Mental Health Providers' Decision-Making Around the Implementation of Evidence-Based Treatment for PTSD.

It is estimated that <15% of veterans with posttraumatic stress disorder (PTSD) have engaged in two evidence-based psychotherapies highly recommended by VA-cognitive processing therapy (CPT) and prolonged exposure (PE). CPT and PE guidelines specify which patients are appropriate, but research suggests that providers may be more selective than the guidelines. In addition, PTSD clinical guidelines encourage "shared decision-making," but there is little research on what processes providers use to make decisions about CPT/PE. Sixteen licensed psychologists and social workers from two VA medical centers working with ≥1 patient with PTSD were interviewed about patient factors considered and decision-making processes for CPT/PE use. Qualitative analyses revealed that patient readiness and comorbid conditions influenced decisions to use or refer patients with PTSD for CPT/PE. Providers reported mentally derived and instances of patient-involved decision-making around CPT/PE use. Continued efforts to assist providers in making informed and collaborative decisions about CPT/PE use are discussed.

Development and Validation of a Computerized-Adaptive Test for PTSD (P-CAT).

OBJECTIVE: The primary purpose was to develop, field test, and validate a computerized-adaptive test (CAT) for posttraumatic stress disorder (PTSD) to enhance PTSD assessment and decrease the burden of symptom monitoring. METHODS: Data sources included self-report and interviewer-administered diagnostic interviews. The sample included 1,288 veterans. In phase 1, 89 items from a previously developed PTSD item pool were administered to a national sample of 1,085 veterans. A multidimensional graded-response item response theory model was used to calibrate items for incorporation into a CAT for PTSD (P-CAT). In phase 2, in a separate sample of 203 veterans, the P-CAT was validated against three other self-report measures (PTSD Checklist, Civilian Version; Mississippi Scale for Combat-Related PTSD; and Primary Care PTSD Screen) and the PTSD module of the Structured Clinical Interview for DSM-IV. RESULTS: A bifactor model with one general PTSD factor and four subfactors consistent with DSM-5 (reexperiencing, avoidance, negative mood-cognitions, and arousal), yielded good fit. The P-CAT discriminated veterans with PTSD from those with other mental health conditions and those with no mental health conditions (Cohen's d effect sizes >.90). The P-CAT also discriminated those with and without a PTSD diagnosis and those who screened positive versus negative for PTSD. Concurrent validity was supported by high correlations (r=.85-.89) with the validation measures. CONCLUSIONS: The P-CAT appears to be a promising tool for efficient and accurate assessment of PTSD symptomatology. Further testing is needed to evaluate its responsiveness to change. With increasing availability of computers and other technologies, CAT may be a viable and efficient assessment method.

Using Mixed Methods to Examine the Role of Veterans' Illness Perceptions on Depression Treatment Utilization and HEDIS Concordance.

BACKGROUND: Although depression screening occurs annually in the Department of Veterans Affairs (VA) primary care, many veterans may not be receiving guideline-concordant depression treatment. OBJECTIVES: To determine whether veterans' illness perceptions of depression may be serving as barriers to guideline-concordant treatment. RESEARCH DESIGN: We used a prospective, observational design involving a mailed questionnaire and chart review data collection to assess depression treatment utilization and concordance with Healthcare Effectiveness Data and Information Set guidelines adopted by the VA. The Self-Regulation Model of Illness Behavior guided the study. SUBJECTS: Veterans who screened positive for a new episode of depression at 3 VA primary care clinics in the US northeast. MEASURES: The Illness Perceptions Questionnaire-Revised, measuring patients' perceptions of their symptoms, cause, timeline, consequences, cure or controllability, and coherence of depression and its symptoms, was our primary measure to calculate veterans' illness perceptions. Treatment utilization was assessed 3 months after the positive depression screen through chart review. Healthcare Effectiveness Data and Information Set (HEDIS) guideline-concordant treatment was determined according to a checklist created for the study. RESULTS: A total of 839 veterans screened positive for a new episode of depression from May 2009-June 2011; 275 (32.8%) completed the survey. Ninety-two (33.9%) received HEDIS guideline-concordant depression treatment. Veterans' illness perceptions of their symptoms, cause, timeline, and controllability of depression predicted receiving guideline-concordant treatment. CONCLUSIONS: Many veterans are not receiving guideline-concordant treatment for depression. HEDIS guideline measures may not be assessing all aspects of quality depression care. Conversations about veterans' illness perceptions and their specific needs are encouraged to ensure that appropriate treatment is achieved.

