Associate Professor - Med Center Line, Psychiatry and Behavioral Sciences
Postdoctoral Fellow, Stanford/Palo Alto VA, Health Services Research (2000)
Ph.D., Yale University, Clinical Psychology (1998)
B.S., M.I.T., Political Science (1982)
Current Research and Scholarly Interests
My health services and implementation research aims at improving processes and outcomes of mental health care for veterans other people suffering from post-traumatic stress and other mental disorders.
My primary focus is improving access to evidence-based treatments PTSD and other psychiatric disorders. My second emphasis is using telemedicine technologies to expand access to effective care. My third interest is measurement-based care, using ongoing data on patient progress to inform patients' and clinicians' decisions.
Targeted Strategies to Accelerate Evidence-Based Psychotherapy Implementation in Military Settings
Clinician and Patient Perspectives on Initial Implementation of Measurement-Based Care in the VA Health Care System
Promoting Effective, Routine, and Sustained Implementation of Stress Treatments (PERSIST)
Graduate and Fellowship Programs
Maintenance and Reach of Exposure Psychotherapy for Posttraumatic Stress Disorder 18 Months After Training.
Journal of traumatic stress
2017; 30 (1): 63-70
This study examined aspects of clinicians' work environment that facilitated sustained use of prolonged exposure (PE) therapy. Surveys were completed by 566 U.S. Department of Veterans Affairs clinicians 6 and 18 months after intensive training in PE. The number of patients treated with PE at 18 months (reach) was modeled as a function of clinician demographics, clinician beliefs about PE, and work context factors. There were 342 clinicians (60.4%) who used PE at 6 and 18 months after training, 58 (10.2%) who used PE at 18 but not 6 months, 95 (16.7%) who used PE at 6 but not 18 months, and 71 (12.5%) who never adopted PE. Median reach was 12% of clinicians' appointments with patients with posttraumatic stress disorder. Reach was predicted by flow of interested patients (incident response ratio [IRR] = 1.21 to 1.51), PE's perceived effectiveness (IRR = 1.04 to 1.31), working in a PTSD specialty clinic (IRR = 1.06 to 1.26), seeing more patients weekly (IRR = 1.04 to 1.25), and seeing fewer patients in groups (IRR = 0.83 to 0.99). Most clinicians trained in PE sustained use of the treatment, but on a limited basis. Strategies to increase reach of PE should address organizational barriers and patient engagement.
View details for DOI 10.1002/jts.22153
View details for PubMedID 28103401
Context Matters: Team and Organizational Factors Associated with Reach of Evidence-Based Psychotherapies for PTSD in the Veterans Health Administration
Administration and Policy in Mental Health
View details for DOI 10.1007/s10488-017-0809-y
Participatory System Dynamics Modeling: Increasing Stakeholder Engagement and Precision to Improve Implementation Planning in Systems.
Administration and policy in mental health
2016; 43 (6): 834-849
Implementation planning typically incorporates stakeholder input. Quality improvement efforts provide data-based feedback regarding progress. Participatory system dynamics modeling (PSD) triangulates stakeholder expertise, data and simulation of implementation plans prior to attempting change. Frontline staff in one VA outpatient mental health system used PSD to examine policy and procedural "mechanisms" they believe underlie local capacity to implement evidence-based psychotherapies (EBPs) for PTSD and depression. We piloted the PSD process, simulating implementation plans to improve EBP reach. Findings indicate PSD is a feasible, useful strategy for building stakeholder consensus, and may save time and effort as compared to trial-and-error EBP implementation planning.
View details for PubMedID 27480546
A Review of Studies on the System-Wide Implementation of Evidence-Based Psychotherapies for Posttraumatic Stress Disorder in the Veterans Health Administration.
Administration and policy in mental health
2016; 43 (6): 957-977
Since 2006, the Veterans Health Administration (VHA) has instituted policy changes and training programs to support system-wide implementation of two evidence-based psychotherapies (EBPs) for posttraumatic stress disorder (PTSD). To assess lessons learned from this unprecedented effort, we used PubMed and the PILOTS databases and networking with researchers to identify 32 reports on contextual influences on implementation or sustainment of EBPs for PTSD in VHA settings. Findings were initially organized using the exploration, planning, implementation, and sustainment framework (EPIS; Aarons et al. in Adm Policy Ment Health Health Serv Res 38:4-23, 2011). Results that could not be adequately captured within the EPIS framework, such as implementation outcomes and adopter beliefs about the innovation, were coded using constructs from the reach, effectiveness, adoption, implementation, maintenance (RE-AIM) framework (Glasgow et al. in Am J Public Health 89:1322-1327, 1999) and Consolidated Framework for Implementation Research (CFIR; Damschroder et al. in Implement Sci 4(1):50, 2009). We highlight key areas of progress in implementation, identify continuing challenges and research questions, and discuss implications for future efforts to promote EBPs in large health care systems.
View details for PubMedID 27474040
An RCT of Effects of Telephone Care Management on Treatment Adherence and Clinical Outcomes Among Veterans With PTSD.
This study assessed whether adding telephone care management to usual outpatient mental health care improved treatment attendance, medication compliance, and clinical outcomes of veterans with posttraumatic stress disorder (PTSD).In a multisite randomized controlled trial, 358 veterans were assigned to either usual outpatient mental health treatment (N=165) or usual care plus twice-a-month telephone care management (TCM) and support in the first three months of treatment (N=193). Treatment utilization and medication refills were determined from U.S. Department of Veterans Affairs administrative data. PTSD, depression, quality of life, aggressive behavior, and substance use were assessed with self-report questionnaires at intake, four months, and 12 months.Telephone care managers reached 95% of TCM participants (N=182), completing an average 5.1 of 6.0 planned telephone calls. During the three-month intervention period, TCM participants completed 43% more mental health visits (M±SD=5.9±6.8) than did those in usual care (4.1±4.2) (incident rate ratio=1.36, χ(2)=6.56, df=1, p<.01). Treatment visits in the nine-month follow-up period and medication refills did not differ by condition. Only 9% of participants were scheduled to receive evidence-based psychotherapy. Slopes of improvement in PTSD, depression, alcohol misuse, drug problems, aggressive behavior, and quality of life did not differ by condition or treatment attendance.TCM improved PTSD patients' treatment attendance but not their outcomes. TCM can enhance treatment engagement, but outcomes depend on the effectiveness of the treatments that patients receive.
View details for PubMedID 27745535
Effectiveness of National Implementation of Prolonged Exposure Therapy in Veterans Affairs Care
2013; 70 (9): 949-955
IMPORTANCE Posttraumatic stress disorder (PTSD) is a pervasive and often debilitating condition that affects many individuals in the general population and military service members. Effective treatments for PTSD are greatly needed for both veterans returning from Iraq and Afghanistan and veterans of other eras. Prolonged exposure (PE) therapy has been shown to be highly efficacious in clinical trials involving women with noncombat trauma, but there are limited data on its effectiveness in real-world clinical practice settings and with veterans. OBJECTIVE To evaluate the effectiveness of PE as implemented with veterans with PTSD in a large health care system. DESIGN, SETTING, AND PARTICIPANTS This evaluation included 1931 veterans treated by 804 clinicians participating in the Department of Veterans Affairs (VA) PE Training Program. After completing a 4-day experiential PE training workshop, clinicians implemented PE (while receiving consultation) with a minimum of 2 veteran patients who had a primary diagnosis of PTSD. MAIN OUTCOMES AND MEASURES Changes in PTSD and depression symptoms were assessed with the PTSD Checklist and the Beck Depression Inventory II, measured at baseline and at the final treatment session. Multiple and single imputation were used to estimate the posttest scores of patients who left treatment before completing 8 sessions. Demographic predictors of treatment dropout were also examined. RESULTS Intent-to-treat analyses indicate that PE is effective in reducing symptoms of both PTSD (pre-post d = 0.87) and depression (pre-post d = 0.66), with effect sizes comparable to those reported in previous efficacy trials. The proportion of patients screening positive for PTSD on the PTSD Checklist decreased from 87.6% to 46.2%. CONCLUSIONS Clinically significant reductions in PTSD symptoms were achieved among male and female veterans of all war eras and veterans with combat-related and non-combat-related PTSD. Results also indicate that PE is effective in reducing depression symptoms, even though depression is not a direct target of the treatment.
View details for DOI 10.1001/jamapsychiatry.2013.36
View details for Web of Science ID 000325182200010
View details for PubMedID 23863892
Symptom Presentation and Prescription of Sleep Medications for Veterans With Posttraumatic Stress Disorder.
journal of nervous and mental disease
2017; 205 (2): 112-118
This study tested whether sleep medications prescribed to veterans diagnosed with posttraumatic stress disorder (PTSD) are being targeted to patients who report more severe insomnia or nightmares. Secondary analysis of survey and pharmacy data was conducted in samples of veterans from two periods: from 2006 to 2008 and from 2009 to 2013. Logistic regression tested associations between self-reported insomnia and nightmare severity, and being prescribed trazodone, prazosin, zolpidem, and benzodiazepines, controlling for PTSD severity and other covariates. In both samples, insomnia severity independently predicted trazodone receipt, and nightmare severity independently predicted prazosin receipt. In the later study, insomnia severity predicted receipt of zolpidem. Veterans in the later sample were more likely to receive trazodone, prazosin, and non-benzodiazepine hypnotics, and less likely to receive benzodiazepines than those in the earlier sample. Further research is needed to evaluate and optimize pharmacological and psychosocial treatments for sleep problems among veterans with PTSD.
View details for DOI 10.1097/NMD.0000000000000657
View details for PubMedID 28106623
Post-training Beliefs, Intentions, and Use of Prolonged Exposure Therapy by Clinicians in the Veterans Health Administration
ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH
2017; 44 (1): 123-132
To examine how changes in beliefs during the training process predict adoption of prolonged exposure therapy (PE) by veterans health administration clinicians who received intensive training in this evidence-based treatment. Participants completed a 4-day PE workshop and received expert consultation as they used PE with two or more training cases. Participants were surveyed prior to the workshop, after the workshop, after case consultation (n = 1.034), and 6 months after training (n = 810). Hierarchical regression was used to assess how pre-training factors, and changes in beliefs during different stages of training incrementally predicted post-training intent to use PE and how many patients clinicians were treating with PE 6 months after training. Post-training intent to use PE was high (mean = 6.2, SD = 0.81 on a 1-7 scale), yet most participants treated only 1 or 2 patients at a time with PE. Pre-training factors predicted intent to use and actual use of PE. Changes in beliefs during the workshop had statistically significant yet modest effects on intent and use of PE. Changes in beliefs during case consultation had substantial effects on intent and actual use of PE. Pre-training factors and changes in beliefs during training (especially during case consultation) influence clinicians' adoption of PE. Use of PE was influenced not only by its perceived clinical advantages/disadvantages, but also by contextual factors (working in a PTSD specialty clinic, perceived control over one's schedule, and ability to promote PE to patients and colleagues).
View details for DOI 10.1007/s10488-015-0689-y
View details for Web of Science ID 000392383600012
View details for PubMedID 26487392
Peer Support and Outcome for Veterans with Posttraumatic Stress Disorder (PTSD) in a Residential Rehabilitation Program
COMMUNITY MENTAL HEALTH JOURNAL
2016; 52 (8): 1089-1092
This observational study aims to determine the characteristics of peer support that change attitudes toward recovery and PTSD symptom severity. The study respondents were a sample of 55 VA patients who were residents at a residential rehabilitation program for PTSD where they were the recipients of peer support. Veterans perceived greater support from other veterans (mean = 4.04 on 1-5 scale, SD = 0.78) than from any other source. Greater perceived support from the peer support provider, other veterans and mental health staff was associated with improvements from intake to discharge in recovery attitudes. Greater perceived support from other veterans and mental health staff was associated with an improvement in PTSD symptoms. Results from this study suggest that positive perceptions of peer support favorably influences attitudes toward recovery, from PTSD, in veterans who are the recipients of such support.
