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1.
J Clin Psychiatry ; 82(6)2021 Oct 05.
Artigo em Inglês | MEDLINE | ID: mdl-34610227

RESUMO

Objective: Fluoxetine, paroxetine, sertraline, topiramate, and venlafaxine have previously shown efficacy for posttraumatic stress disorder (PTSD) in randomized clinical trials. Two prior studies using Department of Veterans Affairs (VA) medical records data show these medications are also effective in routine practice. Using an expanded retrospective cohort, we assessed the possibility of differential patterns of response based on patient and clinical factors.Methods: We identified 6,839 VA outpatients with clinical diagnoses of PTSD between October 1999 and September 2019 who initiated one of the medications and met pre-specified criteria for treatment duration and dose, combined with baseline and endpoint PTSD checklist (PCL) measurements. We compared 12-week changes in PCL score within clinical subgroups defined by sex, race and ethnicity, and military exposures, as well as comorbidities. Comorbidities were identified using International Classification of Diseases diagnostic codes and grouped according to major diagnostic classifications in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (eg, Psychotic Disorders, Depressive Disorders). We used a propensity score weighting approach to balance covariates among medication arms within each clinical subgroup. In our exploratory analyses using unweighted data for the overall cohort, we built penalized logistic regression models to identify covariates that predicted meaningful improvement.Results: There were no significant differences between medications in our weighted subgroup analyses. In unweighted exploratory analyses, higher baseline PCL scores and concurrent receipt of evidence-based psychotherapy predicted meaningful improvement, while high levels of disability predicted not realizing meaningful improvement.Conclusions: In the largest real-world study of medications for PTSD to date, we did not observe a pattern of differential response among clinical subgroups. All patients taking medications for PTSD, especially those with the highest levels of disability, should consider combined treatment with evidence-based psychotherapy.

2.
Artigo em Inglês | MEDLINE | ID: mdl-34360101

RESUMO

Suicide is a significant public health concern worldwide and in the United States. Despite the far-reaching impact of suicide, risk factors are still not well understood and efforts to accurately assess risk have fallen short. Current research has highlighted how potentially modifiable environmental exposures (i.e., meteorological, pollution, and geographic exposures) can affect suicide risk. A scoping review was conducted to evaluate the strength of the historical and current literature on the environment's effect on suicide and suicide risk. Three databases (i.e., Medline, Embase, and PsychInfo) were reviewed to identify relevant studies and two authors independently reviewed studies considering pre-determined inclusion criteria. A total of 46 meteorological studies were included as well as 23 pollution studies and 12 geographic studies. Descriptive statistics, including counts, percentages, review of studies' sample size (minimum, maximum, median, and interquartile range), were calculated using Excel and SAS 9.4. Overall, strong evidence supports that exposure to sunlight, temperature, air pollution, pesticides, and high altitude increases suicide risk, although effect sizes range from very small to small.


Assuntos
Poluentes Atmosféricos , Poluição do Ar , Suicídio , Poluentes Atmosféricos/análise , Poluentes Atmosféricos/toxicidade , Poluição do Ar/efeitos adversos , Poluição do Ar/análise , Gerenciamento de Dados , Exposição Ambiental/efeitos adversos , Exposição Ambiental/análise , Humanos
3.
Neurotherapeutics ; 2021 Jul 09.
Artigo em Inglês | MEDLINE | ID: mdl-34244925