Postdeployment resilience as a predictor of mental health in operation enduring freedom/operation iraqi freedom returnees.

BACKGROUND: Much of the research on the impact of trauma exposure among veterans has focused on factors that increase risk for mental health problems. Fewer studies have investigated factors that may prevent mental health problems following trauma exposure. This study examines resilience variables as factors that may prevent subsequent mental health problems. PURPOSE: To determine whether military service members returning from Afghanistan and Iraq who exhibit higher levels of resilience, including hardiness (encompassing control, commitment, and challenge), self-efficacy, and social support after returning from deployment are less vulnerable to subsequent mental health problems, alcohol, and drug use. METHODS: A national sample of 512 service members was surveyed between 3 and 12 months of return from deployment and 6-12 months later. Data were collected in 2008-2009 and analyzed in 2013. Regression analyses ascertained whether resilience 3-12 months after return predicted later mental health and substance problems, controlling for demographic characteristics, mental health, and risk factors, including predeployment stressful events, combat exposure, and others. RESULTS: Greater hardiness predicted several indicators of better mental health and lower levels of alcohol use 6-12 months later, but did not predict subsequent posttraumatic stress symptom severity. Postdeployment social support predicted better overall mental health and less posttraumatic stress symptom severity, alcohol, and drug use. CONCLUSIONS: Some aspects of resilience after deployment appear to protect returning service members from the negative effects of traumatic exposure, suggesting that interventions to promote and sustain resilience after deployment have the potential to enhance the mental health of veterans.

The role of coping in depression treatment utilization for VA primary care patients.

OBJECTIVE: To examine the impact of Veterans' coping strategies on mental health treatment engagement following a positive screen for depression. METHODS: A mixed-methods observational study using a mailed survey and semi-structured interviews. Sample included 271 Veterans who screened positive for depression during a primary care visit at one of three VA medical centers and had not received a diagnosis of depression or prescribed antidepressants 12 months prior to screening. A subsample of 23 Veterans was interviewed. RESULTS: Logistic regression models showed that Veterans who reported more instrumental support and active coping were more likely to receive depression or other mental health treatment within three months of their positive depression screen. Those who reported emotional support or self-distraction as coping strategies were less likely to receive any treatment in the same time frame. Qualitative analyses revealed that how Veterans use these and other coping strategies can impact treatment engagement in a variety of ways. CONCLUSIONS: The relationship between Veterans' use of coping strategies and treatment engagement for depression may not be readily apparent without in-depth exploration. PRACTICE IMPLICATIONS: In VA primary care clinics, nurse care managers and behavioral health providers should explore how Veterans' methods of coping may impact treatment engagement.

Is DSM-IV criterion A2 associated with PTSD diagnosis and symptom severity?

The diagnostic criteria for posttraumatic stress disorder (PTSD) have received significant scrutiny. Several studies have investigated the utility of Criterion A2, the subjective emotional response to a traumatic event. The American Psychiatric Association (APA) has proposed elimination of A2 from the PTSD diagnostic criteria for DSM-5; however, there is mixed support for this recommendation and few studies have examined A2 in samples at high risk for PTSD such as veterans. In the current study of 908 veterans who screened positive for a traumatic event, A2 was not significantly associated with having been told by a doctor that the veteran had PTSD. Those who endorsed A2, however, reported greater PTSD symptom severity in the 3 DSM-IV symptom clusters of reexperiencing (d = 0.45), avoidance (d = 0.61), and hyperarousal (d = 0.44), and A2 was significantly associated with PTSD symptom severity for all 3 clusters (R(2) = .25, .25, and .27, respectively) even with trauma exposure in the model. Thus, although A2 may not be a necessary criterion for PTSD diagnosis, its association with PTSD symptom severity warrants further exploration of its utility.