View details for DOI 10.1007/s10597-015-9982-1
View details for Web of Science ID 000388590000029
View details for PubMedID 26839108
Relationships Between Racial/Ethnic Minority Status, Therapeutic Alliance, and Treatment Expectancies Among Veterans With PTSD
2016; 13 (3): 317-321
Our objective was to examine the relationships between veterans' racial/ethnic minority status, components of therapeutic alliance (bond, tasks, and goals) with former outpatient providers, and expectancies for Department of Veterans Affairs (VA) posttraumatic stress disorder (PTSD) residential treatment. Veterans (N = 819; 37% minority, 63% White) completed surveys at intake into VA PTSD residential treatment programs. As hypothesized, racial/ethnic minority status was related to weaker overall alliance, therapeutic bond, and goal agreement with former outpatient provider. Alliance with former provider was also associated with expectancies for residential treatment. After controlling for other variables, task agreement (not therapeutic bond) and racial/ethnic minority status were linked to higher expectancies. However, effect sizes were small. Thus, we found little evidence of clinically significant differences by racial/ethnic minority status on expectancies of VA PTSD residential treatment. Future research should investigate these relationships among veterans with PTSD not admitted to VA PTSD residential treatment and in other treatment settings, as well as nonveteran racial/ethnic minorities with PTSD. (PsycINFO Database Record
View details for DOI 10.1037/ser0000029
View details for Web of Science ID 000383106000013
View details for PubMedID 25915471
Effects of a Comprehensive Training Program on Clinician Beliefs About and Intention to Use Prolonged Exposure Therapy for PTSD
PSYCHOLOGICAL TRAUMA-THEORY RESEARCH PRACTICE AND POLICY
2016; 8 (3): 348-355
Evidence for treatment efficacy does not guarantee adoption in clinical practice. Attitudinal "buy-in" from clinicians is also important. This study examines evaluation data from a national training program in an evidence-based treatment for PTSD, Prolonged Exposure (PE) therapy, to assess changes in clinician beliefs related to the importance of specific treatment goals, PE outcome expectations, self-efficacy to deliver PE, perceived time and emotional burdens associated with delivering PE, and intentions to use PE.Training included both an interactive workshop and posttraining telephone consultation. Participants were 943 licensed mental health clinicians who treated veterans with PTSD. They completed questionnaires before and after the workshop, and after consultation.Results indicated that workshop participation was associated with significant increases in perceptions of the importance of helping patients improve by employing PE, expectations that patients would benefit from PE, and self-efficacy to deliver PE, and with reduced expectations of negative patient outcomes and concerns about distressing patients. The workshop alone had little impact on expected clinician emotional burden and no impact on anticipated time burden. Participation in ongoing case consultation was associated with additional increases in expected positive patient outcomes and clinician self-efficacy and further reductions in concerns about distressing patients and negative patient outcomes. Unlike the workshop, consultation was associated with decreased expectancies that PE would take too much time and would be emotionally burdensome to provide.Overall, the results suggest that the combination of workshop and ongoing consultation can significantly improve beliefs likely to affect treatment adoption. (PsycINFO Database Record
View details for DOI 10.1037/tra0000004
View details for Web of Science ID 000376205900012
View details for PubMedID 26524541
Multifaceted academic detailing program to increase pharmacotherapy for alcohol use disorder: interrupted time series evaluation of effectiveness.
Addiction science & clinical practice
2016; 11 (1): 15-?
Active consideration of effective medications to treat alcohol use disorder (AUD) is a consensus standard of care, yet knowledge and use of these medications are very low across diverse settings. This study evaluated the overall effectiveness a multifaceted academic detailing program to address this persistent quality problem in the US Veterans Health Administration (VHA), as well as the context and process factors that explained variation in effectiveness across sites.An interrupted time series design, analyzed with mixed-effects segmented logistic regression, was used to evaluate changes in level and rate of change in the monthly percent of patients with a clinically documented AUD who received naltrexone, acamprosate, disulfiram, or topiramate. Using data from a 20 month post-implementation period, intervention sites (n = 37) were compared to their own 16 month pre-implementation performance and separately to the rest of VHA.From immediately pre-intervention to the end of the observation period, the percent of patients in the intervention sites with AUD who received medication increased over 3.4 % in absolute terms and 68 % in relative terms (i.e., 4.9-8.3 %). This change was significant compared to the pre-implementation period in the intervention sites and secular trends in control sites. Sites with lower pre-implementation adoption, more person hours of detailing, but fewer people detailed, had larger immediate increases in medication receipt after implementation. The average number of detailing encounters per person was associated with steeper increases in slope over time.This study found empirical support for a multifaceted quality improvement strategy aimed at increasing access to and utilization of pharmacotherapy for AUD. Future studies should focus on determining how to enhance the programs effects, especially in non-responsive locations.
View details for DOI 10.1186/s13722-016-0063-8
View details for PubMedID 27633982
TELEMEDICINE VERSUS IN-PERSON DELIVERY OF COGNITIVE PROCESSING THERAPY FOR WOMEN WITH POSTTRAUMATIC STRESS DISORDER: A RANDOMIZED NONINFERIORITY TRIAL
DEPRESSION AND ANXIETY
2015; 32 (11): 811-820
This study examined the effectiveness of telemedicine to provide psychotherapy to women with posttraumatic stress disorder (PTSD) who might be unable to access treatment. Objectives were to compare clinical and process outcomes of PTSD treatment delivered via videoteleconferencing (VTC) and in-person (NP) in an ethnically diverse sample of veteran and civilian women with PTSD.A randomized controlled trial of Cognitive Processing Therapy, an evidence-based intervention for PTSD, was conducted through a noninferiority design to compare delivery modalities on difference in posttreatment PTSD symptoms. Women with PTSD, including 21 veterans and 105 civilians, were assigned to receive psychotherapy delivered via VTC or NP. Primary treatment outcomes were changes in PTSD symptoms in the completer sample.Improvements in PTSD symptoms in the VTC condition (n = 63) were noninferior to outcomes in the NP condition (n = 63). Clinical outcomes obtained when both conditions were pooled together (N = 126) demonstrated that PTSD symptoms declined substantially posttreatment (mean = -20.5, 95% CI -29.6 to -11.4) and gains were maintained at 3- (mean = -20.8, 95% CI -30.1 to -11.5) and 6-month followup (mean = -22.0, 95% CI -33.1 to -10.9. Veterans demonstrated smaller symptom reductions posttreatment (mean = -9.4, 95% CI -22.5 to 3.7) than civilian women (mean = -22.7, 95% CI -29.9 to -15.5.Providing psychotherapy to women with PTSD via VTC produced outcomes comparable to NP treatment. VTC can increase access to specialty mental health care for women in rural or remote areas.
View details for DOI 10.1002/da.22397
View details for Web of Science ID 000364392300011
View details for PubMedID 26243685
Military Sexual Assault, Gender, and PTSD Treatment Outcomes of US Veterans
JOURNAL OF TRAUMATIC STRESS
2015; 28 (2): 92-101
This study examined whether gender and military sexual assault (MSA) were associated with psychiatric severity differences at initiation of treatment for posttraumatic stress disorder (PTSD) and whether MSA and gender predicted psychiatric treatment outcomes. Male (n = 726) and female (n = 111) patients were recruited from 7 U.S. Department of Veterans Affairs (VA) PTSD specialty intensive treatment programs and completed an intake survey; 69% (n = 574) of the participants completed a 4-month postdischarge follow-up survey. Measures included current PTSD and depressive symptoms, aggressive/violent behaviors, alcohol and drug use severity, and quality of life. Multilevel multivariate regression analyses were conducted to examine the main and interaction effects of gender and MSA on psychiatric treatment outcomes at 4-month follow-up, including demographics, baseline severity, hostile fire, and treatment length of stay. Baseline PTSD severity did not differ by gender or MSA status, but women had more severe depressive symptoms (d = 0.40) and less aggressive/violent symptoms (d = -0.46) than men. Gender, MSA status, and the interaction between gender and MSA did not predict treatment outcomes as hypothesized. Male and female veterans with and without MSA responded equally well to treatment in VA PTSD intensive treatment programs.
View details for DOI 10.1002/jts.21992
View details for Web of Science ID 000352818300002
View details for PubMedID 25847514
The Effect of Medical Comorbidities on Male and Female Veterans' Use of Psychotherapy for PTSD.
2015; 53 (4): S120-7
Posttraumatic stress disorder (PTSD) is associated with an increased risk for medical comorbidities that may prevent participation in psychotherapy. The present study investigated whether medical comorbidities were associated with lower initiation rates and fewer psychotherapy visits for PTSD. Because women are more likely to initiate psychotherapy after traumatic events, we also assessed whether relationships were weaker among women.Veterans (N=482, 47% women) recently diagnosed with PTSD completed a survey assessing demographics, mood, functional status, and interest in treatment. Data on medical comorbidities, psychotherapy visits, antidepressant prescriptions, and service connection were assessed longitudinally through administrative files. Logistic and negative binomial regressions assessed associations between number of medical comorbidities in the 2 years before the survey and the initiation and number of psychotherapy visits for PTSD in the year after the survey. All analyses were stratified by sex and controlled for survey and administrative variables.The relationship between medical comorbidities and number of psychotherapy visits was stronger among women than among men. A greater number of medical comorbidities was associated with significantly fewer psychotherapy visits in the total sample [incidence rate ratio: 0.91; 95% confidence interval (CI): 0.83, 1.00] and among women (incidence rate ratio: 0.87; 95% CI: 0.77, 0.99), but not among men (95% CI: 0.75, 1.01). Medical comorbidities were not associated with the initiation of psychotherapy among men or women.Addressing medical comorbidities may help individuals remain in psychotherapy for PTSD. Medical comorbidities may play a larger role in the number of psychotherapy visits among women than men.
View details for DOI 10.1097/MLR.0000000000000284
View details for PubMedID 25767965
Training in the Implementation of Prolonged Exposure Therapy: Provider Correlates of Treatment Outcome
JOURNAL OF TRAUMATIC STRESS
2015; 28 (1): 65-68
The authors examined the degree to which provider characteristics, such as profession, treatment orientation, prior experience in treating posttraumatic stress disorder (PTSD), prior experience with prolonged exposure (PE) therapy, and attitudes about PE, were related to the clinical outcomes of veterans receiving care from clinicians participating in the national Department of Veterans Affairs (VA) PE Training Program. Positive patient outcomes were achieved by providers of every profession, theoretical orientation, level of clinical experience treating PTSD, and prior PE training experience. With 1,105 providers and 32 predictors (13 provider variables), power was at least 90% power to detect an effect of β = .15. Profession was the only provider characteristic significantly related to outcomes, but the mean effect (a 2 point difference on the PTSD Checklist) was too small to be clinically meaningful. The results support the intensive training model used in the VA PE training program and demonstrate that clinicians of varying backgrounds can be trained using interactive training workshops followed by case consultation to deliver PE effectively.
