Change in Trauma Narratives and Perceived Recall Ability over a Course of Cognitive Processing Therapy for PTSD.

This study sought to evaluate changes in written trauma narratives completed during a course of Cognitive Processing Therapy (CPT). Participants were 22 female survivors of interpersonal assault who represented a subset of participants from two larger CPT treatment trials. Participants completed two written trauma narratives over the course of treatment. We predicted that narratives would increase in length and peritraumatic detail, and that participants would perceive an increase in their recall ability for important aspects of the trauma. Although narrative length and amount of peritraumatic detail did not change significantly from first to final narrative, participants evidenced changes in the content of the peritraumatic details. Patients commonly omitted assaultive acts from one of their narratives. There was a greater degree of fluctuation within the reporting of sexual assaults, as compared to physical assaults, with 55% of participants reporting a forced sexual act in one narrative, but not the other. Participants did not report significant changes in perceived recall ability for the traumatic event after completing the narratives, but did report improvements in perceived recall from pre to posttreatment. Overall, findings indicate that clients included different details (but not more details) in their final narrative, and that perceived increases in recall ability may not be a typical experience for clients as they complete written narratives in the context of trauma treatment.

Veterans' perspectives on initiating evidence-based psychotherapy for posttraumatic stress disorder.

Evidence-based psychotherapies (EBP) for posttraumatic stress disorder (PTSD) are effective at reducing symptoms and improving quality of life. Despite their effectiveness, few veterans receive EBP. To examine veterans' experiences initiating EBP for PTSD, we conducted qualitative interviews with those who completed at least 8 sessions of prolonged exposure (PE) or cognitive processing therapy (CPT). Veterans reported learning about EBP from therapists, psychiatrists, and other veterans. Ambivalence and delaying EBP initiation were common. Barriers included fears that EBP would increase symptoms, beliefs that avoidance was helpful, disbelief of the therapy rationale, particularly for PE, and less commonly, lack of knowledge about EBP. Facilitators included feeling a "need to talk about it," prior treatment that increased confidence in the ability to handle EBP, prior knowledge of the EBP therapist, provider behaviors that facilitated buy-in, encouragement from other veterans, and desperation for symptom relief. There were few differences in barriers and facilitators between PE and CPT, although veterans in PE were more likely to express skepticism of the therapy rationale. These results highlight the importance of "word of mouth" about EBP among the veteran community and identifying provider behaviors that may promote EBP initiation.

Psychotherapy Utilization Among Rural and Urban Veterans From 2007 to 2010.

PURPOSE: This study evaluated change in rural and urban veterans' psychotherapy use during a period of widespread effort within the Veterans Health Administration (VHA) to engage rural veterans in mental health care. METHODS: National VHA administrative databases were queried for patients receiving a new diagnosis of depression, anxiety, or posttraumatic stress disorder in fiscal years (FY) 2007 and 2010. Using the US Department of Agriculture Rural-Urban Continuum Codes, we identified urban (FY 2007: n = 192,347; FY 2010: n = 231,471) and rural (FY 2007: n = 72,923; FY 2010: n = 81,905) veterans. Veterans' psychotherapy use during the 12 months following diagnosis was assessed. FINDINGS: From FY 2007 to 2010, the proportion of veterans receiving any psychotherapy increased from 17% to 22% for rural veterans and 24% to 28% for urban veterans. Rural veterans were less likely to receive psychotherapy across both fiscal years; however, the magnitude of this disparity decreased significantly from 2007 (odds ratio [OR] = 1.51) to 2010 (OR = 1.41). Similarly, although urban veterans received more psychotherapy sessions, urban-rural disparities in the receipt of 8 or more psychotherapy sessions decreased over the study period (2007: OR = 2.32; 2010: OR = 1.69). CONCLUSIONS: Rural and urban veterans are increasingly making use of psychotherapy, and rural-urban gaps in psychotherapy use are shrinking. These improvements suggest that recent VHA efforts to engage rural veterans in care have been successful at reducing differences between rural and urban veterans with respect to access and engagement in psychotherapy.

