Protection Affordable Care Act (ACA) improved PMAD diagnosis and treatment rates among Michigan Medicaid enrollees. METHODS: We applied an interrupted time series framework to administrative Michigan Medicaid claims data to determine if PMAD monthly diagnosis or treatment rates changed after ACA implementation for births 2012 through 2018. We evaluated three treatment types, including psychotherapy, prescription medication, and either psychotherapy or prescription medication. Participants included the 170,690 Medicaid enrollees who had at least one live birth between 2012 and 2018, with continuous enrollment from 9 months before birth through 3 months postpartum. RESULTS: ACA implementation was associated with a statistically significant 0.76% point increase in PMAD diagnosis rates (95% CI: 0.01 to 1.52). However, there were no statistically significant changes in treatment rates among enrollees with a PMAD diagnosis. CONCLUSION: The ACA may have improved PMAD detection and documentation in clinical settings. While a higher rate of PMAD cases were identified after ACA Implementation, Post-ACA cases were treated at similar rates as Pre-ACA cases.

Role of Institutional Support for Evidence-Based Psychotherapy in Satisfaction and Burnout Among Veterans Affairs Therapists.

OBJECTIVE: Burnout is widespread among psychotherapists and leads to negative mental and other health outcomes, absenteeism, and turnover. Job resources, including institutional support for evidence-based practices, can buffer against burnout and may improve satisfaction among therapists. The Veterans Health Administration (VHA) is the nation's largest integrated health system and employs 23,000 therapists, including psychologists, social workers, and counselors. The authors assessed associations between perceived institutional support for evidence-based treatment and satisfaction and burnout among VHA therapists. METHODS: This analysis used data from the VHA's national 2018 Mental Health Provider Survey. Responding therapists (N=5,341) answered questions about the quality of mental health care and job satisfaction. Multilevel logistic regression models were used to predict burnout and satisfaction. The authors tested availability of evidence-based treatment and measurement-based care (MBC) as predictors; analyses were adjusted for therapist workload, demographic characteristics, and potential clustering by facility. RESULTS: VHA therapists had less burnout and more job satisfaction when they perceived receiving institutional support for evidence-based psychotherapy (EBP) and MBC, irrespective of whether the analyses were adjusted for workload. Less difficulty in scheduling EBP was significantly associated with decreased likelihood of burnout (OR=0.83, p<0.001) and increased satisfaction (OR=1.09, p=0.008). Less difficulty ending psychotherapy was significantly associated with decreased likelihood of burnout (OR=0.89, p=0.002) and increased satisfaction (OR=1.12, p=0.004). CONCLUSIONS: Support for evidence-based practices, including EBP and MBC, was closely linked to VHA therapists' satisfaction and burnout. Expanding support for therapists to provide evidence-based treatment may benefit therapists, patients, and the health care system.

Residential greenspace and major depression among older adults living in urban and suburban areas with different climates across the United States.

BACKGROUND AND AIM: Residential greenspace could alleviate depression - a leading cause of disability. Fewer studies of depression and greenspace have considered major depression, and, to our knowledge, none have considered how climate, which determines vegetation abundance and type, may change the impacts of greenspace. Our aim was to investigate whether residential greenspace is associated with major depression among older adults and explore effect modification by climate. METHODS: We used biennial interviews between 2008 and 2016 from the Health and Retirement Study. We calculated greenness within walking distance of home addresses as the maximum NDVI for the year of each participant interview averaged within a 1 km buffer. Reflecting clinical criteria, a score of ≥5 on the CIDI-SF indicated major depression in the preceding 12-months. We characterized climate using Köppen-Geiger classifications. To estimate prevalence ratios, we used Poisson regression. Our models adjusted for sociodemographic characteristics, geography, annual sunshine, and bluespace. RESULTS: The 21,611 eligible participants were 65 ± 10 years old on average, 55% female, 81% White, 12% Black, 10% Hispanic/Latino, and 31% had at least a 4-year college degree. The 12-month prevalence of a major depression was 8%. In adjusted models, more residential greenspace was associated with a lower prevalence of major depression (prevalence ratio per IQR, 0.91; 95% CI, 0.84 to 0.98). There was evidence of effect modification by climate (P forinteraction, 0.062). We observed stronger associations in tropical (prevalence ratio per IQR 0.69; 95% CI, 0.47 to 1.01) and cold (prevalence ratio per IQR, 0.83; 95% CI, 0.74 to 0.93) climates compared to arid (prevalence ratio per IQR 0.99; 95% CI, 0.90 to 1.09) and temperate (prevalence ratio per IQR 0.98; 95% CI, 0.86 to 1.11) climates. CONCLUSIONS: Residential greenspace may help reduce major depression. However, climate may influence how people benefit from greenspace.

Racial Disparities in Diagnosis of Postpartum Mood and Anxiety Disorders Among Symptomatic Medicaid Enrollees, 2012-2015.

