What's in a treatment name? How people with posttraumatic stress disorder (PTSD) symptoms interpret and react to PTSD treatment names.

Prior research has rarely examined how people understand or react to the names of psychological treatments. In the case of evidence-based psychotherapies for posttraumatic stress disorder (PTSD), such reactions may be relevant to the low rates of uptake of such treatments. Participants who screened positive for PTSD (n = 887) completed questions assessing their initial reactions to PTSD treatment names as well as how a different name would affect their openness to treatment. In addition, they gave brief responses to open-ended questions about the reason for their initial reactions, and content analysis was used to better understand these reasons. The results indicated that among the treatment name options, cognitive processing therapy (CPT) and present-centered therapy (PCT) were viewed most positively. Approximately 40% of the sample preferred plain language alternatives for treatment names. Content analyses focused on descriptions of the treatments-which could be accurate or inaccurate-as well as whether respondents evaluated a treatment name itself as positive or negative. Some names conveyed treatments more accurately (e.g., CPT and written exposure therapy) than others (e.g., eye movement desensitization and reprocessing and prolonged exposure [PE]). Some names were also evaluated more positively (e.g., PCT) than others (e.g., PE). The general term "trauma-focused therapy" was seen as positive and clear. Addressing the ways patients react to psychological terms and treatment names could help clarify misperceptions about evidence-based psychotherapies and promote more widespread uptake of effective treatments for PTSD.

Discrepancies in perceptions of PTSD symptoms among veteran couples: Links to poorer relationship and individual functioning.

Veteran and intimate partner perceptions of posttraumatic stress disorder (PTSD) may differ, and little is known about how agreement or disagreement on symptom severity is related to relationship satisfaction. Veterans and their partners (N = 199 couples) completed a baseline assessment for a clinical trial evaluating two couple-based PTSD interventions. Veterans completed the PTSD Checklist for DSM-5 (PCL-5). Partners completed the collateral PCL-5 (PCL-5-C), which asked them to rate the severity of the veteran's PTSD symptoms. Both partner and veteran completed the Couples Satisfaction Index (CSI-32). Intraclass correlations (ICC) assessed agreement between PCL-5 and PCL-5-C total and subscale scores, which was low for total PCL and for all subscales (ICC = 0.15-0.46). Actor-Partner Interdependence Models (APIMs; actor-only pattern) tested associations between relationship satisfaction and PTSD symptom severity (total PCL and subscales), and the magnitude and direction of difference between PCL-5 and PCL-5-C (total and subscales). For veterans, more severe total PTSD and negative cognition/mood scores were associated with lower relationship satisfaction, and the direction of discrepancy for negative cognition/mood (i.e., higher veteran-rated PTSD symptoms relative to partner's collateral report) was also associated with lower satisfaction. For partners, more severe collateral-reported symptoms for total PTSD and all four subscales were associated with lower relationship satisfaction; further, a larger discrepancy between veterans' and partners' reports of total PTSD, negative cognition/mood, and hyperarousal were associated with lower satisfaction. These results suggest that partners may have different perceptions of PTSD symptoms, and support the potential of fostering a shared understanding of PTSD symptom severity in couples.

"Will it work for me?" Developing patient-friendly graphical displays of posttraumatic stress disorder treatment effectiveness.

The goal of this study was to create simple visual displays to help patients understand the benefits of evidence-based treatment for posttraumatic stress disorder (PTSD). We reviewed randomized trials of the most effective individual, trauma-focused psychotherapies and first-line antidepressants for adults with PTSD. The analytic sample included 65 treatment arms from 41 trials. We used binomial logistic regression to estimate the proportion of participants who lost their PTSD diagnosis at posttreatment and created a sample icon array to display these estimates. We provide a range of estimates (0-100) based on varying the percentage of the sample with a military affiliation. The percentage of participants who no longer met the diagnostic criteria for PTSD among civilian populations was 64.3% for trauma-focused treatment, 56.9% for SSRI/SNRI, and 16.7% for waitlist/minimal attention. For military populations, the proportions of participants who no longer met the diagnostic criteria were 44.2%, 36.7%, and 8.1%, respectively. We present icon arrays for 0%, 7%, 50%, and 100% military affiliation displaying 100 icons, a portion of which were shaded to indicate the number of participants that no longer met the PTSD criteria following treatment. After evidence-based treatment, between one third and two thirds of participants no longer met the PTSD criteria. Providers can use the icon array developed in this study with patients to facilitate communication regarding PTSD treatment effectiveness.

