Demographic and clinical correlates of social anxiety disorder among US veterans: findings from the NESARC-III study.

PURPOSE: Social anxiety disorder (SAD) is among the most highly prevalent and debilitating psychiatric disorders within the US population, but SAD has gone relatively unnoticed within the US veteran population. Preliminary research has demonstrated that SAD is related to decreased mental and physical functioning as well as posttraumatic stress disorder (PTSD) and depression among veterans. METHODS: The present study investigated SAD and its relationship with demographic factors, psychiatric disorders, suicidality, treatment seeking, and social support among veterans. Multivariate survey weighted logistic regression analyses were conducted to observe these associations utilizing data from National Epidemiologic Survey on Alcohol and Related Conditions which contained data on 3119 veterans. RESULTS: SAD was found to be strongly related to PTSD and other anxiety disorder, and these disorders were related to increased treatment seeking for SAD. Further, SAD was associated with lifetime suicide attempts and decreased perceived social support in multivariate models adjusting for demographic factors and psychiatric comorbidities. CONCLUSION: This study highlights the relationships of SAD among veterans by demonstrating its associations with other psychiatric disorders, treatment seeking, suicide attempts, and social support. A deeper understanding of the impact of SAD within the veteran population will inform future prevention and treatment efforts.

An Online Peer Educational Campaign to Reduce Stigma and Improve Help Seeking in Veterans with Posttraumatic Stress Disorder.

BACKGROUND: Although at least 1 in 10 veterans meet criteria for Posttraumatic Stress Disorder (PTSD) related to their military service, treatment seeking is strikingly low due to perceived stigma and other barriers. The National Center for PTSD produced AboutFace, * a web-based video gallery of veterans with PTSD who share their personal stories about PTSD and how treatment has turned their lives around. INTRODUCTION: We conducted a two-stage evaluation of AboutFace, which included (1) a usability testing phase and (2) a randomized, controlled trial phase to explore the feasibility of incorporating AboutFace into a specialized outpatient clinic for PTSD. MATERIALS AND METHODS: Twenty veterans participated in the usability testing phase in which they answered moderator posed questions regarding AboutFace, while actively exploring the website. Sixty veterans participated in the study after completing a PTSD clinic evaluation and were randomized to receive an educational booklet about PTSD treatment or AboutFace before starting treatment. Stigma and attitudes about treatment seeking were assessed at baseline and 2 weeks later. RESULTS: Veterans had positive attitudes about AboutFace and gave suggestions for improvement. Veterans in both conditions reported improved attitudes toward mental illness and treatment seeking from baseline to the 2-week follow-up. DISCUSSION: AboutFace is a promising peer-to-peer approach that can be used to challenge stigma and promote help seeking. CONCLUSIONS: This use of an online peer approach is innovative, relevant to a wide range of healthcare conditions, and has the potential to increase access to care through trusted narratives that promote hope in recovery.

Cultural Change: Implementation of a Recovery Program in a Veterans Health Administration Medical Center Inpatient Unit.

INTRODUCTION: The Freedom Commission's recommendations, Substance Abuse and Mental Health Services Administration's framework, and policy directives on recovery-oriented services have fueled the recovery transformation. Mental health recovery services have been implemented in a broad range of outpatient settings. However, psychiatric inpatient units remained embedded in the traditional model of care. AIMS: The purpose of this article is to describe an ongoing quality improvement implementation of recovery services in a Veterans Health Administration acute psychiatric inpatient unit. METHOD: An interprofessional Partnership for Wellness delivered 4 to 6 hours per day of evidence-based recovery and holistic population-specific health programs. Veteran, system, and program indicators were measured. RESULTS: Preliminary indicators over a 2-year period suggest that Veterans rated group content and relevance high, pre-post psychiatric rehospitalization rates decreased by 46%, and fidelity to recommended strategies was high. CONCLUSIONS: The project success reflects strong leadership, a partnership of committed staff, effective training, and an organizational culture exemplifying excellence in Veteran services and innovation.