Mental and physical health status and alcohol and drug use following return from deployment to Iraq or Afghanistan.

OBJECTIVES: We examined (1) mental and physical health symptoms and functioning in US veterans within 1 year of returning from deployment, and (2) differences by gender, service component (Active, National Guard, other Reserve), service branch (Army, Navy, Air Force, Marines), and deployment operation (Operation Enduring Freedom/Operation Iraqi Freedom [OEF/OIF]). METHODS: We surveyed a national sample of 596 OEF/OIF veterans, oversampling women to make up 50% of the total, and National Guard and Reserve components to each make up 25%. Weights were applied to account for stratification and nonresponse bias. RESULTS: Mental health functioning was significantly worse compared with the general population; 13.9% screened positive for probable posttraumatic stress disorder, 39% for probable alcohol abuse, and 3% for probable drug abuse. Men reported more alcohol and drug use than did women, but there were no gender differences in posttraumatic stress disorder or other mental health domains. OIF veterans reported more depression or functioning problems and alcohol and drug use than did OEF veterans. Army and Marine veterans reported worse mental and physical health than did Air Force or Navy veterans. CONCLUSIONS: Continuing identification of veterans at risk for mental health and substance use problems is important for evidence-based interventions intended to increase resilience and enhance treatment.

Posttraumatic Growth Inventory: Factor Structure in the Context of DSM-IV Traumatic Events.

Studies examining the dimensionality of the Posttraumatic Growth Inventory (PTGI) have yielded varying results. To date, no study has investigated the measure's factor structure in the context of DSM-defined traumatic events. The present study examined the structure in an undergraduate student sample (N = 379) reporting DSM-IV Criterion-A potentially traumatic events. Confirmatory factor analysis (CFA) did not support the original five-factor structure. Follow-up exploratory factor analysis and CFA on random halves of the sample showed poor model fit for 1-, 3-, and 7-factor models. Results suggest that the PTGI factor structure is unclear amongst individuals with DSM-IV traumatic events, and continued use of the total score is most appropriate. Future directions including the utility of the PTGI factors are discussed.

Neural representation of object approach in a decision-making motor circuit.

Although behavior is ultimately guided by decision-making neurons and their associated networks, the mechanisms underlying neural decision-making in a behaviorally relevant context remain mostly elusive. To address this question, we analyzed goldfish escapes in response to distinct visual looming stimuli with high-speed video and compared them with electrophysiological responses of the Mauthner cell (M-cell), the threshold detector that initiates such behaviors. These looming stimuli evoke powerful and fast body-bend (C-start) escapes with response probabilities between 0.7 and 0.91 and mean latencies ranging from 142 to 716 ms. Chronic recordings showed that these C-starts are correlated with M-cell activity. Analysis of response latency as a function of the different optical parameters characterizing the stimuli suggests response threshold is closely correlated to a dynamically scaled function of angular retinal image size, (t), specifically kappa(t) = (t-delta x e(-beta(t-delta)), where the exponential term progressively reduces the weight of (t). Intracellular recordings show that looming stimuli typically evoked bursts of graded EPSPs with peak amplitudes up to 9 mV in the M-cell. The proposed scaling function kappa(t) predicts the slope of the depolarizing envelope of these EPSPs and the timing of the largest peak. An analysis of the firing rate of presynaptic inhibitory interneurons suggests the timing of the EPSP peak is shaped by an interaction of excitatory and inhibitory inputs to the M-cell and corresponds to the temporal window in which the probabilistic decision of whether or not to escape is reached.