Home-based delivery of variable length prolonged exposure therapy: A comparison of clinical efficacy between service modalities.

OBJECTIVE: This study examined clinical and retention outcomes following variable length prolonged exposure (PE) for posttraumatic stress disorder (PTSD) delivered by one of three treatment modalities (i.e., home-based telehealth [HBT], office-based telehealth [OBT], or in-home-in-person [IHIP]). METHOD: A randomized clinical trial design was used to compare variable-length PE delivered through HBT, OBT, or IHIP. Treatment duration (i.e., number of sessions) was determined by either achievement of a criterion score on the PTSD Checklist for Diagnostic and Statistical Manual-5 (DSM-5; PTSD Checklist for DSM-5) for two consecutive sessions or completion of 15 sessions. Participants received PE via HBT (n = 58), OBT (n = 59) or IHIP (n = 58). Data were collected between 2012 and 2018, and PTSD was diagnosed using the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5), administered at baseline, posttreatment, and 6 months following treatment completion. The primary clinical outcome was CAPS-5 PTSD severity. Secondary outcomes included self-reported PTSD and depression symptoms, as well as treatment dropout. RESULTS: The clinical effectiveness of PE did not differ by treatment modality across any time point; however, there was a significant difference in treatment dropout. Veterans in the HBT (odds ratio [OR] = 2.67; 95% confidence interval [CI] = 1.10, 6.52; p = .031) and OBT (OR = 5.08; 95% CI = 2.10; 12.26; p < .001) conditions were significantly more likely than veterans in IHIP to drop out of treatment. CONCLUSIONS: Providers can effectively deliver PE through telehealth and in-home, in-person modalities although the rate of treatment completion was higher in IHIP care.

The Impact of Treatment Description Format on Patient Preferences for Posttraumatic Stress Disorder Treatment.

The present study examined how the format in which treatment information is presented impacts individuals' preferences for posttraumatic stress disorder (PTSD) treatments. Adults who screened positive for PTSD (N = 301) were randomized into groups to learn about five first-line treatments; participants either read sequential text descriptions or reviewed a comparison chart that presented side-by-side information. Participants rated treatment acceptability, rank ordered treatments from most to least preferred, and indicated their confidence in this ranking. Compared with participants in the text group, those in the chart group assigned more favorable acceptability ratings to prolonged exposure therapy (PE) and more moderate ratings to medications. Cognitive processing therapy was the most common first-choice treatment (43.6%). Forced-choice treatment rankings were similar across conditions, although participants in the chart group ranked PE more favorably than those in the text group, odds ratio (OR) = 0.54, 95% CI [0.35, 0.82], p = .004. Confidence in treatment rankings did not differ across conditions. The results suggest that perceptions of treatment acceptability can be influenced by the format in which treatment information is presented. In settings where the goal is to increase treatment acceptability, side-by-side formats may offer an advantage over sequential descriptions of each treatment.

Delivering Prolonged Exposure Therapy via Videoconferencing During the COVID-19 Pandemic: An Overview of the Research and Special Considerations for Providers.

Leveraging technology to provide evidence-based therapy for posttraumatic stress disorder (PTSD), such as prolonged exposure (PE), during the COVID-19 pandemic helps ensure continued access to first-line PTSD treatment. Clinical video teleconferencing (CVT) technology can be used to effectively deliver PE while reducing the risk of COVID-19 exposure during the pandemic for both providers and patients. However, provider knowledge, experience, and comfort level with delivering mental health care services, such as PE, via CVT is critical to ensure a smooth, safe, and effective transition to virtual care. Further, some of the limitations associated with the pandemic, including stay-at-home orders and physical distancing, require that providers become adept at applying principles of exposure therapy with more flexibility and creativity, such as when assigning in vivo exposures. The present paper provides the rationale and guidelines for implementing PE via CVT during COVID-19 and includes practical suggestions and clinical recommendations.

Importance of knowledge in the behavioural treatment of panic disorder.