Changes in the Beck Depression Inventory-II's underlying symptom structure over 1 month of inpatient treatment.

Research has not investigated changes in the symptom structure of depression over the course of mental health treatment. In the present study, 1025 psychiatric inpatients were recruited and assessed for depression symptom severity using the Beck Depression Inventory-II (BDI-II) at admission and after 1 month of treatment. A three-factor BDI-II model was tested using confirmatory factor analysis and fit reasonably well at both time points. Measurement invariance testing results demonstrated that factor loadings increased, indicating that the meaning of the three underlying depression dimensions changed through treatment. However, observed variable intercepts and residual error variances decreased significantly after 1 month of treatment, reflecting decreases in symptom severity as well as measurement error. Thus, depressive symptom severity decreased over the course of treatment, and the underlying factor structure of depression improved in fit after treatment. Implications for changes to the structure of depression symptoms and in the clinical practice of tracking depression over time are discussed.

Factors associated with SF-12 physical and mental health quality of life scores in adults with stroke.

BACKGROUND: Studies of poststroke quality of life (QOL) have not consistently identified which factors are most likely to independently influence the physical and mental aspects of QOL. In this study, we sought to identify which sociodemographic, comorbid disease conditions, and disability factors independently influenced the physical and mental aspects of poststroke QOL. METHODS: We completed a cross-sectional study of 666 US adults with a history of stroke from the 2007 Medical Expenditure Panel Survey (MEPS). We used sequentially built multiple linear regression models to identify sociodemographic, comorbidity, and stroke-related disability factors that independently affected short form-12 (SF-12) physical component summary (PCS) and mental component summary (MCS) scores. STATA software (version 10; StataCorp LP, College Station, TX) was used to perform the analysis to account for the complex survey design of the MEPS. RESULTS: In fully adjusted models using a nationally representative sample of US adults, being non-Hispanic black (ß = 3.58), 45 to 64 years of age (ß = -3.48), 65 years of age or older (ß = -2.90), married (ß = -3.50), middle (ß = 2.78) and high income (ß = 3.73), or having hypertension (ß = -2.25), cardiovascular disease (ß = -2.05), arthritis (ß = -4.49), depression (ß = -2.98), physical limitations (ß = -7.60), social limitations (ß = -4.12), and a need for assistance with instrumental activities of daily living (ß = -4.49) were independently correlated with PCS scores. Being 45 to 64 years of age (ß = 3.96), depressed (ß = -15.92), or having social limitations (ß = -3.62) were independently correlated with MCS scores. CONCLUSIONS: Sociodemographic, comorbidity, and stroke-related disability factors have differential effect on physical and mental aspects of QOL in poststroke patients.

Development and feasibility pilot of Considering PTSD Treatment: An online intervention with peer support.

Considering PTSD Treatment is an online program adapted from the National Center for PTSD's AboutFace website. Developed to help veterans overcome barriers to seeking treatment for posttraumatic stress disorder (PTSD), the program features videos of veterans describing PTSD and what treatment was like. Peer specialists are available at the beginning and end to chat with participants. We describe initial pilot feasibility data in 50 veterans recruited through online ads who screened positive for PTSD and were not currently in treatment. Eighty percent of participants who consented enrolled in the program and 64.0 % completed all modules. On average, participants rated the program at least "moderately" helpful and over 90 % reported feeling more knowledgeable about PTSD and PTSD treatment. Of the 21 participants who completed the one month follow-up, 52.4 % said they had talked to or were assessed by a provider and 61.9 % said they started treatment. There was not a significant change in stigma scores from baseline to follow-up. Results provide initial support for the feasibility, acceptability, and effectiveness of Considering PTSD Treatment for increasing treatment seeking readiness and support the need for a larger randomized controlled trial.

Do psychosocial treatment outcomes vary by race or ethnicity? A review of meta-analyses.

