Impact of PTSD treatment on postconcussive symptoms in veterans: A comparison of sertraline, prolonged exposure, and their combination.

Many Veterans who served in Iraq and Afghanistan struggle with posttraumatic stress disorder (PTSD) and the effects of traumatic brain injuries (TBI). Some people with a history of TBI report a constellation of somatic, cognitive, and emotional complaints that are often referred to as postconcussive symptoms (PCS). Research suggests these symptoms may not be specific to TBI. This study examined the impact of PTSD treatment on PCS in combat Veterans seeking treatment for PTSD. As part of a larger randomized control trial, 198 Operation Iraqi Freedom, Operation Enduring Freedom, Operation New Dawn (OIF/OEF/OND) Veterans with PTSD received Prolonged Exposure Therapy, sertraline, or the combination. Potential deployment related TBI, PCS, PTSD and depression symptoms were assessed throughout treatment. Linear mixed models were used to predict PCS change over time across the full sample and treatment arms, and the association of change in PTSD and depression symptoms on PCS was also examined. Patterns of change for the full sample and the subsample of those who reported a head injury were examined. Results showed that PCS decreased with treatment. There were no significant differences across treatments. No significant differences were found in the pattern of symptom change based on TBI screening status. Shifts in PCS were predicted by change PTSD and depression. Results suggest that PCS reduced with PTSD treatment in this population and are related to shift in depression and PTSD severity, further supporting that reported PCS symptoms may be better understood as non-specific symptoms.

Using Behavioral Economics to Reduce Low-Value Care Among Older Adults: A Cluster Randomized Clinical Trial.

Importance: Use of low-value care is common among older adults. It is unclear how to best engage clinicians and older patients to decrease use of low-value services. Objective: To test whether the Committing to Choose Wisely behavioral economic intervention could engage primary care clinicians and older patients to reduce low-value care. Design, Setting, and Participants: Stepped-wedge cluster randomized clinical trial conducted at 8 primary care clinics of an academic health system and a private group practice between December 12, 2017, and September 4, 2019. Participants were primary care clinicians and older adult patients who had diabetes, insomnia, or anxiety or were eligible for prostate cancer screening. Data analysis was performed from October 2019 to November 2023. Intervention: Clinicians were invited to commit in writing to Choosing Wisely recommendations for older patients to avoid use of hypoglycemic medications to achieve tight glycemic control, sedative-hypnotic medications for insomnia or anxiety, and prostate-specific antigen tests to screen for prostate cancer. Committed clinicians had their photographs displayed on clinic posters and received weekly emails with alternatives to these low-value services. Educational handouts were mailed to applicable patients before scheduled visits and available at the point of care. Main Outcomes and Measures: Patient-months with a low-value service across conditions (primary outcome) and separately for each condition (secondary outcomes). For patients with diabetes, or insomnia or anxiety, secondary outcomes were patient-months in which targeted medications were decreased or stopped (ie, deintensified). Results: The study included 81 primary care clinicians and 8030 older adult patients (mean [SD] age, 75.1 [7.2] years; 4076 men [50.8%] and 3954 women [49.2%]). Across conditions, a low-value service was used in 7627 of the 37 116 control patient-months (20.5%) and 7416 of the 46 381 intervention patient-months (16.0%) (adjusted odds ratio, 0.79; 95% CI, 0.65-0.97). For each individual condition, there were no significant differences between the control and intervention periods in the odds of patient-months with a low-value service. The intervention increased the odds of deintensification of hypoglycemic medications for diabetes (adjusted odds ratio, 1.85; 95% CI, 1.06-3.24) but not sedative-hypnotic medications for insomnia or anxiety. Conclusions and Relevance: In this stepped-wedge cluster randomized clinical trial, the Committing to Choose Wisely behavioral economic intervention reduced low-value care across 3 common clinical situations and increased deintensification of hypoglycemic medications for diabetes. Use of scalable interventions that nudge patients and clinicians to achieve greater value while preserving autonomy in decision-making should be explored more broadly. Trial Registration: ClinicalTrials.gov Identifier: NCT03411525.

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.

Benzodiazepine Discontinuation and Mortality Among Patients Receiving Long-Term Benzodiazepine Therapy.