View details for DOI 10.1002/jts.21980
View details for Web of Science ID 000349986900009
View details for PubMedID 25630446
- Associations of Psychotherapy Dose and SSRI or SNRI Refills With Mental Health Outcomes Among Veterans With PTSD PSYCHIATRIC SERVICES 2014; 65 (10): 1244-1248
Peeking into the black box: Mechanisms of action for anger management treatment
JOURNAL OF ANXIETY DISORDERS
2014; 28 (7): 687-695
We investigated potential mechanisms of action for anger symptom reductions, specifically, the roles of anger regulation skills and therapeutic alliance on changes in anger symptoms, following group anger management treatment (AMT) among combat veterans with posttraumatic stress disorder (PTSD). Data were drawn from a published randomized controlled trial of AMT conducted with a racially diverse group of 109 veterans with PTSD and anger symptoms residing in Hawaii. Results of latent growth curve models indicated that gains in calming skills predicted significantly larger reductions in anger symptoms at post-treatment, while the development of cognitive coping and behavioral control skills did not predict greater symptom reductions. Therapeutic alliance had indirect effects on all outcomes mostly via arousal calming skills. Results suggest that generalized symptom reduction may be mediated by development of skills in calming physiological arousal. In addition, arousal reduction skills appeared to enhance one's ability to employ other anger regulation skills.
View details for DOI 10.1016/j.janxdis.2014.07.001
View details for Web of Science ID 000342121900008
View details for PubMedID 25124505
- Predictors of Anger Treatment Outcomes JOURNAL OF CLINICAL PSYCHOLOGY 2014; 70 (10): 905-913
Factors Related to Clinician Attitudes Toward Prolonged Exposure Therapy for PTSD
JOURNAL OF TRAUMATIC STRESS
2014; 27 (4): 423-429
This study examines pretraining attitudes toward prolonged exposure (PE) therapy in a sample of 1,275 mental health clinicians enrolled in a national PE training program sponsored by the U.S. Department of Veterans Affairs. Attitudes assessed via survey included values placed on outcomes targeted by PE, outcome expectancies (positive expectancies for patient improvement and negative expectancies related to patient deterioration, clinician time burden, and clinician emotional burden), and self-efficacy for delivering PE. Results indicated that clinicians were receptive to learning PE and had positive expectations about the treatment, but expressed concerns that PE might increase patient distress. Responses varied by clinician characteristics with psychologists, clinicians working in specialty PTSD treatment settings (as opposed to those in mental health clinics and other clinic types), and those with a primarily cognitive-behavioral orientation expressing attitudes that were most supportive of learning and implementing PE across various indicators. Implications for addressing attitudinal barriers to implementation of PE therapy are discussed.
View details for DOI 10.1002/jts.21945
View details for Web of Science ID 000341198000006
View details for PubMedID 25158635
Preferences for Gender-Targeted Health Information: A Study of Male Veterans Who Have Experienced Military Sexual Trauma
AMERICAN JOURNAL OF MENS HEALTH
2014; 8 (3): 240-248
No prior research has examined men's opinions or preferences regarding receiving health education materials related to sexual violence. The objective of the current study was to investigate whether male veteran patients who have experienced military sexual trauma (MST) prefer gender-targeted versus gender-neutral printed health information and whether receipt of this information increased utilization of outpatient mental health services in the following 6-month period. In-person 45-minute interviews were conducted with 20 male veterans receiving health care services at a large Veterans Health Administration facility to evaluate opinions on a gender-targeted and a gender-neutral brochure about MST. An additional 153 veterans received psychoeducational materials through the mail and participated in the completion of a survey as part of a psychoeducational intervention. Our results demonstrate that male veterans prefer gender-targeted information about sexual trauma compared to gender-neutral information. Whereas veterans in the study had clear preferences for gender-targeted materials, receipt of information about MST (whether gender-targeted or gender-neutral) did not increase utilization of mental health care in the 6 months following receipt of these materials. These results demonstrated that materials about sexual trauma are acceptable to men and should be gender-targeted. Further research is needed to examine strategies to increase access to mental health care among male Veterans who have experienced MST.
View details for DOI 10.1177/1557988313508304
View details for Web of Science ID 000334429900006
View details for PubMedID 24232582
Cognitive Processing Therapy for Posttraumatic Stress Disorder Delivered to Rural Veterans via Telemental Health: A Randomized Noninferiority Clinical Trial
JOURNAL OF CLINICAL PSYCHIATRY
2014; 75 (5): 470-476
To compare clinical and process outcomes of cognitive processing therapy-cognitive only version (CPT-C) delivered via videoteleconferencing (VTC) to in-person in a rural, ethnically diverse sample of veterans with posttraumatic stress disorder (PTSD).A randomized clinical trial with a noninferiority design was used to determine if providing CPT-C via VTC is effective and "as good as" in-person delivery. The study took place between March 2009 and June 2013. PTSD was diagnosed per DSM-IV. Participants received 12 sessions of CPT-C via VTC (n = 61) or in-person (n = 64). Assessments were administered at baseline, midtreatment, immediately posttreatment, and 3 and 6 months posttreatment. The primary clinical outcome was posttreatment PTSD severity, as measured by the Clinician-Administered PTSD Scale.Clinical and process outcomes found VTC to be noninferior to in-person treatment. Significant reductions in PTSD symptoms were identified at posttreatment (Cohen d = 0.78, P < .05) and maintained at 3- and 6-month follow-up (d = 0.73, P < .05 and d = 0.76, P < .05, respectively). High levels of therapeutic alliance, treatment compliance, and satisfaction and moderate levels of treatment expectancies were reported, with no differences between groups (for all comparisons, F < 1.9, P > .17).Providing CPT-C to rural residents with PTSD via VTC produced outcomes that were "as good as" in-person treatment. All participants demonstrated significant reductions in PTSD symptoms posttreatment and at follow-up. Results indicate that VTC can offer increased access to specialty mental health care for residents of rural or remote areas.ClinicalTrials.gov identifier: NCT00879255.
View details for DOI 10.4088/JCP.13m08842
View details for Web of Science ID 000337255400010
View details for PubMedID 24922484
Presenting Concerns of Veterans Entering Treatment for Posttraumatic Stress Disorder
JOURNAL OF TRAUMATIC STRESS
2013; 26 (5): 640-643
Patient-centered care involves engaging patients as partners in establishing treatment priorities. No prior studies have examined what specific problems veterans hope to address when they enter posttraumatic stress disorder (PTSD) treatment. Veterans starting outpatient (n = 216) and residential (n = 812) PTSD treatment in 2 multisite care management trials specified (open-ended) the 2 or 3 problems that they most wanted to improve through treatment. Over 80% mentioned PTSD-symptom-related concerns including PTSD or trauma (19.2% to 19.9% of patients), anger (31.0% to 36.7%), sleep problems (14.3% to 27.3%), nightmares (12.3% to 19.4%), and estrangement/isolation (7.9% to 20.8%). Other common problems involved depression (23.1% to 36.5%), anxiety not specific to PTSD (23.9% to 27.8%), relationships (20.4% to 24.5%), and improving coping or functioning (19.2% to 20.4%). Veterans' treatment goals varied significantly by outpatient versus residential setting, gender, and period of military service. Our findings confirm the importance of educating patients about how available efficacious treatments relate to clients' personal goals. Our results also suggest that clinicians should be prepared to offer interventions or provide referrals for common problems such as anger, nightmares, sleep, depression, or relationship difficulties if these problems do not remit with trauma-focused psychotherapy or if patients are unwilling to undergo trauma-focused treatment.
View details for DOI 10.1002/jts.21841
View details for Web of Science ID 000326284900018
View details for PubMedID 24123262
Telemedicine: A Cost-Reducing Means of Delivering Psychotherapy to Rural Combat Veterans with PTSD
TELEMEDICINE AND E-HEALTH
2013; 19 (10): 754-759
Although effective psychotherapies for posttraumatic stress disorder (PTSD) exist, high percentages of Veterans in need of services are unable to access them. One particular challenge to providing cost-effective psychological treatments to Veterans with PTSD involves the difficulty and high cost of delivering in-person, specialized psychotherapy to Veterans residing in geographically remote locations. The delivery of these services via clinical videoteleconferencing (CVT) has been presented as a potential solution to this access to care problem.This study is a retrospective cost analysis of a randomized controlled trial investigating telemedicine service delivery of an anger management therapy for Veterans with PTSD. The parent trial found that the CVT condition provided clinical results that were comparable to the in-person condition. Several cost outcomes were calculated in order to investigate the clinical and cost outcomes associated with the CVT delivery modality relative to in-person delivery.The CVT condition was significantly associated with lower total costs compared with the in-person delivery condition. The delivery of mental health services via CVT enables Veterans who would not normally receive these services access to empirically based treatments. Additional studies addressing long-term healthcare system costs, indirect cost factors at the patient and societal levels, and the use of CVT in other geographic regions of the United States are needed.The results of this study provide evidence that CVT is a cost-reducing mode of service delivery to Veterans with PTSD relative to in-person delivery.
View details for DOI 10.1089/tmj.2012.0298
View details for Web of Science ID 000325132300005
View details for PubMedID 23931729
Perceived Barriers to Care and Provider Gender Preferences Among Veteran Men Who Have Experienced Military Sexual Trauma: A Qualitative Analysis
2013; 10 (2): 213-222
Research suggests that there may be unique barriers to accessing care among men who have experienced sexual trauma. The primary goal of the current research was to elucidate potential barriers to accessing military sexual trauma (MST)-related care for male veterans. A secondary goal was to explore whether veterans have preferences regarding the gender of clinicians providing MST-related care. Qualitative analyses were used to examine data collected from semistructured interviews conducted with 20 male veterans enrolled in Veterans Health Administration care who reported MST but who had not received any MST-related mental health care. Veterans identified a number of potential barriers, with the majority of reported barriers relating to issues of stigma and gender. Regarding provider gender preferences, veterans were mixed, with 50% preferring a female provider, 25% a male provider, and 25% reporting no gender preference. These preliminary data suggest that stigma, gender, and knowledge-related barriers may exist for men regarding seeking MST-related care. Interventions to address potential barriers, such as outreach interventions and providing gender-specific psychoeducation, may increase access to care for male veterans who report MST. (PsycINFO Database Record (c) 2013 APA, all rights reserved).
View details for DOI 10.1037/a0029959
View details for Web of Science ID 000319802300010
View details for PubMedID 22984877
The association between substance use disorders and mortality among a cohort of Veterans with posttraumatic stress disorder: Variation by age cohort and mortality type
DRUG AND ALCOHOL DEPENDENCE
2013; 128 (1-2): 98-103
Prior studies of Veterans have linked posttraumatic stress disorder (PTSD) with an increased risk of mortality. Other studies of Veterans have found that substance use disorders (SUDs) are associated with an excess risk of mortality among those with psychiatric disorders. It is not known whether having an SUD increases the risk of mortality among Veterans with PTSD, and whether the association differs by mortality type or varies by age cohort.A cohort of patients who received Veterans Health Administration services during fiscal year (FY) 2004 and diagnosed with PTSD (n=272,509) were followed from FY 2005 through FY 2007 for the main outcomes of mortality and cause of death.SUD was positively associated with mortality during follow-up (adjusted hazards ratio: 1.70; 95% confidence interval: 1.64, 1.77). SUD was a stronger predictor of non-injury-related mortality for the <45 years group compared with the 45-64 or ≥65 group. SUD predicted injury-related mortality for all age groups.Among Veterans with PTSD, the association between SUD and mortality was most pronounced for the youngest age group, which included Iraq/Afghanistan Veterans. For older age groups, which included Vietnam-era Veterans, SUD was a greater predictor of injury-related mortality. The findings could be useful for identifying PTSD patients at excess risk of mortality.