Mental health utilization among older Veterans with coexisting depression and dementia.

OBJECTIVE: We compared mental health service utilization among older, depressed Veterans (60 years or older) with and without coexisting dementia. METHODS: This retrospective study examined data from the 2010 Veterans Health Administration National Patient Care Database outpatient treatment files of Veterans with a newly recognized diagnosis of depression (N = 177,710). RESULTS: Approximately 48.84% with coexisting depression and dementia and 32.00% with depression only received mental health services within 12 months of diagnosis (p < .0001). Veterans with coexisting depression and dementia were more likely to receive medication-management appointments (33.40% vs 20.62%), individual therapy (13.39% vs 10.91%), and family therapy (3.77% vs 1.19%) than depressed Veterans without dementia. CONCLUSION: In general, Veterans with recently diagnosed depression are significantly underusing Veterans Affairs mental health treatment services. Those Veterans who have comorbid dementia are more likely than those with just depression to be enrolled in mental health treatments. Systemic improvements are needed to increase use of mental health services for older, depressed Veterans.

Characteristics of U.S. veterans who begin and complete prolonged exposure and cognitive processing therapy for PTSD.

This retrospective chart-review study examined patient-level correlates of initiation and completion of evidence-based psychotherapy (EBP) for posttraumatic stress disorder (PTSD) among treatment-seeking U.S. veterans. We identified all patients (N = 796) in a large Veterans Affairs PTSD and anxiety clinic who attended at least 1 individual psychotherapy appointment with 1 of 8 providers trained in EBP. Within this group, 91 patients (11.4%) began EBP (either Cognitive Processing Therapy or Prolonged Exposure) and 59 patients (7.9%) completed EBP. The medical records of all EBP patients (n = 91) and a provider-matched sample of patients who received another form of individual psychotherapy (n = 66) were reviewed by 4 independent raters. Logistic regression analyses revealed that Iraq and Afghanistan veterans were less likely to begin EBP than veterans from other service eras, OR = 0.48, 95% CI = [0.24, 0.94], and veterans who were service connected for PTSD were more likely than veterans without service connection to begin EBP, OR = 2.33, 95% CI = [1.09, 5.03]. Among those who began EBP, Iraq and Afghanistan veteran status, OR = 0.09, 95% CI = [0.03, 0.30], and a history of psychiatric inpatient hospitalization, OR = 0.13, 95% CI = [0.03, 0.54], were associated with decreased likelihood of EBP completion.

Predisposing, enabling, and need factors as predictors of low and high psychotherapy utilization in veterans.

This study used national administrative data from the Veterans Health Administration (VHA) to examine predisposing, enabling, and need factors related to multiple levels of psychotherapy utilization in a sample of veterans with posttraumatic stress disorder (PTSD), depression, or anxiety. The database was queried for all veterans who were newly diagnosed with PTSD, depression, or anxiety during the 2010 fiscal year and received at least 1 outpatient psychotherapy session in the year following diagnosis (N = 130,331). Veterans were classified as low (51.0%; 1-3 sessions), moderate (38.3%; 4-18 sessions), high (8.7%; 19-51 sessions), or very high (1.9%; 52 or more sessions) psychotherapy users based on the total number of psychotherapy visits during the 1-year follow-up period. Multinomial logistic regression was used to examine predictors of utilization level. Predisposing factors of gender and marital status were modestly associated with utilization. Several need factors were strongly associated with utilization; very high users had higher rates of PTSD and substance use disorders, more comorbid psychiatric diagnoses, and more inpatient psychiatric visits. Very high users were also more likely to demonstrate enabling factors, including living closer to a VHA facility and seeking care at more complex facilities. Overall, need factors appeared to be most strongly linked to psychotherapy utilization. These results suggest many patients may not receive a clinically optimal dose of psychotherapy, highlighting the need to enhance retention in therapy for low utilizers and examine whether very high utilizers are benefitting from extensive courses of treatment.