Importance: There is interest in reducing long-term benzodiazepine prescribing given harms associated with use, but the cumulative risks or benefits of discontinuation are unknown. Objective: To identify the association of benzodiazepine discontinuation with mortality and other adverse events among patients prescribed stable long-term benzodiazepine therapy, stratified by baseline opioid exposure. Design, Setting, and Participants: This comparative effectiveness study with a trial emulation approach included data from a US commercial insurance database between January 1, 2013, and December 31, 2017. Eligible participants were adults with stable long-term benzodiazepine prescription treatment. Data were analyzed between December 2022 and November 2023. Exposure: Benzodiazepine discontinuation, defined as no benzodiazepine prescription coverage for 31 consecutive days identified during a 6-month grace period after baseline. Main Outcome and Measures: Mortality during 12 months of follow-up; secondary outcomes included nonfatal overdose, suicide attempt or self-inflicted injury, suicidal ideation, and emergency department use, identified in medical claims. Inverse probability weighting was used to adjust for baseline confounders that potentially affected treatment assignment and censoring due to death or disenrollment. Primary analysis used an intention-to-treat approach; a secondary per-protocol analysis estimated associations after accounting for nonadherence. Analyses were stratified by opioid use. Results: The study included 213 011 (136 609 female [64.1%]; mean [SD] age, 62.2 [14.9] years; 2953 Asian [1.4%], 18 926 Black [8.9%], 22 734 Hispanic [10.7%], and 168 398 White [60.2%]) and 140 565 (91 811 female [65.3%]; mean [SD] age, 61.1 [13.2] years; 1319 Asian [0.9%], 15 945 Black [11.3%], 11 989 Hispanic [8.5%], and 111 312 White [79.2%]) patients with stable long-term benzodiazepine use without and with opioid exposure, respectively. Among the nonopioid exposed, the adjusted cumulative incidence of death after 1 year was 5.5% (95% CI, 5.4%-5.8%) for discontinuers, an absolute risk difference of 2.1 percentage points (95% CI, 1.9-2.3 percentage points) higher than for nondiscontinuers. The mortality risk was 1.6 (95% CI, 1.6-1.7) times that of nondiscontinuers. Among those with opioid exposure, the adjusted cumulative incidence of death was 6.3% (95% CI, 6.0%-6.6%) for discontinuers, an absolute risk difference of 2.4 percentage points (95% CI, 2.2-2.7 percentage points) higher than for nondiscontinuers and a mortality risk 1.6 (95% CI, 1.5-1.7) times that of nondiscontinuers. Cumulative incidence of secondary outcomes was also higher among discontinuers. Conclusions and Relevance: This study identifies small absolute increases in risk of harms among patients with stable long-term prescription benzodiazepine treatment who appear to discontinue relative to continuing treatment, including those with and without recent prescription opioid exposure. Policy broadly promoting benzodiazepine discontinuation may have unintended risks.

Agreement between Patient-reported Pain Medication Use and Electronic Medical Record Data in Surgical Amputation Patients.

Background: Opioid misuse after surgery remains a public health crisis in the United States. Recent efforts have focused on tracking pain medication use in surgical populations. However, accurate interpretations of medication use remain quite challenging given inconsistent usage of different datasets. The purpose of this study was to investigate the agreement between electronic medical records (EMR) versus patient self-reported use of pain medications in a surgical amputation population. Methods: Patients undergoing major lower extremity amputation or amputation-related procedures were included in this study. Both self-reported and EMR data for pain medication intake were obtained for each patient at three time points (preoperatively, 4 months postoperatively, and 12 months postoperatively). Percentage agreement and the kappa statistic were calculated for both usage (yes/no) and dose categories. Results: Forty-five patients were included in this study, resulting in 108 pairs of self-reported and EMR datasets. Substantial levels of agreement (>70% agreement, kappa >0.61) for opioid use was seen at preoperative and 12 months postoperative. However, agreement dropped at 4 months postoperatively. Anticonvulsant medication showed high levels, whereas acetaminophen showed lower levels of agreements at all time points. Conclusions: Either self-reported or EMR data may be used in research and clinical settings for preoperative or 12-month postoperative patients with little concern for discrepancies. However, at time points immediately following the expected end of acute surgical pain, self-reported data may be needed for more accurate medication reporting. With these findings in mind, usage of datasets should be driven by study objectives and the dataset's strength (eg, accuracy, ease, lack of bias).

Personalized Multilevel Intervention for Improving Appropriate Use of Colorectal Cancer Screening in Older Adults: A Cluster Randomized Clinical Trial.