View details for DOI 10.1016/j.drugalcdep.2012.08.015
View details for Web of Science ID 000314331700015
View details for PubMedID 22974491
- High-value care for PTSD. Psychiatric services 2013; 64 (2): 201-?
Telephone Monitoring and Support After Discharge From Residential PTSD Treatment: A Randomized Controlled Trial
2013; 64 (1): 13-20
This study assessed whether adding a telephone care management protocol to usual aftercare improved the outcomes of veterans in the year after they were discharged from residential treatment for posttraumatic stress disorder (PTSD).In a multisite randomized controlled trial, 837 veterans entering residential PTSD treatment were assigned to receive either standard outpatient aftercare (N=425) or standard aftercare plus biweekly telephone monitoring and support (N=412) for three months after discharge. Symptoms of PTSD and depression, violence, substance use, and quality of life were assessed by self-report questionnaires at intake, discharge, and four and 12 months postdischarge. Treatment utilization was determined from the Department of Veterans Affairs administrative data.Telephone case monitors reached 355 participants (86%) by phone at least once and provided an average of 4.5 of the six calls planned. Participants in the telephone care and treatment-as-usual groups showed similar outcomes on all clinical measures. Time to rehospitalization did not differ by condition. In contrast with prior studies reporting poor treatment attendance among veterans, participants in both telephone monitoring and treatment as usual completed a mental health visit an average of once every ten days in the year after discharge. Many participants had continuing problems despite high utilization of outpatient care.Telephone care management had little incremental value for patients who were already high utilizers of mental health services. Telephone care management could potentially be beneficial in settings where patients experience greater barriers to engaging with outpatient mental health care after discharge from inpatient treatment.
View details for DOI 10.1176/appi.ps.201200142
View details for Web of Science ID 000313299500005
View details for PubMedID 23117443
Do Benzodiazepines Reduce the Effectiveness of Exposure Therapy for Posttraumatic Stress Disorder?
JOURNAL OF CLINICAL PSYCHIATRY
2013; 74 (12): 1241-1247
Benzodiazepines, other anxiolytics, or sedative hypnotics are prescribed for 30%-50% of posttraumatic stress disorder (PTSD) patients. Prior data and theory suggest that these medications may inhibit response to exposure therapy, one of the most effective PTSD treatments. The present post hoc study reanalyzed results from a psychotherapy trial to assess whether benzodiazepine use was associated with reduced response to exposure therapy.Between August 2002 and October 2005, 283 female veterans and soldiers meeting DSM-IV criteria for PTSD were randomly assigned to 10 weekly 90-minute sessions of either prolonged exposure (n = 140) or present-centered psychotherapy (n = 143). Benzodiazepine use (n = 57) or non-use (n = 226) at intake was not randomly assigned. Multilevel modeling was used to assess the effects of benzodiazepine status, psychotherapy condition, and their interaction on changes on the Clinician-Administered PTSD Scale and the PTSD Checklist during the treatment and 6-month follow-up periods.Consistent with prior reports from these data, prolonged exposure psychotherapy produced greater reductions per week in PTSD symptoms than did present-centered psychotherapy (b = -0.48, P = .02). Patients prescribed benzodiazepines did not have weaker response to prolonged exposure, but demonstrated poorer posttreatment maintenance of gains from present-centered psychotherapy (b = -0.78, P < .001).Prolonged exposure is a sufficiently robust treatment that patients who are taking benzodiazepines can benefit from it. It is unclear whether benzodiazepine use or other patient factors accounted for benzodiazepine recipients' poorer maintenance of gains in present-centered psychotherapy.ClinicalTrials.gov identifier: NCT00032617.
View details for DOI 10.4088/JCP.13m08592
View details for Web of Science ID 000330187000014
View details for PubMedID 24434093
Longitudinal Correlates of Aggressive Behavior in Help-Seeking U.S. Veterans With PTSD
JOURNAL OF TRAUMATIC STRESS
2012; 25 (6): 649-656
The current study examined the longitudinal effects of clinical and treatment utilization factors on aggressive behavior among 376 help-seeking U.S. veterans recently diagnosed with posttraumatic stress disorder (PTSD) who were followed for 5-12 months. Participants were sampled from 4 strata: male Iraq/Afghanistan veterans, female Iraq/Afghanistan veterans, male prior-era veterans, and female prior-era veterans. Hierarchical regression analyses indicated that changes in PTSD severity were significantly associated with changes in aggressive behavior among veterans who reported any aggression at baseline (β = .15). Changes in days of alcohol intoxication also were positively associated with changes in aggressive behavior (β = .16). Participants with both a benzodiazepine prescription and any baseline aggression were significantly more likely to increase in aggressive behavior over time (β = .14). Contrary to our hypotheses, reductions in aggressive behavior were not related to the number of outpatient mental health visits or to first-line recommended psychotropic medications. Results inform assessment and clinical research on changes in aggressive behavior among veterans with PTSD.
View details for DOI 10.1002/jts.21761
View details for Web of Science ID 000312151400006
View details for PubMedID 23225031
Compensation and Treatment: Disability Benefits and Outcomes of US Veterans Receiving Residential PTSD Treatment
JOURNAL OF TRAUMATIC STRESS
2012; 25 (5): 494-502
The U.S. Department of Veterans Affairs (VA) provides specialized intensive posttraumatic stress disorder (PTSD) programs to treat trauma-related symptoms in addition to providing service-connected disability to compensate veterans for injury sustained while serving in the military. Given the percentage of veterans who are receiving treatment for PTSD, in addition to seeking compensation for PTSD, a debate has emerged about the impact of compensation on symptom recovery. This study examined the associations among status of compensation, treatment expectations, military cohort, length of stay, and outcomes for 776 veterans who were enrolled in 5 VA residential PTSD programs between the years of 2005 and 2010. Mixed model longitudinal analyses, with age, gender, and baseline symptoms nested within treatment site in the model, found that treatment expectations were modestly predictive of treatment outcomes. Veterans seeking increased compensation reported marginally lower treatment expectations (d = .008), and did not experience poorer outcomes compared to veterans not seeking increased compensation with the effect of baseline symptoms partialled out. Veterans from the era of the Iraq and Afghanistan conflicts reported lower treatment expectations (d = .020) and slightly higher symptoms at intake (d = .021), but had outcomes at discharge equivalent to veterans from other eras with baseline symptoms partialled out. These findings help further inform the debate concerning disability benefits and symptom changes across time.
View details for DOI 10.1002/jts.21747
View details for Web of Science ID 000310251500002
View details for PubMedID 23047625
Evaluation of a Mentoring Program for PTSD Clinic Managers in the U.S. Department of Veterans Affairs
2012; 63 (10): 1047-1050
This evaluation study elicited feedback from participants in a novel program intended to help posttraumatic stress disorder (PTSD) clinical managers address organizational challenges in providing services and improving care.Program participants were invited to respond to an online survey developed for this study; 46% (N=121) responded.Two-thirds of survey respondents had engaged in mentoring program activities ten or more times in the past six months. Roughly half the respondents reported that the program helped them be more connected to other clinics, learn about innovations in care, and feel more supported. Those who participated more often (β=.25, p<.01) and rated their mentors highly (β=.59, p<.01) reported greater benefits from the program.Mentees who were actively engaged with the mentoring program reported significant benefits. Efforts are under way to enhance the program by strengthening mentor selection and training.
View details for DOI 10.1176/appi.ps.201100446
View details for Web of Science ID 000309488100016
View details for PubMedID 23032678
- Treating Anger and Aggression in Military Populations: Research Updates and Clinical Implications CLINICAL PSYCHOLOGY-SCIENCE AND PRACTICE 2012; 19 (3): 305-322
- Is There a Role for Peer Support Delivered Interventions in the Treatment of Veterans With Post-Traumatic Stress Disorder? MILITARY MEDICINE 2012; 177 (5): 481-483
Concordance between psychotropic prescribing for veterans with PTSD and clinical practice guidelines.
2012; 63 (2): 154-160
Clinical practice guidelines for the pharmacological treatment of posttraumatic stress disorder (PTSD) do not support the use of benzodiazepines and cite insufficient evidence to recommend mood stabilizers. Although guidelines previously recommended second-generation antipsychotics as adjunct medication, recent research findings have also brought this recommendation into question. This study aimed to determine which characteristics of veterans with diagnosed PTSD were associated with receiving prescriptions for benzodiazepines and mood stabilizers and second-generation antipsychotics.The survey responses of 482 veterans with PTSD were combined with prescription information from Veterans Affairs national pharmacy databases. The researchers assessed the use of eight classes of psychotropics prescribed for patients with PTSD in the year after a new PTSD diagnosis. Multivariate logistic regressions identified demographic characteristics, symptom severity, co-occurring psychiatric diagnoses, health service use, and attitudinal characteristics associated with prescribing of benzodiazepines, second-generation antipsychotics, and mood stabilizers.In the absence of a clearly indicated co-occurring psychiatric diagnosis, long-term benzodiazepines were prescribed to 14%, second-generation antipsychotics to 15%, and mood stabilizers to 18% of veterans with PTSD. Benzodiazepine prescribing was associated with symptoms of insomnia. Having a mental health inpatient stay (odds ratio [OR]=8.01, p<.001) and at least one psychotherapy visit (OR=5.37, p<.001) were predictors of being prescribed a second-generation antipsychotic. Reporting more symptom severity (OR=1.84, p<.001) and fewer alcohol use problems (OR=.36, p<.03) predicted being prescribed a mood stabilizer.Prescribing patterns appeared generally consistent with treatment guidelines. Notable exceptions and areas worthy of future attention are discussed.
View details for DOI 10.1176/appi.ps.201100199
View details for PubMedID 22302333
How do components of evidence-based psychological treatment cluster in practice? A survey and cluster analysis
JOURNAL OF SUBSTANCE ABUSE TREATMENT
2012; 42 (1): 45-55
Evidence-based psychological treatments (EBPTs) are clusters of interventions, but it is unclear how providers actually implement these clusters in practice. A disaggregated measure of EBPTs was developed to characterize clinicians' component-level evidence-based practices and to examine relationships among these practices. Survey items captured components of evidence-based treatments based on treatment integrity measures. The Web-based survey was conducted with 75 U.S. Department of Veterans Affairs (VA) substance use disorder (SUD) practitioners and 149 non-VA community-based SUD practitioners. Clinician's self-designated treatment orientations were positively related to their endorsement of those EBPT components; however, clinicians used components from a variety of EBPTs. Hierarchical cluster analysis indicated that clinicians combined and organized interventions from cognitive-behavioral therapy, the community reinforcement approach, motivational interviewing, structured family and couples therapy, 12-step facilitation, and contingency management into clusters including empathy and support, treatment engagement and activation, abstinence initiation, and recovery maintenance. Understanding how clinicians use EBPT components may lead to improved evidence-based practice dissemination and implementation.
View details for DOI 10.1016/j.jsat.2011.07.008
View details for Web of Science ID 000297956900006
View details for PubMedID 21943809
Do veterans with posttraumatic stress disorder receive first-line pharmacotherapy? Results from the longitudinal veterans health survey.