BACKGROUND: Cognitive behavioural therapy (CBT) for panic disorder encourages patients to learn about and make changes to thoughts and behaviour patterns that maintain symptoms of the disorder. Instruments to assess whether or not patients understand therapy content do not currently exist. AIMS: The aim of this study was to examine if increases within specific knowledge domains of panic disorder were related to improvement in panic symptoms following an intensive 2-day panic treatment. METHOD: Thirty-nine Veterans enrolled in an intensive weekend panic disorder treatment completed knowledge measures immediately before the first session of therapy and at the end of the last day of therapy. Four panic disorder experts evaluated items and reached consensus on subscales. Subscales were reduced further to create psychometrically sound subscales of catastrophic misinterpretation (CM), behaviours (BE), and self-efficacy (SE). A simple regression analysis was conducted to determine whether increased knowledge predicted symptom change at a 3-month follow-up assessment. RESULTS: The overall knowledge scale was reduced to three subscales BE (n = 7), CM (n = 13) and SE (n = 8) with good internal consistency. Veterans' knowledge of panic disorder improved from pre- to post-treatment. Greater increase in scores on the knowledge assessment predicted lower panic severity scores at a 3-month follow-up. A follow-up analysis using the three subscales as predictors showed that only changes in CM significantly contributed to the prediction. CONCLUSIONS: In an intensive therapy format, reduction in panic severity was related to improved knowledge overall, but particularly as a result of fewer catastrophic misinterpretations.

Predictors of Initiation and Engagement of Cognitive Processing Therapy Among Veterans With PTSD Enrolled in Collaborative Care.

Collaborative care (CC) increases access to evidence-based pharmacotherapy and psychotherapy. The study aim was to identify the characteristics of rural veterans receiving a telemedicine-based CC intervention for posttraumatic stress disorder (PTSD) who initiated and engaged in cognitive processing therapy (CPT) delivered via interactive video. Veterans diagnosed with PTSD were recruited from 11 community-based outpatient clinics (N = 133). Chart abstraction identified all mental health encounters received during the 12-month study. General linear mixed models were used to identify characteristics that predicted CPT initiation and engagement (attendance at 8 or more sessions). For initiation, higher PTSD severity according to the Clinician Administered PTSD Scale (d = -0.39, p = .038) and opt-out recruitment (vs. self-referral; d = -0.49, p = .010) were negative predictors. For engagement, major depression (d = -1.32, p = .006) was a negative predictor whereas a pending claim for military service connected disability (d = 2.02, p = .008) was a positive predictor. In general, veterans enrolled in CC initiated and engaged in CPT at higher rates than usual care. Those with more severe symptoms and comorbidity, however, were at risk of not starting or completing CPT.

A Comparison of Mental Health Diagnoses Treated via Interactive Video and Face to Face in the Veterans Healthcare Administration.

OBJECTIVE: This study compares the mental health diagnoses of encounters delivered face to face and via interactive video in the Veterans Healthcare Administration (VHA). MATERIALS AND METHODS: We compiled 1 year of national-level VHA administrative data for Fiscal Year 2012 (FY12). Mental health encounters were those with both a VHA Mental Health Stop Code and a Mental Health Diagnosis (n=11,906,114). Interactive video encounters were identified as those with a Mental Health Stop Code, paired with a VHA Telehealth Secondary Stop Code. Primary diagnoses were grouped into posttraumatic stress disorder (PTSD), depression, anxiety, bipolar disorder, psychosis, drug use, alcohol use, and other. RESULTS: In FY12, 1.5% of all mental health encounters were delivered via interactive video. Compared with face-to-face encounters, a larger percentage of interactive video encounters was for PTSD, depression, and anxiety, whereas a smaller percentage was for alcohol use, drug use, or psychosis. CONCLUSIONS: Providers and patients may feel more comfortable treating depression and anxiety disorders than substance use or psychosis via interactive video.

A review of cognitive behavioral therapy for panic disorder in patients with chronic obstructive pulmonary disease: the rationale for interoceptive exposure.

Panic disorder commonly co-occurs in patients with chronic obstructive pulmonary disease (COPD), and translational interventions are needed to address the fear of physiological arousal in this population. This paper examines the utility of interoceptive exposures (IE), a key component of cognitive behavioral therapy (CBT) for panic disorder, in patients with comorbid panic and COPD. Our translational review of the literature suggests that IE is supported by both cognitive- and learning-theory perspectives of panic, and that the breathing exercises associated with IE are safe and highly compatible with existing pulmonary rehabilitation exercises for COPD. Unfortunately, few research studies have examined the use of CBT to treat anxiety in COPD patients, and none have included IE. Given the strong theoretical and empirical support for the use of IE, we suggest that mental health providers should consider incorporating IE into CBT interventions for patients with comorbid panic and COPD.