Importance: Despite guideline recommendations, clinicians do not systematically use prior screening or health history to guide colorectal cancer (CRC) screening decisions in older adults. Objective: To evaluate the effect of a personalized multilevel intervention on screening orders in older adults due for average-risk CRC screening. Design, Setting, and Participants: Interventional 2-group parallel unmasked cluster randomized clinical trial conducted from November 2015 to February 2019 at 2 US Department of Veterans Affairs (VA) facilities: 1 academic VA medical center and 1 of its connected outpatient clinics. Randomization at the primary care physician/clinician (PCP) level, stratified by study site and clinical full-time equivalency. Participants were 431 average-risk, screen-due US veterans aged 70 to 75 years attending a primary care visit. Data analysis was performed from August 2018 to August 2023. Intervention: The intervention group received a multilevel intervention including a decision-aid booklet with detailed information on screening benefits and harms, personalized for each participant based on age, sex, prior screening, and comorbidity. The control group received a multilevel intervention including a screening informational booklet. All participants received PCP education and system-level modifications to support personalized screening. Main Outcomes and Measures: The primary outcome was whether screening was ordered within 2 weeks of clinic visit. Secondary outcomes were concordance between screening orders and screening benefit and screening utilization within 6 months. Results: A total of 436 patients were consented, and 431 were analyzed across 67 PCPs. Patients had a mean (SD) age of 71.5 (1.7) years; 424 were male (98.4%); 374 were White (86.8%); 89 were college graduates (21.5%); and 351 (81.4%) had undergone prior screening. A total of 258 (59.9%) were randomized to intervention, and 173 (40.1%) to control. Screening orders were placed for 162 of 258 intervention patients (62.8%) vs 114 of 173 control patients (65.9%) (adjusted difference, -4.0 percentage points [pp]; 95% CI, -15.4 to 7.4 pp). In a prespecified interaction analysis, the proportion receiving orders was lower in the intervention group than in the control group for those in the lowest benefit quartile (59.4% vs 71.1%). In contrast, the proportion receiving orders was higher in the intervention group than in the control group for those in the highest benefit quartile (67.6% vs 52.2%) (interaction P = .049). Fewer intervention patients (106 of 256 [41.4%]) utilized screening overall at 6 months than controls (96 of 173 [55.9%]) (adjusted difference, -13.4 pp; 95% CI, -25.3 to -1.6 pp). Conclusions and Relevance: In this cluster randomized clinical trial, patients who were presented with personalized information about screening benefits and harms in the context of a multilevel intervention were more likely to receive screening orders concordant with benefit and were less likely to utilize screening. Trial Registration: ClinicalTrials.gov Identifier: NCT02027545.

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).

Testing adaptive interventions to improve PTSD treatment outcomes in Federally Qualified Health Centers: Protocol for a randomized clinical trial.

BACKGROUND: Posttraumatic stress disorder (PTSD) disproportionately affects low-income individuals and is untreated in 70% of those affected. One third of low-income Americans are treated in Federally Qualified Health Centers (FQHCs), which do not have the capacity to provide all patients with first-line treatments such as Prolonged Exposure (PE). To address this problem, FQHCs could use low-intensity interventions (e.g., Clinician-Supported PTSD Coach: CS PTSD Coach) and medium-intensity interventions (e.g., PE for Primary Care: PE-PC) to treat PTSD with fewer resources. However, some patients will still require high-intensity treatments (e.g., full-length PE) for sustained clinical benefit. Thus, there is a critical need to develop stepped-care models for PTSD in FQHCs. METHOD: We are conducting a Sequential, Multiple Assignment, Randomized Trial (SMART) with 430 adults with PTSD in FQHCs. Participants are initially randomized to CS PTSD Coach or PE-PC. After four sessions, early responders step down to lower frequency interaction within their assigned initial treatment strategy. Slow responders are re-randomized to either continue their initial treatment strategy or step up to Full PE for an additional eight weeks. The specific aims are to test the effectiveness of initiating treatment with PE-PC versus CS PTSD Coach in reducing PTSD symptoms and to test the effectiveness of second-stage strategies (continue versus step-up to Full PE) for slow responders. CONCLUSIONS: This project will provide critical evidence to inform the development of an effective stepped-care model for PTSD. Testing scalable, sustainable sequences of PTSD treatments delivered in low-resource community health centers will improve clinical practice for PTSD.

Study protocol: Behavioral economics and self-determination theory to change diabetes risk (BEST Change).