The past two decades have seen an increase in the number of psychotherapy clinical trials that were adequately powered to compare clinical outcomes across different racial and ethnic groups. Reviews have concluded that outcomes are generally equivalent, though there is still widespread skepticism of how these therapies perform in diverse populations. The current study reviewed 23 meta-analyses that considered race/ethnicity as a predictor of treatment outcome in psychotherapies across a range of psychiatric disorders. In general, these reviews did not find differences in outcomes between ethnic/racial minorities relative to White participants. Cumulative evidence of no race/ethnic differences in reported outcomes was strong for some disorders (e.g., depression, PTSD), though data were lacking or insufficient for other mental health conditions (e.g., borderline personality disorder, eating disorders). We also identified several gaps in the literature that provide directions for future research to better understand racial-ethnic differences in psychotherapy outcomes.

Meta-Analysis of the Treatment of Posttraumatic Stress Disorder in Adults With Comorbid Severe Mental Illness.

Objective: To evaluate the efficacy of psychosocial treatments for posttraumatic stress disorder (PTSD) among individuals with a comorbid severe mental illness (SMI; ie, schizophrenia, bipolar disorder, major depressive disorder).Data Sources: PubMed, PsycINFO, CINAHL, and Cochrane Library were searched from January 1998 to March 2020 using keywords related to PTSD, treatment, and severe mental illness.Study Selection: All clinical trials for PTSD psychotherapy among individuals with SMI were included. From 38 potentially eligible studies, a total of 14 clinical trials across 684 individuals with comorbid SMI and PTSD were identified and included in the analysis.Data Extraction: Data on demographic, SMI diagnosis, symptom severity, sample attrition, and treatment protocol received were extracted. Effect size calculations and subsequent meta-analyses were conducted using the Meta-Analysis Package for R (metafor) version 2.1-0 in R (3.6.0).Results: PTSD treatments had a large effect on PTSD outcomes among individuals with SMI, with patients experiencing a standard deviation reduction in PTSD symptomatology pre- to post-treatment (g = -1.009, P < .001, k = 34). Prolonged exposure (g = -1.464; P < .001; SE = 0.276; k = 5), eye movement desensitization and reprocessing (g = -1.351; P < .001; SE = 0.276; k = 5), and brief treatment program (g = -1.009; P < .001; SE = 0.284; k = 5) had the largest effects on PTSD symptoms.Conclusions: Although underrepresented in the PTSD literature, PTSD psychotherapies are effective for individuals with SMI. Treatments with an exposure-based component may have greater efficacy in this clinical population.

A randomized clinical trial of in-person vs. home-based telemedicine delivery of Prolonged Exposure for PTSD in military sexual trauma survivors.

Posttraumatic stress disorder (PTSD) is common in women who experienced Military Sexual Trauma (MST). Despite Veterans Affairs Medical Center-wide screening and tailored MST services, substantial barriers to care exist, and about 50 % of those who start evidence-based treatment for PTSD drop out prematurely. Home-based telemedicine (HBT) may reduce logistical and stigma related barriers to mental health care, thereby reducing dropout. The current randomized clinical trial (NCT02417025) for women veterans with MST-related PTSD (N = 136) compared the efficacy of HBT delivery of Prolonged Exposure (PE) to in-person delivery of PE on measures of PTSD and depression, as well as on "PE dose" received. Hypotheses predicted that women in the HBT PE group would complete more sessions, and evince greater PTSD and depression symptom reduction compared to in-person PE. Results revealed that there were no differences in dose received or PTSD symptom reduction between in-person and HBT conditions; however, dose (i.e., more sessions) was related to reduced PTSD symptom severity. Future research should examine other factors associated with high PTSD treatment dropout among MST patients.

Lessons Learned in Implementing VA Video Connect for Evidence-Based Psychotherapies for Anxiety and Depression in the Veterans Healthcare Administration.