OBJECTIVE: This study quantified the prevalence of postpartum mood and anxiety disorder (PMAD) diagnoses among symptomatic Michigan Medicaid enrollees and explored factors associated with receiving a diagnosis. METHODS: Data sources comprised Michigan Medicaid administrative claims and Phase 7 Michigan Pregnancy Risk Assessment Monitoring System (MI-PRAMS) survey responses, linked at the individual level. Participants were continuously enrolled in Michigan Medicaid, delivered a live birth (2012-2015), responded to the survey, and screened positive for PMAD symptoms on the adapted two-item Patient Health Questionnaire. Unadjusted and adjusted weighted logistic regression analyses were used to predict the likelihood of having a PMAD diagnosis (for the overall sample and stratified by race). RESULTS: The weighted analytic cohort represented 24,353 deliveries across the 4-year study. Only 19.8% of respondents with symptoms of PMAD had a PMAD diagnosis between delivery and 3 months afterward. Black respondents were less likely to have PMAD diagnoses (adjusted odds ratio [AOR]=0.23, 95% CI=0.11-0.49) compared with White respondents. Among White respondents, no covariates were significantly associated with having a diagnosis. However, among Black respondents, more comorbid conditions and more life stressors were statistically significantly associated with having a diagnosis (AOR=3.18, 95% CI=1.27-7.96 and AOR=3.12, 95% CI=1.10-8.88, respectively). CONCLUSIONS: Rate of PMAD diagnosis receipt differed by race and was low overall. Black respondents were less likely than White respondents to receive a diagnosis. Patient characteristics influencing diagnosis receipt also differed by race, indicating that strategies to improve detection of these disorders require a tailored approach.

Racial and ethnic disparities in medication for opioid use disorder access, use, and treatment outcomes in Medicare.

INTRODUCTION: Overdose deaths are increasing disproportionately for minoritized populations in the United States. Disparities in substance use disorder treatment access and use have been a key contributor to this phenomenon. However, little is known about the magnitude of these disparities and the role of social determinants of health (SDOH) and provider characteristics in driving them. Our study measures the association between race and ethnicity and visits with Medication for Opioid Use Disorder (MOUD) providers, MOUD treatment conditional on a provider visit, and opioid overdose following MOUD treatment in Medicare. We also evaluate the role of social determinants of health and provider characteristics in modifying disparities. METHODS: Using a population of 230,198 US Medicare fee-for-service beneficiaries diagnosed with opioid use disorder (OUD), we estimate logistic regression models to quantify the association between belonging to a racial or ethnic group and the probability of visiting a buprenorphine or naltrexone provider, receiving a prescription or medication administration during or after a visit, and experiencing an opioid overdose after treatment with MOUD. Data included Medicare claims data and the Agency for Health Research and Quality Social Determinants of Health Database files between 2013 and 2017. RESULTS: Compared to Non-Hispanic White Medicare beneficiaries, Asian/Pacific Islander, American Indian/Alaska Native, Black, Hispanic, and Other/Unknown Race beneficiaries were between 3.0 and 9.3 percentage points less likely to have a visit with a buprenorphine or naltrexone provider. Conditional on having a buprenorphine or naltrexone provider visit, Asian/Pacific Islander, American Indian/Alaska Native, Black, Hispanic, and Other/Unknown Race were between 2.6 and 8.1 percentage points less likely to receive buprenorphine or naltrexone than white beneficiaries. Controlling for provider characteristics and SDOH increased disparities in visits and MOUD treatment for all groups besides American Indians/Alaska Natives. Conditional on treatment, only Black Medicare beneficiaries were at greater associated risk of overdose than non-Hispanic white beneficiaries, although differences became statistically insignificant after controlling for SDOH and including provider fixed effects. CONCLUSION: Ongoing equity programming and measurement efforts by CMS should include explicit consideration for disparities in access and use of MOUD. This may help ensure greater MOUD utilization by minoritized Medicare beneficiaries and reduce rising disparities in overdose deaths.

Relationship between Depression and Anxiety during Pregnancy, Delivery-Related Outcomes, and Healthcare Utilization in Michigan Medicaid, 2012-2021.

To evaluate associations between depression and/or anxiety disorders during pregnancy (DAP), delivery-related outcomes, and healthcare utilization among individuals with Michigan Medicaid-funded deliveries. We conducted a retrospective delivery-level analysis comparing delivery-related outcomes and healthcare utilization among individuals with and without DAP between January 2012 and September 2021. We used generalized estimating equation models assessing cesarean and preterm delivery; 30-day readmission after delivery; severe maternal morbidity within 42 days of delivery; and ambulatory, inpatient, emergency department or observation (ED), psychotherapy, or substance use disorders (SUD) visits during pregnancy. We adjusted models for age, race/ethnicity, urbanicity, federal poverty level, and obstetric comorbidities. Among 170,002 Michigan Medicaid enrollees with 218,890 deliveries, 29,665 (13.6%) had diagnoses of DAP. Compared to those without DAP, individuals with DAP were more often White, rural dwelling, had lower income, and had more comorbidities. In adjusted models, deliveries with DAP had higher odds of cesarean and preterm delivery OR = 1.02, 95% CI: [1.00, 1.05] and OR = 1.15, 95% CI: [1.11, 1.19] respectively), readmission within 30 days postpartum (OR = 1.14, 95% CI: [1.07, 1.22]), SMM within 42 days (OR = 1.27, 95% CI: [1.18, 1.38]), and utilization compared to those without DAP diagnoses (ambulatory: OR = 7.75, 95% CI: [6.75, 8.88], inpatient: OR = 1.13, 95% CI: [1.11, 1.15], ED: OR = 1.86, 95% CI: [1.80, 1.92], psychotherapy: OR = 172.8, 95% CI: [160.10, 186.58], and SUD: OR = 5.6, 95% CI: [5.37, 5.85]). Among delivering individuals in Michigan Medicaid, DAP had significant associations with adverse delivery-related outcomes and greater healthcare use. Early detection and intervention to address mental illness during pregnancy may help mitigate burdens of these complex yet treatable disorders.