RESUMO

A Taiwanese cohort study found that symptomatic herpes simplex virus (HSV) infection was associated with a threefold increased risk of developing dementia; however, antiherpetic medication reduced the risk by 90%. Our aim was to verify and further investigate this finding in the US Veteran population using comprehensive electronic medical records from the Veterans Health Administration (VHA). Eighty-seven thousand six hundred eighty-seven Veterans aged 50 or older with symptomatic HSV-1/HSV-2 infection and 217,895 matched controls were identified in VHA data between January 1, 2001, and December 31, 2014, and followed until December 31, 2019. International Classification of Diseases (ICD) codes, ninth and tenth revisions, were used to define dementia. To define HSV infection, we utilized VHA data on antiherpetic medications and laboratory tests in addition to ICD codes. Cox proportional hazards models were used to analyze the effects of HSV infection and antiherpetic medication on the risk of developing dementia. The analysis revealed an adjusted HR of 0.80 (95% CI, 0.78-0.83) for the development of dementia among those with symptomatic HSV relative to those without. Among the 61,776 HSV-1/HSV-2 patients who were treated with antiherpetic medication, 4836 patients (7.8%) developed dementia (adjusted HR = 0.75; 95% CI, 0.72-0.78); this translated to a population average of one additional year of being dementia free in those who were taking antiherpetic medication. In contrast to Tzeng et al. we did not find that HSV infection was associated with an increased risk of dementia. Like their findings, we found that antiherpetic medication was associated with a protective effect against dementia. Future prospective studies are needed to further investigate this effect.

4.
PLoS One ; 16(7): e0246217, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34324514

RESUMO

OBJECTIVE: We explored longitudinal trends in sociodemographic characteristics, reported symptoms, laboratory findings, pharmacological and non-pharmacological treatment, comorbidities, and 30-day in-hospital mortality among hospitalized patients with coronavirus disease 2019 (COVID-19). METHODS: This retrospective cohort study included patients diagnosed with COVID-19 in the United States Veterans Health Administration between 03/01/20 and 08/31/20 and followed until 09/30/20. We focused our analysis on patients that were subsequently hospitalized, and categorized them into groups based on the month of hospitalization. We summarized our findings through descriptive statistics. We used Cuzick's Trend Test to examine any differences in the distribution of our study variables across the six months. RESULTS: During our study period, we identified 43,267 patients with COVID-19. A total of 8,240 patients were hospitalized, and 13.1% (N = 1,081) died within 30 days of admission. Hospitalizations increased over time, but the proportion of patients that died consistently declined from 24.8% (N = 221/890) in March to 8.0% (N = 111/1,396) in August. Patients hospitalized in March compared to August were younger on average, mostly black, urban-dwelling, febrile and dyspneic. They also had a higher frequency of baseline comorbidities, including hypertension and diabetes, and were more likely to present with abnormal laboratory findings including low lymphocyte counts and elevated creatinine. Lastly, there was a decline from March to August in receipt of mechanical ventilation (31.4% to 13.1%) and hydroxychloroquine (55.3% to <1.0%), while treatment with dexamethasone (3.7% to 52.4%) and remdesivir (1.1% to 38.9%) increased. CONCLUSION: Among hospitalized patients with COVID-19, we observed a trend towards decreased disease severity and mortality over time.


Assuntos
COVID-19/mortalidade , Saúde dos Veteranos/estatística & dados numéricos , Monofosfato de Adenosina/análogos & derivados , Monofosfato de Adenosina/uso terapêutico , Idoso , Idoso de 80 Anos ou mais , Alanina/análogos & derivados , Alanina/uso terapêutico , COVID-19/tratamento farmacológico , Comorbidade , Dexametasona/uso terapêutico , Feminino , Mortalidade Hospitalar , Hospitalização/estatística & dados numéricos , Humanos , Estudos Longitudinais , Contagem de Linfócitos , Linfócitos/imunologia , Masculino , Pessoa de Meia-Idade , Respiração Artificial/métodos , Estudos Retrospectivos , Estados Unidos
5.
Gen Hosp Psychiatry ; 72: 7-14, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34214935