BACKGROUND: The Diabetes Prevention Program (DPP) and metformin can prevent or delay the onset of type 2 diabetes mellitus (T2DM) among patients with prediabetes. Yet, even when these evidence-based strategies are accessible and affordable, uptake is low. Thus, there is a critical need for effective, scalable, and sustainable approaches to increase uptake and engagement in these interventions. METHODS: In this randomized controlled trial, we will test whether financial incentives and automated messaging to promote autonomous motivation for preventing T2DM can increase DPP participation, metformin use, or both among adults with prediabetes. Participants (n = 380) will be randomized to one of four study arms. Control Arm participants will receive usual care and educational text messages about preventing T2DM. Incentives Arm participants will receive the Control Arm intervention plus financial incentives for DPP participation or metformin use. Tailored Messages Arm participants will receive the Control Arm intervention plus tailored messages promoting autonomous motivation for preventing T2DM. Combined Arm participants will receive the Incentives Arm and Tailored Messages Arm interventions plus messages to increase the personal salience of financial incentives. The primary outcome is change in hemoglobin A1c from baseline to 12 months. Secondary outcomes are change in body weight, DPP participation, and metformin use. DISCUSSION: If effective, these scalable and sustainable approaches to increase patient motivation to prevent T2DM can be deployed by health systems, health plans, and employers to help individuals with prediabetes lower their risk for developing T2DM.

Assessment of Outcome-Based Measures of Depression Care Quality in Veterans Health Administration Facilities.

To inform the potential use of patient-reported depression symptom outcomes as measures of care quality, this study collected and analyzed longitudinal Patient Health Questionnaire (PHQ9) scores among 1,638 patients who screened positive for major depression according to a PHQ9 ≥ 10 across 29 Department of Veterans Affairs facilities. The study found baseline PHQ9, prior mental health visits, physical functioning, and treatment expectancy were consistently associated with subsequent PHQ9 outcomes. No facilities outperformed any others on PHQ9 scores at the 6-month primary endpoint, and the corresponding intra-class coefficient was ≤ .01 for the entire sample (n = 1,214) and 0.03 for the subgroup of patients with new depression episodes (n = 629). Measures of antidepressant receipt, psychotherapy, or treatment intensification were not associated with 6-month PHQ9 scores. PHQ9 outcomes are therefore unlikely to be useful as quality indicators for VA healthcare facilities due to low inter-facility variation, and new care process measures are needed to inform care for patients with chronic depression prevalent in this sample.

Use of and Retention on Video, Telephone, and In-Person Buprenorphine Treatment for Opioid Use Disorder During the COVID-19 Pandemic.

Importance: The coronavirus disease 2019 (COVID-19) pandemic prompted policy changes to allow increased telehealth delivery of buprenorphine, a potentially lifesaving medication for opioid use disorder (OUD). It is unclear how characteristics of patients who access different treatment modalities (in-person vs telehealth, video vs telephone) vary, and whether modality is associated with retention-a key indicator of care quality. Objectives: To compare patient characteristics across receipt of different treatment modalities and to assess whether modality was associated with retention during the year following COVID-19-related policy changes. Design, Setting, and Participants: This cross-sectional study was conducted in the national Veterans Health Administration. Participants included patients who received buprenorphine for OUD during March 23, 2020, to March 22, 2021. Analyses examining retention were stratified by buprenorphine initiation time (year following COVID-19-related changes; prior to COVID-19-related changes). Exposures: Patient characteristics; treatment modality (at least 1 video visit, at least 1 telephone visit but no video, only in-person). Main Outcomes and Measures: Treatment modality; 90-day retention. Results: Among 17 182 patients, 7094 (41.3%) were aged 30 to 44 years and 6251 (36.4%) were aged 45 to 64 years; 15 835 (92.2%) were male, 14 085 (82.0%) were White, and 16 292 (94.8%) were non-Hispanic; 6547 (38.1%) had at least 1 video visit, 8524 (49.6%) had at least 1 telephone visit but no video visit, and 2111 (12.3%) had only in-person visits. Patients who were younger, male, Black, unknown race, Hispanic, non-service connected, or had specific mental health/substance use comorbidities were less likely to receive any telehealth. Among patients who received telehealth, those who were older, male, Black, non-service connected, or experiencing homelessness and/or housing instability were less likely to have video visits. Retention was significantly higher for patients with telehealth compared with only in-person visits regardless of initiation time (for initiated in year following COVID-19-related changes: adjusted odds ratio [aOR], 1.31; 95% CI, 1.12-1.53; for initiated prior to COVID-19-related changes: aOR, 1.23; 95% CI, 1.08-1.39). Among patients with telehealth, higher retention was observed in those with video visits compared with only telephone for patients who initiated in the year following COVID-19 (aOR, 1.47; 95% CI, 1.26-1.71). Conclusions and Relevance: In this cross-sectional study, many patients accessed buprenorphine via telephone and some were less likely to have any video visits. These findings suggest that discontinuing or reducing telephone access may disrupt treatment for many patients, particularly groups with access disparities such as Black patients and those experiencing homelessness. Telehealth was associated with increased retention for both new and continuing patients.