Examining veterans' preferences for how to deliver couples-based treatments for posttraumatic stress disorder: Home-based telehealth or in-person?

Understanding the modality by which veterans prefer to receive couples-based posttraumatic stress disorder (PTSD) treatment (i.e., home-based telehealth, in-person) may increase engagement in PTSD psychotherapy. This study aimed to understand veterans' preferred modality for couples-based PTSD treatments, individual factors associated with preference, and reasons for their preference. One hundred sixty-six veterans completed a baseline assessment as part of a clinical trial. Measures included a closed- and open-ended treatment preference questionnaire, as well as demographics, clinical symptoms, functioning, and relational measures, such as relationship satisfaction. Descriptive statistics and correlations examined factors associated with preference. An open-ended question querying veterans' reasons for their preferred modality was coded to identify themes. Though veterans as a group had no clear modality preference (51% preferring home-based telehealth and 49% preferring in-person treatment), veterans consistently expressed high levels of preference strength in the modality they chose. The presence of children in the home was associated with stronger preference for home-based telehealth. Veterans who preferred in-person care found it to be more credible and had more positive treatment expectancies. Veterans who preferred home-based telehealth believed it was flexible and increased access to care. For both preference groups, veterans' preferred modality was viewed as facilitating interpersonal relations and being more comfortable than the alternative modality. Veterans expressed strong preference for receiving their desired treatment modality for couples-based PTSD treatment. Results suggest that it is important to offer multiple treatment delivery options in couples-based PTSD treatment and matching couples to their preferred modality supports individualized, patient-centered care. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Enhancing Problem-Solving Therapy With Smartphone Technology: A Pilot Randomized Controlled Trial.

OBJECTIVE: Development of smartphone apps for mental health care has outpaced research on their effectiveness. This pilot study tested Moving Forward, an app designed to support problem-solving therapy (PST). METHODS: Thirty-three veterans seeking mental health care in U.S. Department of Veterans Affairs primary care clinics were randomly assigned to receive six sessions of PST accompanied by either the Moving Forward app (N=17) or a workbook (N=16). Participants completed measures of anxiety, depression, stress, problem-solving style, satisfaction, and between-session practice at baseline and 6- and 12-week follow-ups. Qualitative interviews were used to elicit feedback. RESULTS: Participants in both groups reported high satisfaction and reductions in depression, anxiety, and stress. Veterans who used the app reported skills practice, and qualitative data indicated that patients perceived the app as valuable, with the potential to reduce barriers to care. CONCLUSIONS: This study provides preliminary evidence to support the ability of the Moving Forward app to augment brief psychotherapy in primary care clinics.

A randomized trial of brief couple therapy for PTSD and relationship satisfaction.

OBJECTIVE: This three-arm randomized trial tested a brief version of cognitive-behavioral conjoint therapy (bCBCT) delivered in two modalities compared to couples' psychoeducation in a sample of U.S. veterans with posttraumatic stress disorder (PTSD) and their intimate partners. METHOD: Couples were randomized to receive (a) in-person, office-based bCBCT (OB-bCBCT), (b) bCBCT delivered via home-based telehealth (HB-bCBCT), or (c) an in-person psychoeducation comparison condition (PTSD family education [OB-PFE]). Primary outcomes were clinician-assessed PTSD severity (Clinician Administered PTSD Scale), self-reported psychosocial functioning (Brief Inventory of Psychosocial Functioning), and relationship satisfaction (Couples Satisfaction Index) at posttreatment and through 6-month follow-up. RESULTS: PTSD symptoms significantly decreased by posttreatment with all three treatments, but compared to PFE, PTSD symptoms declined significantly more for veterans in OB-bCBCT (between-group d = 0.59 [0.17, 1.01]) and HB-bCBCT (between-group d = 0.76 [0.33, 1.19]) treatments. There were no significant differences between OB-bCBCT and HB-bCBCT. Psychosocial functioning and relationship satisfaction showed significant small to moderate improvements, with no differences between treatments. All changes were maintained through 6-month follow-up. CONCLUSIONS: A briefer, more scalable version of CBCT showed sustained effectiveness relative to an active control for improving PTSD symptoms when delivered in-person or via telehealth. Both bCBCT and couples' psychoeducation improved psychosocial and relational outcomes. These results could have a major impact on PTSD treatment delivery within large systems of care where access to brief, evidence-based PTSD treatments incorporating family members are needed. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Deploying a telemedicine collaborative care intervention for posttraumatic stress disorder in the U.S. Department of Veterans Affairs: A stepped wedge evaluation of an adaptive implementation strategy.