Increasing engagement in evidence-based PTSD treatment through shared decision-making: a pilot study.

Within the Veterans Health Administration, post-traumatic stress disorder (PTSD) treatment decisions are left to the patient and provider, allowing substantial variability in the way treatment decisions are made. Theorized to increase treatment engagement, shared decision-making interventions provide a standardized framework for treatment decisions. This study sought to develop (phase 1) and pilot test the feasibility and potential effectiveness (phase 2) of a brief shared decision-making intervention to promote engagement in evidence-based PTSD treatment. An initial version of the intervention was developed and then modified according to stakeholder feedback. Participants in the pilot trial were 27 Iraq and Afghanistan Veterans recruited during an intake assessment at a Veterans Affairs PTSD clinic. Participants randomized to the intervention condition (n = 13) participated in a 30-minute shared decision-making session, whereas patients randomized to the usual care condition (n = 14) completed treatment planning during their intake appointment, per usual clinic procedures. Among the 20 study completers, a greater proportion of participants in the intervention condition preferred an evidence-based treatment and received an adequate (≥9 sessions) dose of psychotherapy. Results provide preliminary support for the feasibility and potential effectiveness of the intervention and suggest that larger-scale trials are warranted.

Diagnostic specificity and mental health service utilization among veterans with newly diagnosed anxiety disorders.

OBJECTIVE: This study examined rates of specific anxiety diagnoses (posttraumatic stress disorder, generalized anxiety disorder, panic disorder, obsessive-compulsive disorder, social anxiety disorder, and specific phobia) and anxiety disorder not otherwise specified (anxiety NOS) in a national sample of Veterans and assessed their mental health service utilization. METHOD: This study used administrative data extracted from Veteran Health Administration outpatient records to identify patients with a new anxiety diagnosis in fiscal year 2010 (N = 292,244). Logistic regression analyses examined associations among diagnostic specificity, diagnostic location, and mental health service utilization. RESULTS: Anxiety NOS was diagnosed in 38% of the sample. Patients in specialty mental health were less likely to receive an anxiety NOS diagnosis than patients in primary care (odds ratio [OR] = 0.36). Patients with a specific anxiety diagnosis were more likely to receive mental health services than those with anxiety NOS (OR = 1.65), as were patients diagnosed in specialty mental health compared with those diagnosed in primary care (OR = 16.29). CONCLUSION: Veterans diagnosed with anxiety NOS are less likely to access mental health services than those with a specific anxiety diagnosis, suggesting the need for enhanced diagnostic and referral practices, particularly in primary care settings.

Changes in psychotherapy utilization among veterans with depression, anxiety, and PTSD.

OBJECTIVE: Large-scale health care systems such as the Veterans Health Administration (VHA) have recently invested heavily in the expansion of psychotherapy services. This study examined longitudinal changes in use of psychotherapy at the VHA during a period of substantial programmatic change targeting increased availability and quality of mental health care. METHODS: This retrospective cohort study used data from the VHA National Patient Care Database outpatient treatment files to identify patients with a new-onset diagnosis of depression, anxiety, or posttraumatic stress disorder during fiscal years (FYs) 2004 (N=424,428), 2007 (N=494,318), and 2010 (N=583,733). Use of psychotherapy during the 12 months after diagnosis was assessed. RESULTS: The proportion of patients receiving any psychotherapy increased across the three study time points (FY 2004, 21%; FY 2007, 22%; and FY 2010, 27%). Amount of psychotherapy also increased such that with time a growing proportion of patients received eight or more psychotherapy sessions. The median time between diagnosis and start of psychotherapy decreased from 56 to 47 days from FY 2004 to FY 2010. Consistent with VHA expansion efforts, more substantial increases in psychotherapy reach, amount, and timeliness occurred between FY 2007 and 2010 than between FY 2004 and FY 2007. CONCLUSIONS: These findings highlight recent increases in the use of VHA psychotherapy and correspond to substantial efforts to improve access to mental health services. Despite these advances, most newly diagnosed patients received no psychotherapy or a low-intensity amount of psychotherapy. Additional efforts to promote veteran engagement in needed mental health services appear warranted.