RESUMO

OBJECTIVE: Irregular discharge is a concern among mental health populations and associated with poor outcomes. Little is known about the relationship between irregular discharge and treatment setting. Because care processes differ between acute inpatient and residential settings, it is important to evaluate irregular discharge in these settings. METHOD: A retrospective study was conducted in patients with mental health conditions admitted to acute inpatient or residential mental health settings in the Department of Veterans Affairs, 2003-2019. Logistic regression and multivariate Cox proportional hazards were used to evaluate factors associated with irregular discharge risk in the first 90- days of admission. RESULTS: Among 1.8 million discharges, 7.4% had an irregular discharge within 90- days of admission. Younger age was a central predictor of risk. Irregular discharge rates were four-fold higher in residential versus acute settings. When accounting for length of stay (LOS) across settings, there was a modest higher risk of irregular discharge from acute versus residential settings (HR = 1.06, 95% Confidence Interval 1.04-1.07). CONCLUSIONS: Patients are at high risk for irregular discharge from acute and residential settings when they are young. LOS is an important determinant of irregular discharge risk.. Interventions are needed to address drivers of irregular discharge.

6.
J Rural Health ; 2021 Jun 15.
Artigo em Inglês | MEDLINE | ID: mdl-34128267

RESUMO

PURPOSE: To assess the role that race-ethnicity plays in modifying the observed rural-urban disparity in suicide among Veteran Health Administration (VHA) users. METHODS: We performed a retrospective cohort study of 10,737,864 VHA users between 2003 and 2017, using cross-linked VHA medical records and National Death Index mortality data to assess longitudinal race-stratified rural-urban differences in age- and sex-adjusted annual suicide rates. We used Poisson regression and generated incident rate ratios (IRRs) to formally assess the impact of race on the rural-urban suicide disparity. Given evidence of effect modification, we performed additional race-stratified Poisson regression models. FINDINGS: Rurality is significantly associated with a higher risk of suicide in models which do not control for race (IRR = 1.14, 95% CI: 1.10-1.17). However, when race is added to the model, rural residence is no longer significant (0.98, CI: 0.95-1.01). Stratified models demonstrate that rural residence is significantly associated with a higher suicide risk among Hispanic VHA users (1.41, CI: 1.11-1.79), but it is not substantially associated with suicide among White (0.97, CI: 0.94-1.00) and Black (1.03, CI: 0.86-1.23) VHA users. White VHA users have considerably higher suicide rates than Black and Hispanic VHA users, though the suicide rate among Hispanic VHA users, particularly those in rural settings, increased markedly over the period of observation. CONCLUSIONS: Race significantly modifies the relationship between rural residence and suicide risk. Studies seeking to assess suicide disparity between rural and urban VHA user populations must include adjustment or stratification by race.

7.
Psychiatr Serv ; : appips202000537, 2021 May 12.
Artigo em Inglês | MEDLINE | ID: mdl-33979200

RESUMO

OBJECTIVE: Risk for suicide is high after psychiatric hospitalization. The World Health Organization's Brief Intervention and Contact (BIC) program has shown efficacy in preventing suicide. A version adapted for the U.S. Department of Veterans Affairs (VA) was studied to determine preliminary effects. METHODS: Patients receiving psychiatric hospitalization because of acute risk for self-harm were randomly assigned to the VA BIC or standard care alone. Effect sizes (Hedges' g) for suicidal ideation (primary outcome), social connectedness (measured as thwarted belongingness and perceived burdensomeness), hopelessness, and engagement were calculated at 1 and 3 months. RESULTS: Patients were randomly assigned to the VA BIC (N=10) or standard care (N=9). The VA BIC had a medium or large effect on most measures at 1 month (suicidal ideation, g=0.45). Effects diminished at 3 months, except for thwarted belongingness (g=0.81). CONCLUSIONS: The VA BIC had meaningful effects on suicide-related outcomes. The largest effect was seen in the first month.