Patient-Centered Pain Care Using Artificial Intelligence and Mobile Health Tools: A Randomized Comparative Effectiveness Trial.

Importance: Cognitive behavioral therapy for chronic pain (CBT-CP) is a safe and effective alternative to opioid analgesics. Because CBT-CP requires multiple sessions and therapists are scarce, many patients have limited access or fail to complete treatment. Objectives: To determine if a CBT-CP program that personalizes patient treatment using reinforcement learning, a field of artificial intelligence (AI), and interactive voice response (IVR) calls is noninferior to standard telephone CBT-CP and saves therapist time. Design, Setting, and Participants: This was a randomized noninferiority, comparative effectiveness trial including 278 patients with chronic back pain from the Department of Veterans Affairs health system (recruitment and data collection from July 11, 2017-April 9, 2020). More patients were randomized to the AI-CBT-CP group than to the control (1.4:1) to maximize the system's ability to learn from patient interactions. Interventions: All patients received 10 weeks of CBT-CP. For the AI-CBT-CP group, patient feedback via daily IVR calls was used by the AI engine to make weekly recommendations for either a 45-minute or 15-minute therapist-delivered telephone session or an individualized IVR-delivered therapist message. Patients in the comparison group were offered 10 therapist-delivered telephone CBT-CP sessions (45 minutes/session). Main Outcomes and Measures: The primary outcome was the Roland Morris Disability Questionnaire (RMDQ; range 0-24), measured at 3 months (primary end point) and 6 months. Secondary outcomes included pain intensity and pain interference. Consensus guidelines were used to identify clinically meaningful improvements for responder analyses (eg, a 30% improvement in RMDQ scores and pain intensity). Data analyses were performed from April 2021 to May 2022. Results: The study population included 278 patients (mean [SD] age, 63.9 [12.2] years; 248 [89.2%] men; 225 [81.8%] White individuals). The 3-month mean RMDQ score difference between AI-CBT-CP and standard CBT-CP was -0.72 points (95% CI, -2.06 to 0.62) and the 6-month difference was -1.24 (95% CI, -2.48 to 0); noninferiority criterion were met at both the 3- and 6-month end points (P < .001 for both). A greater proportion of patients receiving AI-CBT-CP had clinically meaningful improvements at 6 months as indicated by RMDQ (37% vs 19%; P = .01) and pain intensity scores (29% vs 17%; P = .03). There were no significant differences in secondary outcomes. Pain therapy using AI-CBT-CP required less than half of the therapist time as standard CBT-CP. Conclusions and Relevance: The findings of this randomized comparative effectiveness trial indicated that AI-CBT-CP was noninferior to therapist-delivered telephone CBT-CP and required substantially less therapist time. Interventions like AI-CBT-CP could allow many more patients to be served effectively by CBT-CP programs using the same number of therapists. Trial Registration: ClinicalTrials.gov Identifier: NCT02464449.

Improving function through primary care treatment of PTSD: The IMPACT study protocol.

Despite the availability of effective psychological interventions for PTSD, access to and retention in these interventions remains problematic. Of note, the Veterans Health Administration (VHA) developed and implemented post-deployment health surveys that screen for PTSD in primary care (PC), but effective PC-based, psychological intervention treatment options have yet to be established. To address the literal physical gap between where the patients first present for care (i.e., primary care) and where they must go to receive first-line treatment for PTSD (i.e., specialty mental health), study investigators developed a 4-6 visit Prolonged Exposure for Primary Care (PE-PC) treatment that has shown efficacy in reduction of PTSD. To extend previous work to recovery-based mental health care, the Improving Function Through Primary Care Treatment of PTSD (IMPACT) study examined function as assessed by the World Health Organization Disability Assessment Schedule [WHODAS 2.0; (Axelsson, Lindsäter, Ljótsson, Andersson, & Hedman-Lagerlöf, 2017)]. Veterans presenting in VHA primary care mental health integration (PCMHI) clinics with PTSD or significant subsyndromal PTSD who met minimal inclusion and exclusion criteria were randomly assigned to PE-PC or treatment as usual (TAU). If proven effective in improving function, PE-PC would provide a new access point for high quality PTSD care and allow greater numbers of veterans to access effective PTSD treatment. Trial Registration: http://ClinicalTrials.gov: NCT03581981.

Evaluation of Antipsychotic Reduction Efforts in Patients With Dementia in Veterans Health Administration Nursing Homes.