OBJECTIVE: To address barriers to trauma-focused psychotherapy for veterans with posttraumatic stress disorder (PTSD), we compared two implementation strategies to promote the deployment of telemedicine collaborative care. METHOD: We conducted a Hybrid Type III Effectiveness Implementation trial at six VA medical centers and their 12 affiliated Community Based Outpatient Clinics. The trial used a stepped wedge design and an adaptive implementation strategy that started with standard implementation, followed by enhanced implementation for VA medical centers that did not achieve the performance benchmark. Implementation outcomes for the 544 veterans sampled from the larger population targeted by the intervention were assessed from chart review (care management enrollment and receipt of trauma-focused psychotherapy) and telephone survey (perceived access and PTSD symptoms) after each implementation phase. The primary outcome was enrollment in care management. RESULTS: There was no significant difference between standard implementation and enhanced implementation on any of the implementation outcomes. 41.6% of sampled veterans had a care manager encounter, but only 6.0% engaged in trauma-focused psychotherapy. CONCLUSIONS: While telemedicine collaborative care was shown to be effective at engaging veterans in trauma-focused psychotherapy in a randomized controlled trial, neither standard nor enhanced implementation strategies were sufficient to support successful deployment into routine care. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02737098.

Veterans self-reported reasons for non-attendance in psychotherapy for posttraumatic stress disorder.

This study explored rates of non-attendance (i.e., non-initiation, inconsistent attendance, early discontinuation) in cognitive processing therapy (CPT) and other posttraumatic stress disorder (PTSD) focused individual and group psychotherapies (i.e., interventions with at least some PTSD and/or trauma-related content) and characterized veterans' self-reported reasons for non-attendance in these treatments. Baseline and 6-month follow-up data from the Telemedicine Outreach for PTSD study, a pragmatic randomized effectiveness trial conducted in 11 Veterans Health Administration community-based outpatient clinics, was examined (N = 265 veterans). Over 90% of veterans with a scheduled psychotherapy appointment attended at least one appointment by 6-month follow-up. Self-reported treatment completion was higher for veterans attending individual CPT (25%) than for those attending PTSD-focused individual (4.4%) and group psychotherapy (15.5%). However, rates of inconsistent attendance (13.3%) and early discontinuation (18.3%) were also higher in veterans attending CPT when compared to other forms of PTSD-focused psychotherapy (inconsistent attendance-individual: 2.2%, group: 6.9%; early discontinuation-individual: 14.6%; group: 10.3%). Issues with scheduling appointments was one of the most frequently reported reasons for non-attendance across treatments (> 20%). Logistical barriers, including transportation (CPT), therapy taking too much time (PTSD-focused individual psychotherapy) and not being able to afford counseling (PTSD-focused group psychotherapy), were also commonly cited (i.e., > 15%). Those scheduled to attend CPT (26%) or PTSD-focused individual psychotherapy (11%) also cited treatment efficacy concerns as a reason for non-attendance. Findings suggest logistical barriers, particularly scheduling convenient appointments, and beliefs about treatment may be important to address when engaging veterans in psychotherapy for PTSD. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Drivers of Preference for Evidence-Based PTSD Treatment: A Qualitative Assessment.