8.
Psychol Med ; : 1-10, 2021 May 18.
Artigo em Inglês | MEDLINE | ID: mdl-34001290

RESUMO

BACKGROUND: While evidence-based psychotherapy (EBP) for posttraumatic stress disorder (PTSD) is a first-line treatment, its real-world effectiveness is unknown. We compared cognitive processing therapy (CPT) and prolonged exposure (PE) each to an individual psychotherapy comparator group, and CPT to PE in a large national healthcare system. METHODS: We utilized effectiveness and comparative effectiveness emulated trials using retrospective cohort data from electronic medical records. Participants were veterans with PTSD initiating mental healthcare (N = 265 566). The primary outcome was PTSD symptoms measured by the PTSD Checklist (PCL) at baseline and 24-week follow-up. Emulated trials were comprised of 'person-trials,' representing 112 discrete 24-week periods of care (10/07-6/17) for each patient. Treatment group comparisons were made with generalized linear models, utilizing propensity score matching and inverse probability weights to account for confounding, selection, and non-adherence bias. RESULTS: There were 636 CPT person-trials matched to 636 non-EBP person-trials. Completing ⩾8 CPT sessions was associated with a 6.4-point greater improvement on the PCL (95% CI 3.1-10.0). There were 272 PE person-trials matched to 272 non-EBP person-trials. Completing ⩾8 PE sessions was associated with a 9.7-point greater improvement on the PCL (95% CI 5.4-13.8). There were 232 PE person-trials matched to 232 CPT person-trials. Those completing ⩾8 PE sessions had slightly greater, but not statistically significant, improvement on the PCL (8.3-points; 95% CI 5.9-10.6) than those completing ⩾8 CPT sessions (7.0-points; 95% CI 5.5-8.5). CONCLUSIONS: PTSD symptom improvement was similar and modest for both EBPs. Although EBPs are helpful, research to further improve PTSD care is critical.

10.
J Eval Clin Pract ; 2021 May 24.
Artigo em Inglês | MEDLINE | ID: mdl-34028937

RESUMO

RATIONALE AIMS AND OBJECTIVES: As quality measurement becomes increasingly reliant on the availability of structured electronic medical record (EMR) data, clinicians are asked to perform documentation using tools that facilitate data capture. These tools may not be available, feasible, or acceptable in all clinical scenarios. Alternative methods of assessment, including natural language processing (NLP) of clinical notes, may improve the completeness of quality measurement in real-world practice. Our objective was to measure the quality of care for a set of evidence-based practices using structured EMR data alone, and then supplement those measures with additional data derived from NLP. METHOD: As a case example, we studied the quality of care for posttraumatic stress disorder (PTSD) in the United States Department of Veterans Affairs (VA) over a 20-year period. We measured two aspects of PTSD care, including delivery of evidence-based psychotherapy (EBP) and associated use of measurement-based care (MBC), using structured EMR data. We then recalculated these measures using additional data derived from NLP of clinical note text. RESULTS: There were 2 098 389 VA patients with a diagnosis of PTSD between 2000 and 2019, 72% (n = 1 515 345) of whom had not previously received EBP for PTSD and were treated after a 2015 mandate to document EBP using templates that generate structured EMR data. Using structured EMR data, we determined that 3.2% (n = 48 004) of those patients met our EBP for PTSD quality standard between 2015 and 2019, and 48.1% (n = 23 088) received associated MBC. With the addition of NLP-derived data, estimates increased to 4.1% (n = 62 789) and 58.0% (n = 36 435), respectively. CONCLUSION: Healthcare quality data can be significantly improved by supplementing structured EMR data with NLP-derived data. By using NLP, health systems may be able to fill the gaps in documentation when structured tools are not yet available or there are barriers to using them in clinical practice.