OBJECTIVE: The Veterans Health Administration (VHA) and the Centers for Medicare and Medicaid Services (CMS) each created initiatives to reduce off-label use of antipsychotics in patients with dementia in nursing homes. Although CMS has reported antipsychotic reductions, the impact on prescribing of antipsychotic and other CNS-active medications in the VHA remains unclear. The authors evaluated national trends in antipsychotic and other CNS-active medication prescribing for nursing home patients with dementia in the VHA. METHODS: The study sample was all veterans with dementia residing in VHA nursing homes for more than 30 days (N=35,742). Using an interrupted time-series design, the quarterly prevalences of antipsychotic, antidepressant, antiepileptic, anxiolytic, opioid, and memory medication prescribing were evaluated from FY2009 through FY2018. RESULTS: Antipsychotic prescribing in VHA nursing homes declined from FY2009 to FY2018 (from 33.7% to 27.5%), with similar declines in anxiolytic prescribing (from 33.5% to 27.1%). During this period, prescribing of antiepileptics, antidepressants, and opioids increased significantly (antiepileptics: from 26.8% to 43.3%; antidepressants: from 56.8% to 63.4%; opioids: from 32.6% to 41.2%). Gabapentin served as the main driver of antiepileptic increases (from 11.1% to 23.5%). Increases in antidepressant prescribing included sertraline, mirtazapine, and trazodone. From FY2009 to FY2018, the overall prescribing of non-antipsychotic psychotropic medications grew from 75.0% to 81.1%. CONCLUSIONS: Antipsychotic and anxiolytic prescribing for VHA nursing home residents with dementia declined, although overall prescribing of other psychotropic and opioid medications increased. Policies focused primarily on reducing antipsychotic use without considering use in the context of other medications may contribute to growth in alternative medication classes with even less evidence of benefit and similar risks.

Change in posttraumatic stress disorder-related thoughts during treatment: Do thoughts drive change when pills are involved?

Posttraumatic negative thoughts about one's self and the world are related to posttraumatic stress disorder (PTSD) symptom severity and change in cognitive behavioral treatment (CBT), but little is known about this association when CBT is delivered with medication. The current study presents a planned comparison of changes in negative posttraumatic thoughts during (a) prolonged exposure (PE) plus pill placebo (PE+PLB), (b) sertraline plus enhanced medication management (SERT+EMM), and (c) PE plus sertraline (PE+SERT) as part of a randomized clinical trial in a sample of 176 veterans. Lagged regression modeling revealed that change in posttraumatic negative thoughts was associated with PTSD symptom change in the conditions in which participants received sertraline, ds = 0.14-0.25, ps = 0.04-.001). However, contrary to previous research, the models that started with symptom change were also statistically significant, d = 0.23, p < .001, for the lagged effect of symptoms on negative thoughts about self in the SERT+EMM condition, indicating a bidirectional association between such thoughts and PTSD symptoms. In the PE+PLB condition, no significant association between posttraumatic thoughts and PTSD symptoms emerged in either direction. These results suggest that the previously demonstrated role of change in posttraumatic thoughts leading to PTSD symptom reduction in PE may be altered when combined with pill administration, either active or placebo.

Predictors of Response to Prolonged Exposure, Sertraline, and Their Combination for the Treatment of Military PTSD.

Objective: The current study is an analysis of predictors of posttraumatic stress disorder (PTSD) treatment response in a clinical trial comparing (1) prolonged exposure plus placebo (PE + PLB), (2) PE + sertraline (PE + SERT), and (3) sertraline + enhanced medication management (SERT + EMM) with predictors including time since trauma (TST), self-report of pain, alcohol use, baseline symptoms, and demographics.Methods: Participants (N = 196) were veterans with combat-related PTSD (DSM-IV-TR) of at least 3 months' duration recruited between 2012 and 2016 from 4 sites in the 24-week PROlonGed ExpoSure and Sertraline (PROGrESS) clinical trial (assessments at weeks 0 [intake], 6, 12, 24, 36, and 52).Results: Across treatment conditions, (1) longer TST was predictive of greater week 24 PTSD symptom improvement (ß = 1.72, P = .01) after adjusting for baseline, (2) higher baseline pain severity was predictive of smaller symptom improvement (ß = -2.96, P = .003), and (3) Hispanic patients showed greater improvement than non-Hispanic patients (ß = 12.33, P = .03). No other baseline characteristics, including alcohol consumption, were significantly predictive of week 24 improvement. Comparison of TST by treatment condition revealed a significant relationship only in those randomized to the PE + SERT condition (ß = 2.53, P = .03). Longitudinal analyses showed similar results.Conclusions: The finding that longer TST shows larger symptom reductions is promising for PTSD patients who might not seek help for years following trauma. Higher baseline pain severity robustly predicted attenuated and slower response to all treatment conditions, suggesting a common neuropathologic substrate. Finally, in the current study, alcohol use did not impede the effectiveness of pharmacotherapy for PTSD.Trial Registration: ClinicalTrials.gov identifier: NCT01524133.