A top priority for the Veteran's Healthcare Administration is improving access to high-quality mental healthcare. Mobile and telemental healthcare are a vital component of increasing access for veterans. The Veteran's Healthcare Administration is making efforts to further broaden how veterans receive their care through VA Video Connect, which allows veterans to connect with their provider from their residence or workplace. In this mixed-methods study, successes and challenges associated with the rapid implementation of VA Video Connect telemental health appointments are examined through (1) administrative data and (2) qualitative interviews at one medical center. Within 1 year of the telehealth initiative, the number of providers experienced with telemental health increased from 15% to 85%, and telehealth appointments increased from 5376 to 14,210. Provider reported barriers included administrative challenges and concerns regarding care. Having an implementation model of telehealth champions and a team of experienced mental health providers allowed for rapid adoption of telehealth. Utilizing a similar model in other settings will further enable more veterans with depression and anxiety to have access to evidence-based psychotherapy, regardless of location or national crisis. With the dramatic increase in both training for providers as well as veteran use of telemental healthcare during the COVID-19 pandemic response, future research should aim to better understand which teams were able to switch to telehealth easily versus those which struggled, along with examining system-wide and provider-level factors that facilitated continued use of telehealth after social distancing requirements related to COVID-19 were relaxed.

The effect of minority status and rural residence on actions to control high blood pressure in the U.S.

OBJECTIVE: We examined actions to control high blood pressure (HBP) and health-care provider recommendations for blood pressure control among adults by racial/ethnic group and rural/urban residence. METHODS: We examined data from 45,024 participants with HBP in the 2007 Behavioral Risk Factor Surveillance System (BRFSS) survey. We used multiple logistic regression analyses to assess the independent association between current actions to control HBP and health-care provider recommendations for blood pressure control by race/ethnicity and rural/urban status after accounting for confounders. RESULTS: Black people, regardless of rural or urban residence, were more likely to report reducing salt and alcohol intake, changing eating habits, and taking medications than both white urban and white rural adults. Black people, regardless of rural or urban status, were more likely to be advised to cut down on salt, reduce alcohol use, and change eating habits. Black rural adults were also more likely to report being advised to take medications than white urban adults, while white rural adults were less likely to be advised to exercise than white urban adults. CONCLUSIONS: Race/ethnicity and rural/urban status have a differential effect on actions to control HBP and provider advice to control HBP.

Therapist fidelity with an exposure-based treatment of PTSD in adults with schizophrenia or schizoaffective disorder.

This study examined therapists' fidelity to a manualized, multicomponent cognitive-behavioral intervention for posttraumatic stress disorder (PTSD), including exposure therapy, among public sector patients with a psychotic disorder. Independent raters assessed therapists' competence and adherence, rating 20% of randomly selected audio taped sessions (n=57 sessions, coded by two raters, with strong interrater agreement). Adherence ratings indicated that therapists complied well with the protocol, and competency ratings typically averaged "very good" or higher (6 on 7-point Likert scale). Findings suggest that therapists can effectively deliver a manualized cognitive-behavioral intervention for PTSD, with exposure therapy, to patients with severe mental illness without compromise to the structure of sessions and/or the therapeutic relationship.

Delayed-onset post-traumatic stress disorder among war veterans in primary care clinics.

BACKGROUND: Only limited empirical data support the existence of delayed-onset post-traumatic stress disorder (PTSD). AIMS: To expand our understanding of delayed-onset PTSD prevalence and phenomenology. METHOD: A cross-sectional, epidemiological design (n = 747) incorporating structured interviews to obtain relevant information for analyses in a multisite study of military veterans. RESULTS: A small percentage of veterans with identified current PTSD (8.3%, 7/84), current subthreshold PTSD (6.9%, 2/29), and lifetime PTSD only (5.4%, 2/37) met criteria for delayed onset with PTSD symptoms initiating more than 6 months after the index trauma. Altogether only 0.4% (3/747) of the entire sample had current PTSD with delayed-onset symptoms developing more than 1 year after trauma exposure, and no PTSD symptom onset was reported more than 6 years post-trauma. CONCLUSIONS: Retrospective reports of veterans reveal that delayed-onset PTSD (current, subthreshold or lifetime) is extremely rare 1 year post-trauma, and there was no evidence of PTSD symptom onset 6 or more years after trauma exposure.

Equity in Veterans Affairs disability claims adjudication in a national sample of veterans.