11.
J Rural Health ; 2021 Apr 26.
Artigo em Inglês | MEDLINE | ID: mdl-33900641

RESUMO

PURPOSE: To examine the association between contextual factors, represented by geographic and community health variables, and suicide among rural and urban Department of Veterans Affairs health care users (VA users). METHODS: We performed a retrospective cohort study of 12,700,847 VA users between 2003 and 2017. We assigned contextual factors based on individuals' home address at the ZIP Code (area deprivation), county (sunlight exposure, altitude, and community health), and state level (firearm ownership), using publicly available data sources. We grouped contextual factors by quintiles or prespecified thresholds, depending on the nature of each variable. We obtained mortality data from the National Death Index. We measured the effect of living in a place with the highest versus lowest level of each contextual factor on odds of suicide using logistic regression, adjusting for individual compositional factors abstracted from VA electronic medical records data. We used random forest modeling to build prediction models for suicide based on contextual factors among rural and urban veterans. FINDINGS: Almost all contextual factors we examined were significantly associated with suicide among rural and urban VA users, even after adjusting for individual compositional factors. However, no contextual variables were strong protective or risk factors (0.52.0), and prediction models leveraging these contextual factors had poor accuracy among both rural (0.51, 95% CI: 0.48-0.54) and urban (0.53, 95% CI: 0.51-0.55) VA users. CONCLUSIONS: A wide variety of contextual factors is significantly associated with suicide among rural and urban VA users. However, the factors we measured contributed very little to individual-level suicide risk.

12.
Br J Psychiatry ; : 1-8, 2021 Mar 03.
Artigo em Inglês | MEDLINE | ID: mdl-33653425

RESUMO

BACKGROUND: Suicide risk is high in the 30 days after discharge from psychiatric hospital, but knowledge of the profiles of high-risk patients remains limited. AIMS: To examine sex-specific risk profiles for suicide in the 30 days after discharge from psychiatric hospital, using machine learning and Danish registry data. METHOD: We conducted a case-cohort study capturing all suicide cases occurring in the 30 days after psychiatric hospital discharge in Denmark from 1 January 1995 to 31 December 2015 (n = 1205). The comparison subcohort was a 5% random sample of all persons born or residing in Denmark on 1 January 1995, and who had a first psychiatric hospital admission between 1995 and 2015 (n = 24 559). Predictors included diagnoses, surgeries, prescribed medications and demographic information. The outcome was suicide death recorded in the Danish Cause of Death Registry. RESULTS: For men, prescriptions for anxiolytics and drugs used in addictive disorders interacted with other characteristics in the risk profiles (e.g. alcohol-related disorders, hypnotics and sedatives) that led to higher risk of postdischarge suicide. In women, there was interaction between recurrent major depression and other characteristics (e.g. poisoning, low income) that led to increased risk of suicide. Random forests identified important suicide predictors: alcohol-related disorders and nicotine dependence in men and poisoning in women. CONCLUSIONS: Our findings suggest that accurate prediction of suicide during the high-risk period immediately after psychiatric hospital discharge may require a complex evaluation of multiple factors for men and women.

13.
Psychiatr Serv ; 72(4): 384-390, 2021 04 01.
Artigo em Inglês | MEDLINE | ID: mdl-33530729

RESUMO

OBJECTIVE: To identify geographic variation in mental health service use in the Department of Veterans Affairs (VA), the authors constructed utilization-based VA mental health service areas (MHSAs) for outpatient treatment and mental health referral regions (MHRRs) for residential and acute inpatient treatment. METHODS: MHSAs are empirically derived geographic groupings of one or more counties containing one or more VA outpatient mental health clinics. For each county within an MHSA, patients received most of their VA-provided outpatient mental health care within that MHSA. MHSAs were aggregated into MHRRs according to where VA users in each MHSA received most of their residential and acute inpatient mental health care. Attribution loyalty was evaluated with the localization index-the fraction of VA users living in each geographic area who used their designated MHSA and MHRR facility. Variation in outpatient mental health visits and in acute inpatient and residential mental health stays was determined for the 2008-2018 period. RESULTS: A total of 441 MHSAs were aggregated to 115 MHRRs (representing 3,909,080 patients with 52,372,303 outpatient mental health visits). The mean±SD localization index was 59.3%±16.4% for MHSAs and 67.8%±12.7% for MHRRs. Adjusted outpatient mental health visits varied from a mean of 0.88 per year in the lowest quintile of MHSAs to 3.14 in the highest. Combined residential and acute inpatient days varied from 0.29 to 1.79 between the lowest and highest quintiles. CONCLUSIONS: MHSAs and MHRRs validly represented mental health utilization patterns in the VA and displayed considerable variation in mental health service provision across different locations.