The primary care companion to CNS disorders
2012; 14 (2)
Objective: Guidelines addressing the treatment of veterans with posttraumatic stress disorder (PTSD) strongly recommend a therapeutic trial of selective serotonin reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors (SNRIs). This study examined veteran characteristics associated with receiving such first-line pharmacotherapy, as well as how being a veteran of the recent conflicts in Afghanistan and Iraq impact receipt of pharmacotherapy for PTSD.Method: This was a national study of 482 Veterans Affairs (VA) outpatients between the ages of 18 and 69 years who had been newly diagnosed with PTSD (DSM-IV criteria: 309.81) during a VA outpatient visit between May 31, 2006, and December 7, 2007. Participants completed a mailed survey between August 11, 2006, and April 6, 2008. Veterans from the Afghanistan and Iraq conflicts and female veterans were intentionally oversampled. Logistic regression models were developed to predict 2 dependent variables: odds of initiating an SSRI/SNRI and, among veterans who initiated an SSRI/SNRI, odds of receiving an adequate therapeutic trial. Each dependent variable was regressed on a variety of sociodemographic and survey characteristics.Results: Of the 377 veterans prescribed a psychotropic medication, 73% (n = 276) received an SSRI/SNRI, of whom 61% (n = 168) received a therapeutic trial. Afghanistan and Iraq veterans were less likely to receive a therapeutic trial (odds ratio [OR] = 0.45; 95% CI, 0.27-0.75; P < .01), with presence of a comorbid depression diagnosis in the year after the index episode moderating this relationship, which further decreased the odds of completing a therapeutic trial (OR = 0.29; 95% CI, 0.09-0.95; P < .05).Conclusions: Reduced levels of receipt of first-line pharmacotherapy among recent veteran returnees parallel previous findings of less mental health treatment utilization in this population and warrant investigation.
View details for DOI 10.4088/PCC.11m01162
View details for PubMedID 22943028
View details for PubMedCentralID PMC3425460
Stigma, Help-Seeking Attitudes, and Use of Psychotherapy in Veterans With Diagnoses of Posttraumatic Stress Disorder
JOURNAL OF NERVOUS AND MENTAL DISEASE
2011; 199 (11): 879-885
Survey and medical record data from 482 Veterans Affairs (VA) patients who recently received diagnoses of posttraumatic stress disorder (PTSD) were examined to determine need and predisposing factors associated with utilization of psychotherapy and counseling. More than half (58%) of participants initiated VA psychotherapy for PTSD within a year of diagnosis. Of those, one third completed eight or more sessions. Roughly two thirds of participants initiated counseling at a Vet Center. Initiating PTSD psychotherapy was associated with greater impairment but not with stigma, concerns about fitting in, or satisfaction with care. The use of Vet Center counseling was associated with desire for help, concerns about fitting in, and satisfaction with care. Unexpectedly, veterans with greater stigma concerns completed more psychotherapy visits and Vet Center counseling. Negative attitudes about mental health treatment did not seem to be substantial barriers to engaging in psychotherapy among these VA patients. Future research should consider enabling treatment system factors in addition to predisposing patient characteristics.
View details for DOI 10.1097/NMD.0b013e3182349ea5
View details for Web of Science ID 000296712800011
View details for PubMedID 22048141
The Comparative Effectiveness of Cognitive Processing Therapy for Male Veterans Treated in a VHA Posttraumatic Stress Disorder Residential Rehabilitation Program
JOURNAL OF CONSULTING AND CLINICAL PSYCHOLOGY
2011; 79 (5): 590-599
To examine the effectiveness of group cognitive processing therapy (CPT) relative to trauma-focused group treatment as usual (TAU) in the context of a Veterans Health Administration (VHA) posttraumatic stress disorder (PTSD) residential rehabilitation program.Participants were 2 cohorts of male patients in the same program treated with either CPT (n = 104) or TAU (n = 93; prior to the implementation of CPT). Cohorts were compared on changes from pre- to posttreatment using the PTSD Checklist (PCL; Weathers, Litz, Herman, Huska, & Keane, 1993) and other measures of symptoms and functioning. Minorities represented 41% of the sample, and the mean age was 52 years (SD = 9.22). The CPT group was significantly younger and less likely to receive disability benefits for PTSD; however, these variables were not related to outcome.Analyses of covariance controlling for intake symptom levels and cohort differences revealed that CPT participants evidenced more symptom improvement at discharge than TAU participants on the PCL, F(3, 193) = 15.32, p < .001, b = 6.25, 95% CI [3.06, 9.44], and other measures. In addition, significantly more patients treated with CPT were classified as "recovered" or "improved" at discharge, χ2(1, N = 197) = 4.93, p = .032.There is still room for improvement, as substantial numbers of veterans continue to experience significant symptoms even after treatment with CPT in a residential program. However, CPT appears to produce significantly more symptom improvement than treatment conducted before the implementation of CPT. The implementation of this empirically supported treatment in VHA settings is both feasible and sustainable and is likely to improve care for male veterans with military-related PTSD.
View details for DOI 10.1037/a0024466
View details for Web of Science ID 000295339900003
View details for PubMedID 21744946
- Perceived Barriers to Care Among Veterans Health Administration Patients With Posttraumatic Stress Disorder PSYCHOLOGICAL SERVICES 2011; 8 (3): 212-223
Therapist Adherence to Manualized Cognitive-Behavioral Therapy for Anger Management Delivered to Veterans With PTSD Via Videoconferencing
JOURNAL OF CLINICAL PSYCHOLOGY
2011; 67 (6): 629-638
Therapist adherence to a manualized cognitive-behavioral anger management group treatment (AMT) was compared between therapy delivered via videoconference (VC) and the traditional in-person modality, using data from a large, randomized controlled trial comparing the effectiveness of AMT for veterans with combat-related posttraumatic stress disorder. Therapist adherence was rated for the presence or absence of process and content treatment elements. Secondary analyses were conducted using a repeated measures ANOVA. Overall adherence to the protocol was excellent (M = 96%, SD = 1%). Findings indicate that therapist adherence to AMT is similar across delivery modalities and VC is a viable service delivery strategy that does not compromise a therapist's ability to effectively structure sessions and manage patient care.
View details for DOI 10.1002/jclp.20779
View details for Web of Science ID 000289586700009
View details for PubMedID 21360528
How Does Tele-Mental Health Affect Group Therapy Process? Secondary Analysis of a Noninferiority Trial
JOURNAL OF CONSULTING AND CLINICAL PSYCHOLOGY
2010; 78 (5): 746-750
Video teleconferencing (VTC) is used for mental health treatment delivery to geographically remote, underserved populations. However, few studies have examined how VTC affects individual or group psychotherapy processes. This study compares process variables such as therapeutic alliance and attrition among participants receiving anger management group therapy either through traditional face-to-face delivery or by VTC.The current study represents secondary analyses of a randomized noninferiority trial (Morland et al., in press) in which clinical effectiveness of VTC delivery proved noninferior to in-person delivery. Participants were male veterans (N = 112) with posttraumatic stress disorder (PTSD) and moderate to severe anger problems. The present study examined potential differences in process variables, including therapeutic alliance, satisfaction, treatment credibility, attendance, homework completion, and attrition.No significant differences were found between the two modalities on most process variables. However, individuals in the VTC condition exhibited lower alliance with the group leader than those in the in-person condition. Mean self-leader alliance scores were 4.2 (SD = 0.8) and 4.5 (SD = 0.4), respectively, where 5 represents strongly agree and 4 represents agree with positive statements about the relationship, suggesting that participants in both conditions felt reasonably strong alliance in absolute terms. Individuals who had stronger alliance tended to have better anger outcomes, yet the effect was not strong enough to result in the VTC condition producing inferior aggregate outcomes.Our findings suggest that even if group psychotherapy via VTC differs in subtle ways from in-person delivery, VTC is a viable and effective means of delivering psychotherapy.
View details for DOI 10.1037/a0020158
View details for Web of Science ID 000282393800015
View details for PubMedID 20873910
Tailoring Disaster Mental Health Services to Diverse Needs: An Analysis of 36 Crisis Counseling Projects
HEALTH & SOCIAL WORK
2010; 35 (3): 211-220
The federal Crisis Counseling Program (CCP) funds states' delivery of mental health services after disasters. These services are provided by social workers, other mental health professionals, and paraprofessionals from the local community. The present study examined whether CCP grant recipients that reported more tailoring of their interventions to the needs of diverse community segments achieved greater community penetration. The study reviewed archival records from 36 crisis counseling projects ending between 1996 and 2001. Numbers of clients and client ethnicity were determined through service logs. Tailoring ofservices was determined by content coding of projects' reports. Community demographics were determined from census data. Fifty-six percent of the projects reported using three or more tailoring strategies, suggesting a "precompetence" or greater stage of cultural competence. The proportion of members of racial or ethnic minority groups among program clients closely matched the proportion in grantees' communities. Projects that reported more types of tailored activities reached more clients and served more members ofminority groups. These findings confirm that adapting crisis counseling services to diverse local needs is associated with greater community penetration of mental health services.
View details for Web of Science ID 000280745000006
View details for PubMedID 20853648
Telemedicine for Anger Management Therapy in a Rural Population of Combat Veterans With Posttraumatic Stress Disorder: A Randomized Noninferiority Trial
JOURNAL OF CLINICAL PSYCHIATRY
2010; 71 (7): 855-863
To demonstrate the noninferiority of a telemedicine modality, videoteleconferencing, compared to traditional in-person service delivery of a group psychotherapy intervention for rural combat veterans with posttraumatic stress disorder (PTSD).A randomized controlled noninferiority trial of 125 male veterans with PTSD (according to DSM criteria on the Clinician-Administered PTSD Scale) and anger difficulties was conducted at 3 Veterans Affairs outpatient clinics. Participants were randomly assigned to receive anger management therapy delivered in a group setting with the therapist either in-person (n = 64) or via videoteleconferencing (n = 61). Participants were assessed at baseline, midtreatment (3 weeks), posttreatment (6 weeks), and 3 and 6 months posttreatment. The primary clinical outcome was reduction of anger difficulties, as measured by the anger expression and trait anger subscales of the State-Trait Anger Expression Inventory-2 (STAXI-2) and by the Novaco Anger Scale total score (NAS-T). Data were collected from August 2005 to October 2008.Participants in both groups showed significant and clinically meaningful reductions in anger symptoms, with posttreatment and 3 and 6 months posttreatment effect sizes ranging from .12 to .63. Using a noninferiority margin of 2 points for STAXI-2 subscales anger expression and trait anger and 4 points for NAS-T outcomes, participants in the videoteleconferencing condition demonstrated a reduction in anger symptoms similar ("non-inferior") to symptom reductions in the in-person groups. Additionally, no significant between-group differences were found on process variables, including attrition, adherence, satisfaction, and treatment expectancy. Participants in the in-person condition reported significantly higher group therapy alliance.Clinical and process outcomes indicate delivering cognitive-behavioral group treatment for PTSD-related anger problems via videoteleconferencing is an effective and feasible way to increase access to evidence-based care for veterans residing in rural or remote locations.
View details for DOI 10.4088/JCP.09m05604blu
View details for Web of Science ID 000280470700005
View details for PubMedID 20122374
Aggressive and Unsafe Driving in Male Veterans Receiving Residential Treatment for PTSD
JOURNAL OF TRAUMATIC STRESS
2010; 23 (3): 399-402
Aggressive and unsafe driving was examined in 474 male veterans receiving Veterans Affairs residential treatment for posttraumatic stress disorder (PTSD). Specifically, the authors evaluated if PTSD was associated with aggressive and unsafe driving and if Iraq and Afghanistan War veterans were at higher risk than other war veterans. Approximately two thirds of the sample reported lifetime aggressive driving and one third reported current aggressive driving. Posttraumatic stress disorder severity was associated with aggressive driving, but not other forms of unsafe driving. Iraq and Afghanistan veterans endorsed higher rates of and more frequent aggressive driving than did other veterans. After accounting for PTSD severity, age, income, and marital status being an Iraq and Afghanistan War veteran predicted aggressive driving frequency and infrequent seatbelt use.