INTRODUCTION: Mental health treatment utilization among persons with posttraumatic stress disorder (PTSD) tends to be low but may be improved by aligning treatment with patient preferences. Our objective was to characterize the reasons that drive a person's selection of a specific evidence-based PTSD treatment. MATERIALS AND METHODS: Data were collected using an online survey of adults who screened positive for PTSD. Participants viewed descriptions of five evidence-based PTSD treatments (cognitive processing therapy, prolonged exposure, eye movement desensitization and reprocessing, stress inoculation training, antidepressant medication) and identified their most preferred treatment. Participants then explained why they selected their top choice. These free-text responses (n = 249) were analyzed using thematic coding and constant comparative methods. RESULTS: Identified themes included (1) perceived effectiveness, (2) perceived suitability, (3) requirements of participation, (4) familiarity with the modality, (5) perception of the option as 'better than alternatives,' (6) perception of the option as 'not harmful,' (7) accessibility, and (8) delivery format. Differences in themes were also examined by treatment modality. CONCLUSIONS: By highlighting which pieces of information may be most important to detail when presenting different treatment options, these results can help guide treatment planning conversations, as well as the development of shared decision-making tools.

Therapeutic alliance across trauma-focused and non-trauma-focused psychotherapies among veterans with PTSD.

Trauma-focused psychotherapies for posttraumatic stress disorder (PTSD) are not widely utilized. Clinicians report concerns that direct discussion of traumatic experiences could undermine the therapeutic alliance, which may negatively impact retention and outcome. Studies among adolescents with PTSD found no difference in alliance between trauma-focused and non-trauma-focused psychotherapies, but this has not been tested among adults. The present study is a secondary analysis of a randomized trial of collaborative care, also known as care management, for PTSD. We examined patient-reported therapeutic alliance among 117 veterans with PTSD who participated in cognitive processing therapy (CPT, now called CPT + A; n = 54) or non-trauma-focused supportive psychotherapy for PTSD (n = 73) at VA community outpatient clinics. We tested the hypothesis that alliance in CPT would be noninferior to (i.e., not significantly worse than) non-trauma-focused psychotherapy using patient ratings on the Revised Helping Alliance Questionnaire. Patients' therapeutic alliance scores were high across both groups (CPT: M = 5.13, SD = 0.71, 95% CI [4.96, 5.30]; non-trauma-focused psychotherapy: M = 4.89, SD = 0.64, 95% CI [4.73, 5.05]). The difference between groups (0.23, 95% CI [0.01, 0.48]) was less than the "noninferiority margin" based on suggested clinical cutoffs (0.58 points on a 1-6 scale). These results held even after adjusting for veterans' demographic and clinical characteristics and change in PTSD symptoms from baseline to follow-up. Although there are concerns that direct discussion of traumatic experiences could worsen therapeutic alliance, patients report similar levels of alliance in CPT and non-trauma-focused supportive psychotherapy. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

What Do Veterans Want? Understanding Veterans' Preferences for PTSD Treatment Delivery.

INTRODUCTION: Home-based delivery of psychotherapy may offer a viable alternative to traditional office-based treatment for post-traumatic stress disorder (PTSD) by overcoming several barriers to care. Little is known about patient perceptions of home-based mental health treatment modalities. This study assessed veterans' preferences for treatment delivery modalities and how demographic variables and trauma type impact these preferences. MATERIALS AND METHODS: Veterans with PTSD (N = 180) participating in a randomized clinical trial completed a clinician-administered PTSD assessment and were asked to identify their modality preference for receiving prolonged exposure: home-based telehealth (HBT), office-based telehealth (OBT), or in-home-in-person (IHIP). Ultimately, modality assignment was randomized, and veterans were not guaranteed their preferred modality. Descriptive statistics were used to examine first choice preference. Chi-square tests determined whether there were significant differences among first choice preferences; additional tests examined if age, sex, and military sexual trauma (MST) history were associated with preferences. RESULTS: The study includes 135 male veterans and 45 female veterans from all military branches; respondents were 46.30 years old, on average. Veterans were Caucasian (46%), African-American (28%), Asian-American (9%), American Indian or Alaskan Native (3%), Native Hawaiian or Pacific Islander (3%), and 11% identified as another race. Veterans experienced numerous trauma types (e.g., combat, sexual assault), and 29% had experienced MST. Overall, there was no clear preference for one modality: 42% of veterans preferred HBT, 32% preferred IHIP, and 26% preferred OBT. One-sample binomial tests assuming equal proportions were conducted to compare each pair of treatment options. HBT was significantly preferred over OBT (p = 0.01); there were no significant differences between the other pairs. A multinomial regression found that age group significantly predicted veterans' preferences for HBT compared to OBT (odds ratio [OR] = 10.02, 95% confidence interval [CI]: 1.63, 61.76). Older veterans were significantly more likely to request HBT compared to OBT. Veteran characteristics did not differentiate those who preferred IHIP to OBT. Because there were fewer women (n = 45), additional multinomial regressions were conducted on each sex separately. There was no age group effect among the male veterans. However, compared to female Veterans in the younger age group, older female Veterans were significantly more likely to request HBT over OBT (OR = 10.66, 95% CI: 1.68, 67.58, p = 0.012). MST history did not predict treatment preferences in any analysis. CONCLUSIONS: Fewer than 50% of the sample preferred one method, and each modality was preferred by at least a quarter of all participants, suggesting that one treatment modality does not fit all. Both home-based care options were desirable, highlighting the value of offering a range of options. The use of home-based care can expand access to care, particularly for rural veterans. The current study includes a diverse group of veterans and increases our understanding of how they would like to receive PTSD treatment. The study used a forced choice preference measure and did not examine the strength of preference, which limits conclusions. Future studies should examine the impact of modality preferences on treatment outcomes and engagement.