OBJECTIVES: To address potential equity concerns about the U.S. Department of Veterans Affairs' (VA) process for adjudicating military service-related disability claims. METHODS: Participants were a nationally representative sample of 20,048 veterans completing the 2001 National Survey of Veterans. Sociodemographic, access, and illness correlates of both the award and rate of general disability benefits awarded by the VA were examined using an established theoretical framework. RESULTS: Sociodemographic, access, and illness variables were associated with both the award ("yes/no") and rate of benefits (0-100%) awarded, with combat exposure, unemployment, and physical impairment accounting for the strongest model effects. CONCLUSIONS: Veterans' needs were not overshadowed by factors related to demographic background or access (e.g., race, gender, insurance), reducing concerns about disparities in general VA disability disbursements. These data are timely as disability claims/payments will likely increase dramatically in the near future because of current conflicts in the Middle East.

An adjunctive human-animal interaction intervention for veterans with PTSD: study protocol for a randomized controlled trial.

BACKGROUND: Posttraumatic stress disorder (PTSD) rarely remits over time, and if left untreated, leads to significant distress, functional impairment, and increased health care costs. Fortunately, effective evidence-based treatments (EBTs) for PTSD, such as Prolonged Exposure (PE), exist. Despite their availability and efficacy, a significant number of individuals with PTSD do not initiate treatment when offered or dropout prematurely. One proposed theory suggests that the emotional-numbing symptoms of PTSD (e.g., blunted affect, apathy) can serve as a barrier to engaging in, and successfully completing, treatment; and the broad human-animal interaction (HAI) literature available suggests that HAI can potentially reduce emotional numbing related to PTSD. Accordingly, this manuscript describes an ongoing, federally funded, randomized controlled trial testing the efficacy of RESCUE, an HAI intervention, as a viable adjunctive treatment component for PE. METHODS/DESIGN: The study will include 70 veterans with PTSD treated at a Southeastern Veterans Affairs Medical Center (VAMC). All participants in the trial receive up to 12 sessions of PE. Participants are randomly assigned 1:1 to (1) volunteer at a local animal shelter or (2) volunteer at a community agency of their choice as part of their in-vivo exposure exercises for PE. Outcomes will be examined via standard clinical interviews, self-report questionnaires, and thematic interviews. DISCUSSION: It is hypothesized that participants in the HAI condition will report greater decreases in emotional-numbing symptoms and increased treatment compliance and completion rates relative to those in the community volunteer condition. If successful, RESCUE, could be easily incorporated into standard PE and broadly disseminated. TRIAL REGISTRATION: ClinicalTrials.gov. ID: NCT03504722. Retrospectively registered on 2 May 2017.

Outpatient medical and mental healthcare utilization models among military veterans: results from the 2001 National Survey of Veterans.

Using Andersen's (1995) [Andersen RM. Revisiting the behavioral model and access to medical care: does it matter? Journal of Health and Social Behavior 1995;36:1-10] behavioral model of healthcare use as our theoretical framework, we examined predisposing (i.e., sociodemographic), enabling (i.e., access resources), and need (i.e., illness) models of outpatient medical and mental healthcare utilization among a national sample of US veterans. Participants were 20,048 nationally representative participants completing the 2001 National Survey of Veterans. Outcomes were healthcare use variables for the past year, including the number of Veterans Affairs (VA) and non-VA outpatient healthcare visits, and whether VA and non-VA mental health treatment was used. Univariate results demonstrated that numerous predisposing, enabling and need variables predicted both VA and non-VA healthcare use intensity and mental healthcare use. In multivariate analyses, predisposing, enabling and need variables demonstrated significant associations with both types of healthcare use, but accounted for more variance in mental healthcare use. Need variables provided an additive effect over predisposing and enabling variables in accounting for medical and mental healthcare use, and accounted for some of the strongest effects. The results demonstrate that need remains an important factor that drives healthcare use among veterans and does not seem to be overshadowed by socioeconomic factors that may create unfair disparities in treatment access.