Rates and predictors of referral for individual psychotherapy, group psychotherapy, and medications among Iraq and Afghanistan veterans with PTSD.

This study examined rates of referral for medication, individual psychotherapy, and group psychotherapy within a Veterans Affairs (VA) posttraumatic stress disorder (PTSD) specialty mental health clinic. Participants were 388 Iraq and Afghanistan veterans who were referred for PTSD treatment following a mental health evaluation required for all new VA enrollees. The majority of the sample was referred for medication (79 %), with comparatively fewer referrals for individual (39 %) or group psychotherapy (24 %). Forty percent of participants were referred for combined medication and psychotherapy. Patient demographic and clinical characteristics were examined to determine whether these variables predicted referral type. Female veterans and those with lower clinician ratings of overall functioning were more likely to be referred for individual therapy. Group psychotherapy referrals were more common in veterans who were older, unemployed, identified as an ethnic minority, and had a comorbid anxiety disorder. There were no significant predictors of medication referral.

Manualized therapy for PTSD: flexing the structure of cognitive processing therapy.

OBJECTIVE: This study tested a modified cognitive processing therapy (MCPT) intervention designed as a more flexible administration of the protocol. Number of sessions was determined by client progress toward a priori defined end-state criteria, "stressor sessions" were inserted when necessary, and therapy was conducted by novice CPT clinicians. METHOD: A randomized, controlled, repeated measures, semicrossover design was utilized (a) to test the relative efficacy of the MCPT intervention compared with a symptom-monitoring delayed treatment (SMDT) condition and (b) to assess within-group variation in change with a sample of 100 male and female interpersonal trauma survivors with posttraumatic stress disorder (PTSD). RESULTS: Hierarchical linear modeling analyses revealed that MCPT evidenced greater improvement on all primary (PTSD and depression) and secondary (guilt, quality of life, general mental health, social functioning, and health perceptions) outcomes compared with SMDT. After the conclusion of SMDT, participants crossed over to MCPT, resulting in a combined MCPT sample (n = 69). Of the 50 participants who completed MCPT, 58% reached end-state criteria prior to the 12th session, 8% at Session 12, and 34% between Sessions 12 and 18. Maintenance of treatment gains was found at the 3-month follow-up, with only 2 of the treated sample meeting criteria for PTSD. Use of stressor sessions did not result in poorer treatment outcomes. CONCLUSIONS: Findings suggest that individuals respond at a variable rate to CPT, with significant benefit from additional therapy when indicated and excellent maintenance of gains. Insertion of stressor sessions did not alter the efficacy of the therapy.

A pilot study of a 12-week model of group-based exposure therapy for veterans with PTSD.

Group-based exposure therapy (GBET) is an intensive group treatment that targets posttraumatic stress disorder (PTSD) symptoms through repeated imaginal and in vivo exposure. The purpose of the present study was to assess the feasibility and acceptability of a modified 12-week course of GBET (modified from the standard 16 weeks) and to examine its effectiveness in reducing veterans' PTSD symptoms. Participants were 10 male Operation Iraqi Freedom and Vietnam-era veterans recruited from a PTSD specialty clinic at a large Veterans Affairs Medical Center. All participants were retained and demonstrated clinically significant reductions in PTSD symptoms (η(2) = .84-.87) comparable to the standard protocol. The findings from this small sample indicate that the abbreviated 12-week GBET protocol is a potentially effective treatment for PTSD.