Reductions in guilt cognitions following prolonged exposure and/or sertraline predict subsequent improvements in PTSD and depression.

BACKGROUND AND OBJECTIVES: Reduction of trauma related negative cognitions, such as guilt, is thought to be a mechanism of change within PTSD treatments like prolonged exposure (PE). Research suggests PE can directly address guilt cognitions. However, whether pharmacotherapies for PTSD can remains unclear. METHODS: Data from a randomized controlled trial of PE plus placebo (PE + PLB), sertraline plus enhanced medication management (SERT + EMM), and their combination (PE + SERT) in 195 Veterans from recent wars was analyzed. RESULTS: The unadjusted means and mixed-effects model showed guilt decreased significantly over the follow-up time as expected; however, contrary to our hypothesis, PE conditions were not associated with greater reductions in guilt than the SERT + EMM condition. As hypothesized, week 12 reduction in guilt predicted post-treatment (weeks 24-52) reduction in PTSD and depression, but not impairments in function. LIMITATIONS: Generalizability of findings is limited by the sample being comprised of combat Veterans who were predominantly male, not on SSRI at study entry, willing to be randomized to therapy or medication, and reporting low levels of guilt. To reduce differences in provider attention, SERT + EMM was administered over 30 min to include psychoeducation and active listening; it is unknown if this contributed to effects on guilt. CONCLUSIONS: PE + PLB, SERT + EMM, and PE + SERT were equally associated with reduction in trauma related guilt. Reducing trauma related guilt may be a pathway to reducing PTSD and posttraumatic depression symptoms. Further study is needed to determine how best to treat trauma related guilt and to understand the mechanisms by which guilt improves across different treatments for PTSD.

Benzodiazepine Prescribing from VA and Medicare to Dually Enrolled Older Veterans: A Retrospective Cohort Study.

BACKGROUND: There has been a reduction in BZD prescribing in the Veterans Affairs (VA) health care system since 2013. It is unknown whether the decline in VA-dispensed BZDs has been offset by Medicare Part D prescriptions. OBJECTIVES: To examine (1) whether, accounting for Part D, declines in BZD prescribing to older Veterans remain; (2) patient characteristics associated with obtaining BZDs outside VA and facility variation in BZD source (VA only, VA and Part D, Part D only). DESIGN: Retrospective cohort study with mixed effects multinomial logistic model examining characteristics associated with BZD source. PATIENTS: A total of 1,746,278 Veterans aged ≥65 enrolled in VA and Part D, 2013-2017. MAIN MEASURES: BZD prescription prevalence and source. KEY RESULTS: From January 2013 to June 2017, the quarterly prevalence of older Veterans with Part D filling BZD prescriptions through the VA declined from 5.2 to 3.1% (p<0.001) or, accounting for Part D, from 10.0 to 7.7% (p<0.001). Among those prescribed BZDs between July 2016 and June 2017, 37.0%, 10.2%, and 52.8% received prescriptions from VA only, both VA and Part D, or Part D only, respectively. Older age was associated with higher odds of obtaining BZDs through Part D (e.g., compared to those 65-74, Veterans ≥85 had adjusted odds ratio [AOR] for Part D vs. VA only of 1.8 [95% highest posterior density interval (HPDI), 1.69, 1.86]). Veterans with substance use disorders accounted for few BZD prescriptions from any source but were associated with higher odds of prescriptions through Part D (e.g., alcohol use disorder AOR for Part D vs. VA alone: 1.9 [95% HPDI, 1.63, 2.11]) CONCLUSIONS: The decline in BZD use by older Veterans with Part D coverage remained after accounting for Part D, but the majority of BZD prescriptions came from Medicare. Further reducing BZD prescribing to older Veterans should consider prescriptions from community sources.

Prevalence of Central Nervous System-Active Polypharmacy Among Older Adults With Dementia in the US.