Association of the Mental Health Parity and Addiction Equity Act and the Affordable Care Act on severe maternal morbidity.

OBJECTIVE: This study aimed to characterize the association between Mental Health Parity and the Affordable Care Act and rates of severe maternal morbidity among a population of commercially insured individuals, including individuals with and without perinatal mood and anxiety disorders. METHODS: We conducted a serial, cross-sectional analysis of individuals with an inpatient delivery in Optum's Clinformatics® Data Mart Database from 2008 to 2021. We applied an interrupted time series model with autoregressive integrated moving average to evaluate changes in quarterly severe maternal morbidity rates. RESULTS: Adjusted severe maternal morbidity rates declined from 167.2 (95%CI: [152.6, 181.9]) per 10,000 deliveries in the first quarter of 2008 to 98.2 (95%CI: [83.5, 112.8]) per 10,000 deliveries in the last quarter of 2021. Severe maternal morbidity rates remained higher, but declined to a greater degree, among those with perinatal mood and anxiety disorders (435.6, 95%CI: [379.9, 491.3], to 165.0, 95%CI: [109.3, 220.8] per 10,000 deliveries) compared to those without (153.0, 95%CI: [140.7, 165.3] to 81.8, 95%CI: [69.6, 94.1] per 10,000 deliveries). CONCLUSION: The observed association suggests implementation of Mental Health Parity and Affordable Care Act may have played a role in lowering rates of severe maternal morbidity, particularly among individuals with perinatal mood and anxiety disorders.

Guideline-concordant use of cognitive behavioral therapy for insomnia in the Veterans Health Administration.

OBJECTIVE: To characterize guideline-concordant use of cognitive behavioral therapy for insomnia vs. sleep medications among Veterans Health Administration patients. METHODS: Cognitive behavioral therapy for insomnia was identified from the text of psychotherapy notes within the Veterans Health Administration's electronic medical record. Patients that received first-line cognitive behavioral therapy for insomnia (ie, no prior insomnia treatment) were compared to those who first received a sleep medication in fiscal year 2021. RESULTS: Among 5,519,016 patients, first-line cognitive behavioral therapy for insomnia was received by 9313 (0.2%) whereas 225,618 (4.1%) were newly prescribed a sleep medication without prior cognitive behavioral therapy for insomnia. Patients over 60 years old and those with substance use disorders were less likely to receive first-line cognitive behavioral therapy for insomnia compared to other patients. CONCLUSIONS: Adherence to practice guidelines to provide cognitive behavioral therapy for insomnia as first-line treatment for insomnia disorder remains a challenge, highlighting the need to better integrate effective implementation strategies within therapist training programs. Targeted strategies may be needed for older patients or those with substance use disorders.

Improving function through primary care treatment of posttraumatic stress disorder study outcomes: A randomized controlled trial of prolonged exposure for primary care in veterans.

INTRODUCTION: Despite high cost and wide prevalence of posttraumatic stress disorder (PTSD) in veteran populations, and Veterans Health Administration (VA)-wide mental health provider training in evidence-based treatments for PTSD, most veterans with PTSD do not receive best practices interventions. This may be because virtually all evidence-based PTSD treatment is offered through specialty clinics, which require multiple steps and referrals to access. One solution is to offer PTSD treatment in VA primary care settings, which are often the first and only contact point for veterans. METHOD: The present study, Improving Function Through Primary Care Treatment of PTSD (IMPACT), used a randomized controlled design to compare an adaptation of prolonged exposure for PTSD to primary care (PE-PC) versus best practices Primary Care Mental Health Integration (PCMHI) clinic treatment as usual (TAU) in terms of both functioning and psychological symptoms in 120 veterans recruited between April 2019 and September 2021. RESULTS: Participants were mostly males (81.7%) with a mean age of 43.6 years (SD = 12.8), and more than half were non-White veterans (50.8%). Both conditions evinced significant improvement over baseline across functioning, PTSD, and depression measures, with no differences observed between groups. As observed in prior studies, PTSD symptoms continued to improve over time in both conditions, as measured by structured clinical interview. DISCUSSION: Both PE-PC and best-practices TAU are effective in improving function and reducing PTSD severity and depression severity. Although we did not observe differences between the two treatments, note that this study site and two PCMHI clinics employ primarily cognitive behavioral therapies (e.g., exposure and behavioral activation). (PsycInfo Database Record (c) 2024 APA, all rights reserved).