Assuntos
Serviços de Saúde Mental , Veteranos , Hospitais de Veteranos , Humanos , Análise de Pequenas Áreas , Estados Unidos , United States Department of Veterans Affairs
15.
Adm Policy Ment Health ; 48(1): 70-87, 2021 01.
Artigo em Inglês | MEDLINE | ID: mdl-32394096

RESUMO

We sought to develop a quality standard for the prescription of antidepressants for posttraumatic stress disorder (PTSD) that is both consistent with the underlying evidence supporting antidepressants as a treatment for PTSD and associated with the best levels of symptom improvement. We quantified antidepressant initiation during the first year of PTSD treatment in a 10-year national cohort of Department of Veterans Affairs (VA) users, and compared outcomes in a subgroup who completed patient-reported outcome measurement (PROM) as part of routine practice. We added progressively stringent measurement requirements. Prescribing quality for PTSD in the VA was stable over time. Use of PROM was rare in the case of antidepressant treatment, limiting our assessment of outcomes.

17.
Psychooncology ; 30(4): 581-590, 2021 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-33247977

RESUMO

OBJECTIVE: To evaluate the effect of a preexisting posttraumatic stress disorder (PTSD) diagnosis on suicide and non-suicide mortalities among men with newly diagnosed prostate cancer, and examine potential mediating factors for the relationship between PTSD and suicide. METHODS: We used patient-level data from Veterans Health Administration electronic medical records to identify men (age ≥40 years) diagnosed with prostate cancer between 2004 and 2014. We used Fine and Gray regression model to estimate the risk for competing mortality outcomes (suicide, non-suicide, and alive). We used structural equation models to evaluate the mediating factors. RESULTS: Our cohort comprised 214,649 men with prostate cancer, of whom 12,208 (5.7%) had a preexisting PTSD diagnosis. Patients with PTSD compared to those without utilized more healthcare services and had lower risk cancer at diagnosis. Additionally, they experienced more suicide deaths (N = 26, 0.21% vs. N = 269, 0.13%) and fewer non-suicide deaths (N = 1399, 11.5% vs. N = 45,625, 22.5%). On multivariable analysis, PTSD was an independent suicide risk factor (HR = 2.35; 95% CI: 1.16, 4.78). Depression, substance use disorder, and any definitive prostate cancer treatment were partial mediators. However, PTSD was associated with lower non-suicide mortality risk (HR = 0.86; 95% CI: 0.77, 0.96). CONCLUSION: Patients with PTSD experienced greater suicide risk even after adjusting for important mediators. They may have experienced lower non-suicide mortality risk due to favorable physical health resulting from greater healthcare service use and early diagnosis of lower risk cancer. Our findings highlight the importance of considering psychiatric illnesses when treating patients with prostate cancer and the need for interventions to ameliorate suicide risk.

18.
Mil Med ; 186(9-10): e956-e961, 2021 08 28.
Artigo em Inglês | MEDLINE | ID: mdl-33377975

RESUMO

INTRODUCTION: There is emerging evidence to support that the COVID-19 pandemic and related public health measures may be associated with negative mental health sequelae. Rural populations in particular may fair worse because they share many unique characteristics that may put them at higher risk for adverse outcomes with the pandemic. Yet, rural populations may also be more resilient due to increased sense of community. Little is known about the impact of the pandemic on the mental health and well-being of a rural population pre- and post-pandemic, especially those with serious mental illness. MATERIAL AND METHODS: We conducted a longitudinal, mixed-methods study with assessments preceding the pandemic (between October 2019 and March 2020) and during the stay-at-home orders (between April 23, 2020, and May 4, 2020). Changes in hopelessness, suicidal ideation, connectedness, and treatment engagement were assessed using a repeated-measures ANOVA or Friedman test. RESULTS: Among 17 eligible participants, 11 people were interviewed. Overall, there were no notable changes in any symptom scale in the first 3-5 months before the pandemic or during the stay-at-home orders. The few patients who reported worse symptoms were significantly older (mean age: 71.7 years, SD: 4.0). Most patients denied disruptions to treatment, and some perceived telepsychiatry as beneficial. CONCLUSIONS: Rural patients with serious mental illness may be fairly resilient in the face of the COVID-19 pandemic when they have access to treatment and supports. Longer-term outcomes are needed in rural patients with serious mental illness to better understand the impact of the pandemic on this population.