Importance: Community-dwelling older adults with dementia have a high prevalence of psychotropic and opioid use. In these patients, central nervous system (CNS)-active polypharmacy may increase the risk for impaired cognition, fall-related injury, and death. Objective: To determine the extent of CNS-active polypharmacy among community-dwelling older adults with dementia in the US. Design, Setting, and Participants: Cross-sectional analysis of all community-dwelling older adults with dementia (identified by International Classification of Diseases, Ninth Revision, Clinical Modification or International Statistical Classification of Diseases and Related Health Problems, Tenth Revision diagnosis codes; N = 1 159 968) and traditional Medicare coverage from 2015 to 2017. Medication exposure was estimated using prescription fills between October 1, 2017, and December 31, 2018. Exposures: Part D coverage during the observation year (January 1-December 31, 2018). Main Outcomes and Measures: The primary outcome was the prevalence of CNS-active polypharmacy in 2018, defined as exposure to 3 or more medications for longer than 30 days consecutively from the following classes: antidepressants, antipsychotics, antiepileptics, benzodiazepines, nonbenzodiazepine benzodiazepine receptor agonist hypnotics, and opioids. Among those who met the criterion for polypharmacy, duration of exposure, number of distinct medications and classes prescribed, common class combinations, and the most commonly used CNS-active medications also were determined. Results: The study included 1 159 968 older adults with dementia (median age, 83.0 years [interquartile range {IQR}, 77.0-88.6 years]; 65.2% were female), of whom 13.9% (n = 161 412) met the criterion for CNS-active polypharmacy (32 139 610 polypharmacy-days of exposure). Those with CNS-active polypharmacy had a median age of 79.4 years (IQR, 74.0-85.5 years) and 71.2% were female. Among those who met the criterion for CNS-active polypharmacy, the median number of polypharmacy-days was 193 (IQR, 88-315 polypharmacy-days). Of those with CNS-active polypharmacy, 57.8% were exposed for longer than 180 days and 6.8% for 365 days; 29.4% were exposed to 5 or more medications and 5.2% were exposed to 5 or more medication classes. Ninety-two percent of polypharmacy-days included an antidepressant, 47.1% included an antipsychotic, and 40.7% included a benzodiazepine. The most common medication class combination included an antidepressant, an antiepileptic, and an antipsychotic (12.9% of polypharmacy-days). Gabapentin was the most common medication and was associated with 33.0% of polypharmacy-days. Conclusions and Relevance: In this cross-sectional analysis of Medicare claims data, 13.9% of older adults with dementia in 2018 filled prescriptions consistent with CNS-active polypharmacy. The lack of information on prescribing indications limits judgments about clinical appropriateness of medication combinations for individual patients.

Benzodiazepine Use among Medicare, Commercially Insured, and Veteran Older Adults, 2013-2017.

BACKGROUND/OBJECTIVES: Benzodiazepines (BZDs) are widely prescribed to older adults. Although prescribing has declined in the U.S. Department of Veterans Affairs (VA), Medicare introduced BZD coverage in 2013. It is unknown whether declines in the VA have been widespread among older adults in the United States. DESIGN: Observational study in traditional fee-for-service Medicare, commercial insurance, and the VA. SETTING: United States, 2013-2017. PARTICIPANTS: Adults aged 55 and older in traditional Medicare (234,290,693 person-months), commercial insurance (337,827,125 person-months), and the VA (256,590,369 person-months). MEASUREMENTS: (1) Change in BZD and BZD-opioid co-prescribing modeled by Poisson regression over time; and (2) standardized ratios of BZD and BZD-opioid co-prescribing, using Medicare as the reference. RESULTS: From April 2013 to December 2017, the monthly percentage of adults aged 55 and older who received BZDs fell from 10.4% to 9.3% in Medicare, 6.6% to 6.5% in commercial insurance, and 5.7% to 3.0% in the VA. Monthly BZD-opioid co-prescribing over the same time fell from 4.0% to 3.0% in Medicare, 2.3% to 2.0% in commercial, and 2.2% to .6% for the VA. Age- and sex-adjusted rates of decline for BZD and BZD-opioid co-prescribing were statistically significant for all systems. Annual BZD rate reductions were .98 (Medicare), .99 (commercial), and .87 (VA; P < .001 for all); co-prescribing rate reductions were .95, .99, and .75 (P < .001 for all). Using standardized ratios accounting for demographic and clinical characteristics, both prescribing and co-prescribing were lowest for the VA relative to Medicare (standardized BZD ratio = .40; 95% confidence interval [CI] = .39-.40; standardized BZD-opioid co-prescribing ratio = .35; 95% CI = .35-.35). Prescribing in commercial insurance was also lower (BZD = .65; 95% CI = .65-.65; BZD-opioid co-prescribing = .65; 95% CI = .65-.65). CONCLUSION: BZD prescribing has declined much more to older adults receiving care through the VA than Medicare or commercial insurance. Other systems may learn from strategies implemented in the VA.