View details for DOI 10.1002/jts.20536
View details for Web of Science ID 000279419300012
View details for PubMedID 20564373
Subgroups of New York City Children at High Risk of PTSD After the September 11 Attacks: A Signal Detection Analysis
2010; 61 (1): 64-69
Case finding is an important challenge in mental health programs responding to large-scale disasters. Most people who experience psychological symptoms after such events return to normal functioning within a few months. Yet a significant minority continues to experience enduring symptoms. This study demonstrated the use of signal detection analyses of community survey data to identify subgroups of children who were at highest risk of posttraumatic stress disorder (PTSD) after the September 11 attacks.This study reanalyzed results of a needs assessment survey conducted six months after the World Trade Center attacks on September 11, 2001, with a representative sample of 7,832 New York City public school students in grades 4 to 12. Receiver operating characteristic (ROC) analyses conducted on half the sample resulted in a decision tree for classifying children into groups at varying levels of risk of PTSD. These decision rules were subsequently retested on the second half of the sample.We could reliably classify children into groups with varying probabilities of screening positive on a PTSD screen. Nearly two-thirds of children in grades 4 to 12 who screened positive for probable PTSD were concentrated among 4th graders (35%) and among children who had a friend or family member directly exposed to the attacks (28%).Signal detection analysis of community needs assessment surveys can identify community subgroups most likely to screen positive for mental health problems after a disaster or terrorist attack. This information can help target screening and outreach efforts to community segments that have the highest need for services.
View details for Web of Science ID 000273234800012
View details for PubMedID 20044420
Using Administrative Data to Identify Mental Illness: What Approach Is Best?
AMERICAN JOURNAL OF MEDICAL QUALITY
2010; 25 (1): 42-50
The authors estimated the validity of algorithms for identification of mental health conditions (MHCs) in administrative data for the 133 068 diabetic patients who used Veterans Health Administration (VHA) nationally in 1998 and responded to the 1999 Large Health Survey of Veteran Enrollees. They compared various algorithms for identification of MHCs from International Classification of Diseases, 9th Revision (ICD-9) codes with self-reported depression, posttraumatic stress disorder, or schizophrenia from the survey. Positive predictive value (PPV) and negative predictive value (NPV) for identification of MHC varied by algorithm (0.65-0.86, 0.68-0.77, respectively). PPV was optimized by requiring > or =2 instances of MHC ICD-9 codes or by only accepting codes from mental health visits. NPV was optimized by supplementing VHA data with Medicare data. Findings inform efforts to identify MHC in quality improvement programs that assess health care disparities. When using administrative data in mental health studies, researchers should consider the nature of their research question in choosing algorithms for MHC identification.
View details for DOI 10.1177/1062860609346347
View details for Web of Science ID 000273214000005
View details for PubMedID 19855046
Issues in the design of a randomized noninferiority clinical trial of telemental health psychotherapy for rural combat veterans with PTSD
CONTEMPORARY CLINICAL TRIALS
2009; 30 (6): 513-522
This methodological article provides a description of the design, methods, and rationale of the first prospective, noninferiority designed randomized clinical trial evaluating the clinical and cost implications of delivering an evidence-based cognitive-behavioral group intervention specifically treating posttraumatic stress disorder (PTSD) with a trauma-focused intervention via video teleconferencing (VTC). PTSD is a prevalent mental health problem found among returning Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) military populations. These returning military personnel often live in rural areas and therefore have limited access to care and specialized psychological treatments. In the field of mental health, telemental health (TMH) technology has introduced a potential solution to the persistent problem of access to care in remote areas. This study is enrolling approximately 126 returning veterans with current combat-related PTSD who are receiving services through the Veteran Administration (VA) mental health care clinics on 4 Hawaiian Islands. Cognitive Processing Therapy (CPT), an empirically supported manualized treatment for PTSD, is being delivered across 9 cohorts. Participants are assigned to either the experimental VTC condition or the in-person control condition. Assessments measuring clinical, process, and cost outcomes are being conducted at baseline, mid-treatment, post-treatment, and 3 and 6 months post-treatment. The study employs a noninferiority design to determine if the group treatment delivered via VTC is as good as the traditional in-person modality. In addition, a cost analysis will be performed in order to compare the cost of the 2 modalities. Novel aspects of this trial and specific challenges are discussed.
View details for DOI 10.1016/j.cct.2009.06.006
View details for Web of Science ID 000272111000003
View details for PubMedID 19576299
Innovations in Disaster Mental Health Services and Evaluation: National, State, and Local Responses to Hurricane Katrina (Introduction to the Special Issue)
ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH
2009; 36 (3): 159-164
The severe consequences of Hurricane Katrina on mental health have sparked tremendous interest in improving the quality of mental health care for disaster victims. In this special issue, we seek to illustrate the breadth of work emerging in this area. The five empirical examples each reflect innovation, either in the nature of the services being provided or in the evaluation approach. Most importantly, they portray the variability of post-Katrina mental health programs, which ranged from national to state to local in scope and from educational to clinical in intensity. As a set, these papers address the fundamental question of whether it is useful and feasible to provide different intensities of mental health care to different populations according to presumed need. The issue concludes with recommendations for future disaster mental health service delivery and evaluation.
View details for DOI 10.1007/s10488-009-0218-y
View details for Web of Science ID 000265682500001
View details for PubMedID 19365721
Factors Predicting Crisis Counselor Referrals to Other Crisis Counseling, Disaster Relief, and Psychological Services: A Cross-Site Analysis of Post-Katrina Programs
ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH
2009; 36 (3): 186-194
An important aspect of crisis counseling is linking survivors with services for their unmet needs. We examined determinants of referrals for disaster relief, additional crisis counseling, and psychological services in 703,000 crisis counseling encounters 3-18 months after Hurricane Katrina. Referrals for disaster relief were predicted by clients' losses, age (adults rather than children), and urbanicity. Referrals for additional counseling and psychological services were predicted by urbanicity, losses and trauma exposure, prior trauma, and preexisting mental health problems. Counseling and psychological referrals declined over time despite continuing mental health needs. Results confirm large urban-rural disparities in access to services.
View details for DOI 10.1007/s10488-009-0216-0
View details for Web of Science ID 000265682500004
View details for PubMedID 19381795
Service Characteristics and Counseling Outcomes: Lessons from a Cross-Site Evaluation of Crisis Counseling After Hurricanes Katrina, Rita and Wilma
ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH
2009; 36 (3): 176-185
The 2005 hurricane season was the worst on record, resulting in disaster declarations and the implementation of federally-funded crisis counseling programs in five states. As part of a larger cross-site evaluation of these programs, data from 2,850 participant surveys, 805 provider surveys, and 132,733 encounter logs (submitted from 3 weeks before to 3 weeks after the participant surveys) were aggregated to the county level (N = 50) and used to test hypotheses regarding factors that influence program performance. County-level outcomes (aggregate ratings of participants' perceived benefits) improved as service intensity, service intimacy, and frequency of psychological referrals increased and as provider job stress decreased. The percent of providers with advanced degrees was indirectly related to participants' perceived benefits by increasing service intensity and referral frequency. The results yielded recommendations for achieving excellence in disaster mental health programs.
View details for DOI 10.1007/s10488-009-0215-1
View details for Web of Science ID 000265682500003
View details for PubMedID 19365723
Predicting Mortality in Veterans With Posttraumatic Stress Disorder Thirty Years After Vietnam
JOURNAL OF NERVOUS AND MENTAL DISEASE
2009; 197 (4): 260-265
Previous research has demonstrated elevated mortality rates among Vietnam-era veterans with posttraumatic stress disorder, especially deaths resulting from nonmedical causes. However, information on the relative contribution of particular risk factors to increased mortality is limited. We used receiver operating characteristics methodology to identify patient-level characteristics that predicted 7-year mortality in 79,551 middle-aged, male, posttraumatic stress disorder-diagnosed outpatients seeking mental health treatment within the Veterans Affairs Health Care System between April 1, 1998 and September 30, 1998. Receiver operating characteristics models indicated that the strongest predictor of mortality was a recent history of medical hospitalization, followed by severity of medical diagnoses and presence of a substance disorder. Results highlight the importance of addressing comorbid medical illnesses and addictive disorders when caring for this population.
View details for DOI 10.1097/NMD.0b013e31819dbfce
View details for Web of Science ID 000265249600007
View details for PubMedID 19363382
Relationships among PTSD symptoms, social support, and support source in veterans with chronic PTSD
JOURNAL OF TRAUMATIC STRESS
2008; 21 (4): 394-401
The present study examined the temporal relationship between posttraumatic stress disorder (PTSD) and social support among 128 male veterans treated for chronic PTSD. Level of perceived interpersonal support and stressors were assessed at two time points (6 months apart) for four different potential sources of support: spouse, relatives, nonveteran friends, and veteran peers. Veteran peers provided relatively high perceived support and little interpersonal stress. Spouses were seen as both interpersonal resources and sources of interpersonal stress. More severe PTSD symptoms at Time 1 predicted greater erosion in perceived support from nonveteran friends, but not from relatives. Contrary to expectations, initial levels of perceived support and stressors did not predict the course of chronic PTSD symptoms.
View details for DOI 10.1002/jts.20348
View details for Web of Science ID 000258899800005
View details for PubMedID 18720391
Substance abuse-related mortality among middle-aged male VA psychiatric patients
2008; 59 (3): 290-296
This study evaluated mortality and causes of death over a seven-year period among middle-aged male psychiatric patients with and without co-occurring substance use disorder.This cohort study examined mortality among 169,051 male Vietnam-era veterans ages 40 to 59 treated for psychiatric disorders by the U.S. Department of Veterans Affairs (VA) between April and September 1998. Demographic variables, diagnoses, and prior hospitalizations were obtained from VA electronic medical records. Mortality status was obtained from VA benefits records. Cause-of-death data were purchased from the National Death Index for a random sample of 3,383 decedents. Mortality among psychiatric patients with and without diagnosed co-occurring substance use disorders was compared by logistic regression, with controls for demographic factors, psychiatric and medical diagnoses, and prior hospitalizations. Causes of death for psychiatric patients with and without co-occurring disorders were compared by chi square analyses. Results were compared to age- and race-matched norms for the U.S. population.The risk-adjusted probability of dying was 55% higher among psychiatric patients with co-occurring substance use disorders than among those without substance use disorders (OR=1.58-1.69). Overdoses and substance abuse-linked illnesses accounted for 27.6% of deaths among psychiatric patients with co-occurring substance use disorders, compared with only 8.8% of deaths among other psychiatric patients.Substance use disorders strongly contributed to premature death among male psychiatric patients. Secondary prevention is needed to reduce substance misuse and improve medical care for substance-related illnesses among psychiatric patients with co-occurring substance use disorders.
View details for Web of Science ID 000253788400012
View details for PubMedID 18308910
Psychometric Characteristics of the Teen Addiction Severity Index-Two (T-ASI-2)
2008; 29 (2): 19-32
The Teen Addiction Severity Index-Two (T-ASI-2) was developed as an extension of the T-ASI to assess the severity of substance abuse and related problems among adolescents (N = 371) 12-19 years of age. The T-ASI-2 consists of 18 domains that assess current use of alcohol, tobacco, marijuana, and other drugs, as well as mental health service utilization, treatment satisfaction, school difficulties, social functioning with family members and peers, substance use by family members and peers, depression, anxiety, attention deficit, hyperactivity, defiant and risky behaviors, and readiness for change. Results show that all domains have adequate to excellent internal consistency (.54 to .88, median .80). New domains assessing psychological factors strongly correlated with gold standard assessments in the respective areas. The T-ASI-2 was designed to be a user friendly, cost-effective, viable assessment of substance use behavior and related factors.