Assuntos
COVID-19 , Transtornos Mentais , Psiquiatria , Telemedicina , Idoso , Humanos , Transtornos Mentais/epidemiologia , Saúde Mental , Pandemias , Saúde Pública , População Rural , SARS-CoV-2
19.
Am J Epidemiol ; 2020 Dec 09.
Artigo em Inglês | MEDLINE | ID: mdl-33295947

RESUMO

There are an infinite number of small decisions to be made in routine clinical practice, and most will never be the subject of prospective research studies. Rather than making these decisions arbitrarily, learning health care systems leverage experience represented by electronic health record data and other sources to inform decision making and improve clinical practice. While this approach has been elusive in mental health, Coulombe et al. (AJE-00362-2020.R3) use British National Health Service data to evaluate a decision rule for antidepressant choice created using dynamic weighted survival modeling. Though the results are equivocal in this use case, the work suggests a path forward for data-driven decision making in routine mental health care. Such approaches will be required to set the stage for a learning mental health care system.

20.
Mil Med ; 2020 Nov 13.
Artigo em Inglês | MEDLINE | ID: mdl-33185663

RESUMO

INTRODUCTION: The United States Department of Veterans Affairs (VA) has invested in implementation of evidence-based psychotherapy (EBP) for post-traumatic stress disorder (PTSD) for over a decade, resulting in slow but steady uptake of these treatments nationally. However, no prior research has investigated the geographic variation in initiation of EBP. Our objectives were to determine whether there is geographic variation in the initiation of EBP for PTSD in the VA and to identify patient and clinic factors associated with EBP initiation. MATERIALS AND METHODS: We identified VA patients with PTSD who had not received EBP as of January 2016 (N = 946,667) using retrospective electronic medical records data and determined whether they initiated EBP by December 2017. We illustrated geographic variation in EBP initiation using national and regional maps. Using multivariate logistic regression, we determined patient, regional, and nearest VA facility predictors of initiating treatment. This study was approved by the Veterans Institutional Review Board of Northern New England. RESULTS: Nationally, 4.8% (n = 45,895) initiated EBP from 2016 to 2017, and there was geographic variation, ranging from none to almost 30% at the 3-digit ZIP code level. The strongest patient predictors of EBP initiation were the negative predictor of being older than 65 years (OR = 0.47; 95% CI, 0.45-0.49) and the positive predictor of reporting military-related sexual trauma (OR = 1.96; 95% CI, 1.90-2.03). The strongest regional predictors of EBP initiation were the negative predictor of living in the Northeast (OR = 0.89; 95% CI, 0.86-0.92) and the positive predictor of living in the Midwest (OR = 1.47; 95% CI, 1.44-1.51). The only nearest VA facility predictor of EBP initiation was the positive predictor of whether the facility was a VA Medical Center with a specialized PTSD clinic (OR = 1.23; 95% CI, 1.20-1.26). CONCLUSION: Although less than 5% of VA patients with PTSD initiated EBP, there was regional variation. Patient factors, region of residence, and nearest VA facility characteristics were all associated with whether patients initiated EBP. Strengths of this study include the use of national longitudinal data, while weaknesses include the potential for misclassification of PTSD diagnoses as well as the potential for misidentification of EBP. Our work indicates geographic areas where access to EBP for PTSD may be poor and can help target work improving access. Future studies should also assess completion of EBP for PTSD and related symptomatic and functional outcomes across geographic areas.

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