Sexual assault, mental health, and service use among male and female veterans seen in Veterans Affairs primary care clinics: a multi-site study.

This study examined the nature and prevalence of sexual assault (SA), as well as its relationship to psychiatric sequelae and service use, among the veteran population. We performed a secondary data analysis of a cross-sectional dataset consisting of 643 male and 173 female veterans seen in four Veterans Affairs (VA) primary care clinics. Original data were obtained through semi-structured clinic assessments, structured telephone interviews, and medical chart reviews. Analyses included descriptive statistics, chi-square, analysis of variance (ANOVA), and logistic regression. The lifetime prevalence of SA was 38% among women and 6% among men. Of veterans reporting a history of SA, most experienced child sexual abuse and sexual revictimization. SA victims also had a more extensive trauma history and demonstrated greater psychological impairment in comparison to veterans reporting other types of trauma. However, only 25% of male SA survivors and 38% of female SA survivors used mental health services in the past year. These findings suggest that VA primary care clinics may benefit from expanding the current mandated screen for military sexual trauma to include lifetime experiences and trauma-related symptoms, thereby connecting more veterans with needed mental health services.

Racial disparities in trauma exposure, psychiatric symptoms, and service use among female patients in Veterans Affairs primary care clinics.

OBJECTIVE: We sought to compare female African-American (n = 84) and Caucasian (n = 99) veterans from primary care clinics at 4 Veterans Affairs Medical Centers (VAMCs) on rates of trauma, posttraumatic stress disorder, other psychiatric diagnoses, functional status, and use of VA services and disability benefits. METHODS: Analyses were based on a cross-sectional, epidemiologic design incorporating self-report measures, structured interviews, and chart reviews. RESULTS: With the exception of higher rates of child sexual abuse among Caucasian women and higher rates of physical assault among African-American women, there were no other statistically significant racial differences across analyses. However, some clinically meaningful trends emerged, and the implications of these findings are discussed within the context of our other results. CONCLUSIONS: Among female veterans seen in VA primary care clinics, African-Americans and Caucasians do not differ dramatically with regard to the manifestation or severity of psychopathology, or in their use of relevant VA health care services and disability benefits. These data are important because women represent the fastest growing segment of the VA population after aging veterans. Further research is needed to replicate and extend these findings to ensure that female veterans' needs are adequately identified and met by VAMC providers.

Attitudes toward medical and mental health care delivered via telehealth applications among rural and urban primary care patients.

Adequate health care services are often not available in rural and remote areas, and this problem is expected to grow worse in the near future. "Telehealth" interventions represent a strategy for addressing access to care problems. We examined and compared attitudes toward medical and mental health care delivered via telehealth applications among adult rural (n = 112) and urban (n = 78) primary care patients. We also examined attitudes toward telehealth applications among a subset of patients with posttraumatic stress disorder (PTSD)--a group likely in need of specialized services. Both urban and rural patients were receptive to receiving medical and psychiatric services via telehealth. There were few meaningful differences across variables between urban and rural patients, and there were no meaningful differences by PTSD status. These findings support the feasibility of telehealth applications, particularly for rural patients who may not otherwise receive needed services.

The PTSD symptom scale's latent structure: an examination of trauma-exposed medical patients.

Several studies have employed confirmatory factor analysis (CFA) to evaluate the latent structure of posttraumatic stress disorder (PTSD) assessment measures among various trauma-exposed populations. Findings have generally failed to support the current three-factor DSM-IV PTSD conceptualization, demonstrating the need to consider alternative models. The present study used CFA to evaluate seven models, including intercorrelated and hierarchical versions of two models with the most empirical support. Data were utilized from a heterogeneous trauma-exposed sample of general medical patients (n=252). Based on several indices, the three-factor DSM-IV PTSD model was shown to be inferior to alternative models. The strongest support was found for an intercorrelated four-factor model, separating avoidance and numbing symptoms into distinct factors. Validity for this model was partially supported by divergent relations between factors and external variables. Implications of the results are discussed, and a framework is proposed for resolving discrepant findings in the PTSD CFA literature.