View details for DOI 10.1080/08897070802092942
View details for Web of Science ID 000207708200003
View details for PubMedID 19042321
Does compensation status influence treatment participation and course of recovery from post-traumatic stress disorder?
2007; 172 (10): 1039-1045
We reviewed the empirical literature to examine how seeking compensation and/or being awarded compensation for posttraumatic stress disorder-related disability are associated with participation in mental health treatment and course of recovery. The search for relevant literature was conducted using the PubMed, PsycINFO, Medline, and PILOTS databases and yielded seven studies on veterans and five on motor vehicle accident survivors. The literature indicates that veterans who are seeking or have been awarded compensation participate in treatment at similar or higher rates than do their non-compensation-seeking counterparts. Veteran treatment outcome studies produced either null or mixed findings, with no consistent evidence that compensation-seeking predicts worse outcomes. Studies of motor vehicle accident survivors found no association between compensation status and course of recovery. Recommendations to strengthen future research in this area are provided, including using clear and consistent definitions of compensation status that differentiate compensation-seeking status from award status.
View details for Web of Science ID 000250252000005
View details for PubMedID 17985763
Adolescent substance use assessment in a primary care setting
AMERICAN JOURNAL OF DRUG AND ALCOHOL ABUSE
2007; 33 (3): 447-454
Health initiatives suggest that adolescent substance use assessment may be beneficial as part of primary care to screen for early problematic behaviors. To examine the accuracy of such reporting, we compared the anonymous and confidential self-reports of 180 adolescents in a primary care setting. Matching samples to control for demographic variables, we found that adolescents were more likely to report marijuana use and substance use behaviors, such as selling drugs, when reporting anonymously vs. reporting confidentially. These results challenge the accuracy of confidential self-reports within this setting, and suggest further research is needed.
View details for DOI 10.1080/00952990701315079
View details for Web of Science ID 000246964900011
View details for PubMedID 17613972
"Stay connected": psychological services for retired firefighters after 11 September 2001.
Prehospital and disaster medicine
2007; 22 (1): 49-54
A large number of firefighters retired after 11 September 2001. These retirees were confronted with multiple challenges, including grief, trauma-related physical injuries and psychological distress, difficulties related to the transition of their roles, and deterioration of social support.The Fire Department of New York (FDNY) Counseling Service Unit's "Stay Connected" Program designed and implemented after 11 September 2001 is described in this report. This unique program was designed to use a combination of peer outreach and professional counseling to address the mental health needs of retiring firefighters and their families.Descriptive information about the intervention program was gathered through semi-structured interviews with Counseling Service Unit staff. Client satisfaction surveys were collected during three six-week periods.Quantitative data indicate that clients rated their overall satisfaction with the clerical and counseling staff a perfect 4 out of 4. The report of their overall satisfaction with the services also was nearly at ceiling (3.99 out 4). The perceived helpfulness of the services in resolving the problems experienced by the clients increased significantly over time. Qualitative data indicate that peer involvement and intensive community outreach, i.e., social events, wellness activities, and classes, were integral to the success of the intervention.This project provided valuable lessons about how to develop and implement a "culturally competent"intervention program for public safety workers retiring after a disaster. Creative, proactive, non-traditional outreach efforts and leveraging peers for credibility and support were particularly important.
View details for PubMedID 17484363
Coping, symptoms, and functioning outcomes of patients with posttraumatic stress disorder
JOURNAL OF TRAUMATIC STRESS
2006; 19 (6): 799-811
This study examines the association between approach coping and better functioning outcomes and the reciprocal relationships between coping and posttraumatic stress disorder (PTSD) symptoms in patients diagnosed with PTSD. Posttraumatic stress disorder patients receiving services in five VA health care systems were randomly selected and surveyed at baseline and followed 10 months later. Analyses of longitudinal data using structural equation modeling techniques showed that more approach coping predicted better family and social functioning. Cognitive avoidance coping predicted more PTSD symptoms, and more PTSD symptoms predicted more approach coping and more behavioral avoidance coping. Approach coping may enable patients with chronic PTSD to establish and maintain better relationships with family and friends, despite continuing PTSD.
View details for DOI 10.1002/jts.20185
View details for Web of Science ID 000243184200005
View details for PubMedID 17195979
Telephone monitoring and support for veterans with chronic posttraumatic stress disorder: A pilot study
COMMUNITY MENTAL HEALTH JOURNAL
2006; 42 (5): 501-508
Dropout from outpatient mental health treatment may contribute to high rates of relapse and rehospitalization among veterans with chronic posttraumatic stress disorder (PTSD). In a quasi-experimental cohort study, 87 male and 17 female veterans discharging from residential PTSD treatment received either standard referral to outpatient care (N = 77) or standard referrals supplemented by biweekly telephone calls (N = 27). Telephone monitoring and support was feasible and acceptable to 85% of clients. Compared to prior patient cohorts, clients receiving telephone support were twice as likely (88% vs. 43%) to complete an outpatient visit within 1 month of discharge and reported higher satisfaction with care.
View details for DOI 10.1007/s10597-006-9047-6
View details for Web of Science ID 000241716700006
View details for PubMedID 16897414
Disparities in diabetes care - Impact of mental illness
ARCHIVES OF INTERNAL MEDICINE
2005; 165 (22): 2631-2638
Emerging evidence indicates that patients with mental health conditions (MHCs) may receive less intensive medical care. Diabetes serves as a useful condition in which to test for MHC-related disparities in care. We examined whether quality measures for diabetes care are worse for patients with or without MHCs.This national, cross-sectional study included 313 586 noninstitutionalized Veterans Health Administration patients with diabetes (identified from diagnostic codes and prescriptions) whose Veterans Health Administration facility transmitted laboratory data to a central database; 76 799 (25%) had MHCs (based on diagnostic codes for depressed mood, anxiety, psychosis, manic symptoms, substance use disorders, personality disorders, and other categories). National data from Veterans Health Administration records, Medicare claims, and a national survey were linked to characterize 1999 diabetes care.Failure to meet diabetes performance measures was more common in patients with MHCs: unadjusted odds ratio (95% confidence interval) was 1.24 (1.22-1.27) for no hemoglobin A(1c) testing, 1.25 (1.23-1.28) for no low-density lipoprotein cholesterol testing, 1.05 (1.03-1.07) for no eye examination, 1.32 (1.30-1.35) for poor glycemic control, and 1.17 (1.15-1.20) for poor lipemic control. Disparities persisted after case mix adjustment and were more pronounced with specific MHCs (psychotic, manic, substance use, and personality disorders). The percentage not meeting diabetes care standards increased with increasing number of MHCs.Patients with mental illness merit special attention in national diabetes quality improvement efforts.
View details for Web of Science ID 000233883800015
View details for PubMedID 16344421
Chronic PTSD patients' functioning before and after the September 11 attacks
JOURNAL OF TRAUMATIC STRESS
2005; 18 (6): 781-784
This study examined how treatment-seeking veterans with preexisting posttraumatic stress disorder (PTSD) (n = 178) were affected by vicarious exposure to the September 11 terrorist attacks. Participants were surveyed 0 to 5 months prior to 9/11 and resurveyed 6 months after the attacks. Half the patients reported that thoughts and feelings about 9/11 impaired their functioning some (37%) or most or all of the time (13%). However, there was little evidence that vicarious exposure to 9/11 altered the course of these patients' functioning. Mean symptom, substance use, and role functioning outcomes were unchanged from pre-9/11 levels. Time spent following media coverage of 9/11 events was weakly associated (r = .17 to .18, p < .05) with only two of eight functioning outcomes.
View details for DOI 10.1002/jts.20086
View details for Web of Science ID 000234532900020
View details for PubMedID 16382441
Reliability and acceptability of automated telephone surveys among Spanish- and English-speaking mental health services recipients.
Mental health services research
2005; 7 (3): 181-184
Interactive Voice Response (IVR), an automated system that administers surveys over the phone, is a potentially important technology for mental health services research. Although a number of studies have compared IVR to live interviews, few have looked at IVR in comparison to pencil-and-paper survey administration. Further, few studies have included subjects from those populations most likely to benefit from IVR technology, namely patients with lower education levels and non-English-speaking patients. This randomized clinical study, conducted at a community health center serving low-income English- and Spanish-speaking populations, assessed the reliability of an IVR-administered Brief Symptom Inventory (BSI) relative to a paper-and-pencil version. The study was adequately powered. Results showed that patients gave similar responses to the IVR and paper-and-pencil surveys; in addition, patients were generally equally satisfied with both experiences. We conclude that, while more large-scale research is needed, IVR can be a useful survey administration tool.
View details for PubMedID 16194003
Predicting high-risk behaviors in veterans with posttraumatic stress disorder
JOURNAL OF NERVOUS AND MENTAL DISEASE
2005; 193 (7): 464-472
The present study sought to identify posttraumatic stress disorder (PTSD) patients at high risk for negative behavioral outcomes (violence, suicide attempts, and substance use). The Mississippi Scale for Combat-Related PTSD, the Beck Depression Inventory, and demographic and behavioral data from 409 male combat veterans who completed a VA residential rehabilitation program for PTSD were analyzed using signal detection methods (receiver operating characteristics). A validation sample (N = 221) was then used to test interactions identified in the signal detection analyses. The best predictors of behaviors at follow-up were those same behaviors shortly before intake, followed by depressive and PTSD symptoms. However, for each of the models other than that for hard drug use, cutoffs determined at the symptom level did not lend themselves to replication. Recent high-risk behaviors, rather than patients' history, appear to be more predictive of high-risk behaviors postdischarge.
View details for DOI 10.1097/01.nmd.0000168238.13252.b3
View details for Web of Science ID 000230408100006
View details for PubMedID 15985841
A survey of PTSD screening and referral practices in VA addiction treatment programs
JOURNAL OF SUBSTANCE ABUSE TREATMENT
2005; 28 (4): 313-319
Veterans with posttraumatic stress disorder (PTSD) and substance use disorders (SUDs) demonstrate worse outcomes following treatment for SUDs than do veterans with SUDs only, and so PTSD treatment may enhance SUD outcomes for patients. A survey of current practice patterns in VA SUD treatment programs was undertaken to determine their concurrence with emerging practice guidelines for the assessment and treatment of SUD-PTSD comorbidity. Clinicians in outpatient SUD clinics and/or inpatient SUD programs were surveyed in six VA medical centers in 1999 and 2001 (respondents n = 57 and n = 39, respectively). Although one half to two thirds of clinicians working with SUD patients routinely screen for trauma exposure and PTSD, few assessments are systematically conducted using validated measures. Routine referrals to PTSD specialty and dual-diagnosis programs and to veterans' centers are made by between 35% and 60% of providers across inpatient and outpatient settings. Implications for improvement of clinical outcomes are discussed.
View details for DOI 10.1016/j.jsat.2005.02.006
View details for Web of Science ID 000230061500003
View details for PubMedID 15925265
Conversion and validation of the teen-addiction severity index (T-ASI) for Internet and automated-telephone self-report administration
PSYCHOLOGY OF ADDICTIVE BEHAVIORS
2005; 19 (1): 54-61
This study converted the Teen-Addiction Severity Index (T-ASI) into self-report formats using Internet (Net) and interactive voice response (IVR) automated-telephone technologies. Reliability and convergent validity were assessed among 95 inpatient adolescent participants. Current functioning scores obtained by clinician interview correlated well with self-report Net (mean r=.74, SD=.14) and IVR (mean r=.72, SD=.16). Lifetime history items obtained by clinicians were consistent with self-report Net (mean r=.60, SD=.32; mean kappa=.67, SD=.24) and IVR formats (mean r=.60, SD=.30; mean kappa=.64, SD=.26). Participants rated "ease of use" as being high for both Net and IVR formats. These findings suggest that automated T-ASI administration is a valid and potentially less expensive alternative to clinician-administered T-ASI interviews.