Design of a randomized superiority trial of a brief couple treatment for PTSD.

Interpersonal difficulties are common among veterans with posttraumatic stress disorder (PTSD) and are associated with poorer treatment response. Treatment outcomes for PTSD, including relationship functioning, improve when partners are included and engaged in the therapy process. Cognitive-behavioral conjoint therapy for PTSD (CBCT) is a manualized 15-session intervention designed for couples in which one partner has PTSD. CBCT was developed specifically to treat PTSD, engage a partner in treatment, and improve interpersonal functioning. However, recent research suggests that an abbreviated CBCT protocol may lead to sufficient gains in PTSD and relationship functioning, and yield lower dropout rates. Likewise, many veterans report a preference for receiving psychological treatments through clinical videoteleconferencing (CVT) rather than traditional face-to-face modalities that require travel to VA clinics. This manuscript describes the development and implementation of a novel randomized controlled trial (RCT) that examines the efficacy of an abbreviated 8-session version of CBCT ("brief CBCT," or B-CBCT), and compares the efficacy of this intervention delivered via CVT to traditional in-person platforms. Veterans and their partners were randomized to receive B-CBCT in a traditional Veterans Affairs office-based setting (B-CBCT-Office), CBCT through CVT with the veteran and partner at home (B-CBCT-Home), or an in office-delivered, couple-based psychoeducation control condition (PTSD Family Education). This study is the first RCT designed to investigate the delivery of B-CBCT specifically to veterans with PTSD and their partners, as well as to examine the delivery of B-CBCT over a CVT modality; findings could increase access to care to veterans with PTSD and their partners.

A Comparison of Collaborative Care Outcomes in Two Health Care Systems: VA Clinics and Federally Qualified Health Centers.

OBJECTIVE: Collaborative care for depression results in symptom reduction when compared with usual care. No studies have systematically compared collaborative care outcomes between veterans treated at Veterans Affairs (VA) clinics and civilians treated at publicly funded federally qualified health centers (FQHCs) after controlling for demographic and clinical characteristics. METHODS: Data from two randomized controlled trials that used a similar collaborative care intervention for depression were combined to conduct post hoc analyses (N=759). The Telemedicine-Enhanced Antidepressant Management intervention was delivered in VA community-based outpatient clinics (CBOCs), and the Outreach Using Telemedicine for Rural Enhanced Access in Community Health intervention was delivered in FQHCs. Multivariate logistic regression was used to determine whether veteran status moderated the effect of the intervention on treatment response (>50% reduction in symptoms). RESULTS: There was a significant main effect for intervention (odds ratio [OR]=5.23, p<.001) and a moderating effect for veteran status, with lower response rates among veterans compared with civilians (OR=.21, p=.01). The addition of variables representing medication dosage and number of mental health and general health appointments did not influence the moderating effect. A sensitivity analysis stratified by gender found a significant moderating effect of veteran status for men but not women. CONCLUSIONS: Veteran status was a significant moderator of collaborative care effectiveness for depression, indicating that veterans receiving collaborative care at a CBOC are at risk of nonresponse. Unmeasured patient- or system-level characteristics may contribute to poorer response among veterans.