View details for DOI 10.1037/0893-164X.19.1.54
View details for Web of Science ID 000227729600007
View details for PubMedID 15783278
VA practice patterns and practice guidelines for treating posttraumatic stress disorder
JOURNAL OF TRAUMATIC STRESS
2004; 17 (3): 213-222
Little is known about how recent ISTSS practice guidelines (E. B. Foa, T. M. Keane, & M. J. Friedman, 2000) compare with prevailing PTSD treatment practices for veterans. Prior to guideline dissemination, clinicians in 6 VA medical centers were surveyed in 1999 (n = 321) and in 2001 (n = 271) regarding their use of various assessment and treatment procedures. Practices most consistent with guideline recommendations included psychoeducation, coping skills training, attention to trust issues, depression and substance use screening, and prescribing of SSRIs, anticonvulsants, and trazodone. PTSD and trauma assessment, anger management, and sleep hygiene practices were provided less consistently. Exposure therapy was rarely used. Additional research is needed on training, clinical resources, and organizational factors that may influence VA implementation of guideline recommendations.
View details for Web of Science ID 000221686900004
View details for PubMedID 15253093
Validation of the Addiction Severity Index (ASI) for internet and automated telephone self-report administration
JOURNAL OF SUBSTANCE ABUSE TREATMENT
2004; 26 (4): 253-259
This study assesses the convergent validity of Internet (Net) and interactive voice response (IVR) automated telephone self-report versions of the Addiction Severity Index (ASI) relative to the established, clinician-administered (CA) ASI. Eighty-eight subjects were recruited from an addiction treatment program to complete three ASI assessments. The mean correlation between composite scores obtained by Net and IVR and those obtained via clinician interview was.91 (range.81-.95). For History items, the mean correlation was.77 (range.14-1.00) and the mean kappa coefficient was.75 (range.46-1.00). The results demonstrated the validity of these self-report Net and IVR versions of the ASI. Self-report Net and IVR were rated as "very satisfactory" or "extremely satisfactory" by a majority of respondents for ease of use. Automation can reduce the labor costs associated with ASI administration and may facilitate longitudinal tracking of subjects from home.
View details for DOI 10.1016/j.jsat.2004.01.005
View details for Web of Science ID 000222018400002
View details for PubMedID 15182889
Causes of death among male veterans who received residential treatment for PTSD
JOURNAL OF TRAUMATIC STRESS
2003; 16 (6): 535-543
Previous studies have shown elevated mortality among psychiatric and substance abusing patients, including veterans with PTSD. Although early studies showed elevated deaths from external causes among Vietnam veterans in the early postwar years, more recent studies have also shown increased health problems among veterans with PTSD. This study compared mortality due to behavioral causes versus other diseases among 1,866 male veterans treated for PTSD. Death certificates obtained for 110 veterans indicated behavioral causes accounted for 62.4% of deaths, standardized mortality ratio = 3.4-5.5, including accidents (29.4%), chronic substance abuse (14.7%), and intentional death by suicide, homicide, or police (13.8%). Results suggest possible opportunities to improve outcomes of this at-risk patient population through harm reduction interventions and improved continuity of care.
View details for Web of Science ID 000186638900001
View details for PubMedID 14690350
Physical and sexual abuse history and addiction treatment outcomes
JOURNAL OF STUDIES ON ALCOHOL
2002; 63 (6): 683-687
Prior research on patients with substance use disorders has shown that lifetime physical or sexual abuse is associated with more impaired functioning at treatment intake. The present study sought to determine whether physical or sexual abuse also predicted treatment response (posttreatment outcomes) of individuals with substance use disorders.Male (n = 19,989) and female (n = 622) veterans with substance use disorders were assessed with the Addiction Severity Index (ASI) early in treatment and reassessed an average of 12 months later. Treatment outcomes were compared for patients who did and did not report prior physical or sexual abuse in the initial ASI interview.Lifetime physical or sexual abuse predicted worse outcomes in six of seven domains of functioning, after controlling for baseline functioning, psychiatric diagnoses and demographic variables. Although women were more likely than men to report being abused, the effect of abuse on treatment outcomes was similar for both genders. Psychiatric problems at baseline mediated the effect of abuse history on outcomes. Abuse history moderated the effect of treatment intensity (contacts per month) on outcomes: More frequent treatment contacts were more beneficial for abused patients than for nonabused patients.Individuals with substance use disorders who have a history of physical or sexual abuse may have higher risk for problematic treatment outcomes as a result of greater psychiatric problems, deficits in social support and possible difficulties in establishing treatment alliance. Clinicians may consider increasing the duration and intensity of treatment to temper the negative effects of abuse on later functioning.
View details for Web of Science ID 000180155700006
View details for PubMedID 12529068
How well are clinicians following dementia practice guidelines?
ALZHEIMER DISEASE & ASSOCIATED DISORDERS
2002; 16 (1): 15-23
Although there are numerous clinical guidelines regarding the management of dementia, there have been few studies on their implementation in practice. Clinicians in six United States Department of Veterans Affairs medical centers (n = 200, 85% response rate) were surveyed regarding their use of practices recommended in the California Workgroup Guidelines for Alzheimer's Disease Management. The majority of providers (89% to 73%) reported that they routinely conducted neurological examinations, obtained histories from caregivers, discussed the diagnosis with the patient's family, discussed durable power of attorney, and made legally-required reports of drivers with dementia. Roughly two-thirds of providers said they routinely conducted cognitive screening examinations, screened for depression, reported elder abuse, and discussed care needs and decision-making issues with patients' families. Only half of all outpatient providers implemented caregiver support practices for at least half of their patients. Clinicians' choices of medications for cognition, mood, and behavior problems were broadly consistent with current practice guidelines. These results suggest possible priorities for quality improvement efforts. Further research is needed to clarify reasons for particular gaps between guidelines and practice and to identify specific targets for intervention.
View details for Web of Science ID 000174273000003
View details for PubMedID 11882745
Posttraumatic stress disorder patients' readiness to change alcohol and anger problems
2001; 38 (2): 233-244
View details for Web of Science ID 000171842000011
- PTSD patients? readiness to change alcohol and anger problems. Psychotherapy 2001; 38: 233-244
Is the sequencing of change processes by stage consistent across health problems? A meta-analysis
2000; 19 (6): 593-604
Clinicians and researchers applying the transtheoretical model (J.O. Prochaska, C.C. DiClemente, & J.C. Norcross, 1992) to health promotion often assume that relationships of processes and stages observed in smoking cessation can be generalized to other problems. A reanalysis of 47 cross-sectional studies determined that use of change processes varies by stage, but the sequencing of processes is not consistent across health problems. In smoking cessation, cognitive processes were used in earlier stages than were behavioral processes. In exercise adoption and diet change, use of behavioral and cognitive processes increased together. Results for substance abuse and psychotherapy were less consistent. Substituting new behaviors, making a commitment, considering consequences, seeking information, controlling cues, and using rewards varied most by stage. Future longitudinal studies should assess these processes as potential mediators of lifestyle change.
View details for Web of Science ID 000165751100012
View details for PubMedID 11129363
Six- and ten-item indexs of psychological distress based on the Symptom Checklist-90
2000; 7 (2): 103-111
Clinicians, provider organizations, and researchers need simple and valid measures to monitor mental health treatment outcomes. This article describes development of 6- and 10-item indexes of psychological distress based on the Symptom Checklist-90 (SCL-90). A review of eight factor-analytic studies identified SCL-90 items most indicative of overall distress. Convergent validity of two new indexes and the previously developed SCL-10 were compared in an archival sample of posttraumatic stress disorder patients (n = 323). One index, the SCL-6, was further validated with archival data on substance abuse patients (n = 3,014 and n = 316) and hospital staff (n = 542). The three brief indexes had similar convergent validity, correlating .87 to .97 with the SCL-90 and Brief Symptom Inventory, .49 to .76 with other symptom scales, and .46 to .73 with changes in other symptom measures over time. These results indicate the concise, easily administered indexes are valid indicators of psychological distress.
View details for Web of Science ID 000174445200001
View details for PubMedID 10868247
Integrating stage and continuum models to explain processing of exercise messages and exercise initiation among sedentary college students
2000; 19 (2): 172-180
Concepts from the transtheoretical model (J.O. Prochaska, C.C. DiClemente, & J.C. Norcross, 1992), theory of planned behavior (I. Ajzen, 1985), and the elaboration likelihood model (R.E. Petty & J.T. Cacioppo, 1986b) were used to examine how exercise readiness impacted processing of exercise messages and exercise initiation. Sedentary college students (n = 147) were assessed for exercise attitude, intent, behavior, and stage of change. Students also listed their thoughts after reading messages with either strong or weak arguments for exercise. Attitude predicted depth of message processing, but stage of change did not. Stage of change and intent at baseline predicted exercise adoption at 1- to 3-month follow-up (n = 134), with baseline activity moderating the effect of intent. Tailoring messages to recipients' depth of processing and interactive effects of intent and behavior on exercise adoption should be considered in future research.
View details for DOI 10.1037//0278-6184.108.40.206
View details for Web of Science ID 000087490300008
View details for PubMedID 10762101
Consistency of self-administered and interview-based Addiction Severity Index composite scores
2000; 95 (3): 419-425
This study assesses the viability of a self-administered version of the Addiction Severity Index for monitoring substance abuse patients' functioning.Patients completed the ASI interview and a self-administered questionnaire containing ASI composite items an average of 4 days apart. Composite scores from both formats were compared using correlations and mean differences.Participants were 316 veterans entering substance abuse treatment in a US Department of Veterans Affairs medical center.Composite scores for alcohol, drug, psychiatric, family, legal and employment problems correlated 0.59-0.87 across formats. Patients endorsed more drug use and psychiatric symptoms by questionnaire than by interview. Medical composite scores correlated only 0.47 across formats.This study and previous research suggest that a self-administered questionnaire can be a feasible alternative to ASI interviews for monitoring substance abuse patients' treatment outcomes.
View details for Web of Science ID 000086059900016
View details for PubMedID 10795362
Preschoolers' pretend play and theory of mind: The role of jointly constructed pretence
BRITISH JOURNAL OF DEVELOPMENTAL PSYCHOLOGY
1999; 17: 333-348
View details for Web of Science ID 000082615400002
Preschoolers' attributions of mental states in pretense
1997; 68 (6): 1133-1142
When young children appear to recognize that someone else is engaging in make-believe play, do they infer what the pretender is thinking? Are they aware that the pretender is thinking about a pretend scenario yet knows what the real situation is? Preschoolers ages 3-5 (N = 45) viewed scenes from the Barney & Friends television series depicting either make-believe or realistic actions. Children were questioned concerning the presence of pretense and the thoughts and beliefs of the TV characters. The children were also presented with false belief and appearance/reality theory of mind tasks. Children who identified when TV characters were engaging in pretend play did not necessarily infer the pretenders' thoughts and beliefs. Inferring pretenders' thoughts was related to performance on false belief and appearance/reality tasks, but simply recognizing pretense was not. These data support the view that children initially learn to recognize pretense from contextual cues and are able to infer pretenders' beliefs only with further development of metarepresentational ability.
View details for Web of Science ID A1997YL12000015
View details for PubMedID 9418229