Clinician Documentation on Receipt of Trauma-Focused Evidence-Based Psychotherapies in a VA PTSD Clinic.

The U.S. Department of Veterans Affairs (VA) is implementing two trauma-focused, evidence-based psychotherapies (TF-EBPs) for posttraumatic stress disorder (PTSD): cognitive processing therapy and prolonged exposure therapy (PE). Veterans with PTSD often do not receive these treatments, and little is known about the reasons veterans may not receive TF-EBPs. The aim of this qualitative study was to summarize clinician-reported reasons in medical records for nonreceipt of TF-EBPs. All veterans (N = 63) identified through PTSD screening who were newly engaged in mental health care and received individual evaluations in a PTSD specialty clinic in fiscal year 2008 were included in the sample. Content analysis of electronic medical records revealed multiple potential reasons for nonreceipt of TF-EBPs including referral to other PTSD treatments, other clinical priorities, poor engagement in care, practical barriers, negative beliefs, and receipt of care in other settings. Eight veterans (13%) initiated TF-EBPs. Further interventions to promote engagement in PTSD treatment are warranted.

Meeting veterans where they're @: a VA Home-Based Telemental Health (HBTMH) pilot program.

OBJECTIVES: The first Home-Based Telemental pilot program (HBTMH) in the Department of Veterans Affairs addresses the significant challenge of access to mental health treatment for rural veterans. Though the feasibility of telemental healthcare in clinic-based settings has been well documented, the feasibility of telemental health via webcam and computer in a patient's home or other non-clinic settings is unknown. METHODS: The HBTMH program, established in December 2009 at the Portland VA Medical Center, delivers a wide range of mental health services into the homes and other non-clinic settings of rural veterans via webcam, secure and encrypted software and veteran-owned personal computers. The program adhered to a Standard Operating Procedure (SOP) Manual, evaluated patients with the Assessment for Suitability for Home Based Telemental Health (ASH-25), utilized a Patient Support Person (PSP), and incorporated a peer technical consultant to provide assistance to veterans. The authors describe satisfaction and safety survey results from the initial 40 veterans enrolled. RESULTS: Survey results support the feasibility and safety of using webcams, secure/encrypted software and veteran-owned personal computers for the delivery of mental health services into the home. Veterans report high levels of satisfaction and perceived safety with home-based telemental health. RESULTS also suggest fewer no-show appointments in home-based telemental health compared to clinic-based telemental health. CONCLUSIONS: The authors discuss the strength and limitations of the program as well as potential areas of future research.

Treatment of comorbid pain and PTSD in returning veterans: a collaborative approach utilizing behavioral activation.

OBJECTIVE: We explore preliminary clinical effectiveness and feasibility of an intervention utilizing collaborative care components and behavioral activation (BA) to treat comorbid chronic pain and posttraumatic stress disorder (PTSD). DESIGN: Descriptive, including pre- and posttreatment assessment results. SETTING: Portland Veterans Affairs Medical Center. PARTICIPANTS: Fifty-eight Iraq and Afghanistan veterans with chronic pain and PTSD symptoms. INTERVENTIONS: Veterans participated in a biopsychosocial evaluation and up to eight BA sessions using a collaborative approach involving primary care, mental health, and other clinicians. A physiatrist assisted the psychologist in providing recommendations to primary care providers. OUTCOME MEASURES: Participants were administered pre- and posttreatment measures of PTSD, pain severity, pain interference, mental health, quality of life, satisfaction, and global ratings of change with the purpose of assessing progress and improving quality. RESULTS: Of the 58 participants, 30 completed treatment. Common recommendations included physical therapy and exercise programs, pain medication or pain medication adjustments, and additional diagnostic workups, such as imaging. Participants who completed the program showed significant improvements on measures of PTSD, pain severity, and pain interference. Improvements were also evident on measures of mental health and quality of life. Overall, participants were satisfied with the program, and on average reported feeling "somewhat better." CONCLUSIONS: These findings suggest that a collaborative approach that includes BA is feasible and a potentially effective treatment for comorbid chronic pain and PTSD.

The effects of age on initiation of mental health treatment after positive PTSD screens among Veterans Affairs primary care patients.

OBJECTIVE: The objective was to examine differences by age in mental health treatment initiation in Veterans Health Administration (VA) primary care patients after positive posttraumatic stress disorder (PTSD) screens. METHODS: This was a retrospective cohort study of 71,039 veterans who were administered PTSD screens during primary care encounters in 2007 at four Pacific Northwest VA medical center sites and who had no specialty mental health clinic visits or PTSD diagnoses recorded in the year before screening. Main outcome measures were attendance of any specialty mental health clinic visits or receipt of any antidepressant medication in the year after a positive PTSD screen. RESULTS: Older veterans, compared with veterans less than 30 years old, were less likely to attend any specialty mental health visits after positive PTSD screens [adjusted odds ratios (ORs) ranged from .57 to .12, all P<.001], and veterans 75 years and older were less likely to receive any antidepressant medication (adjusted OR=.56, P<.001). CONCLUSIONS: Initiation of mental health treatment among veterans who screen positive for PTSD varies significantly by age. Further research should examine whether this is due to differences in base rates of PTSD, treatment preferences, provider responses to screens or other age-related barriers to mental health treatment.

Correlates of utilization of PTSD specialty treatment among recently diagnosed veterans at the VA.

OBJECTIVES: This study described utilization of specialty treatment for posttraumatic stress disorder (PTSD) at U.S. Department of Veterans Affairs (VA) facilities among veterans of Operation Enduring Freedom (OEF), in Afghanistan, or of Operation Iraqi Freedom (OIF), in Iraq, and non-OEF-OIF veterans recently diagnosed as having PTSD. It also identified predictors of receiving minimally adequate specialty treatment, defined as attending at least nine clinic visits within 365 days of screening positive for PTSD. METHODS: VA administrative data were obtained for 869 veterans who screened positive for PTSD between November 7, 2006, and September 30, 2008, received a diagnosis of PTSD, and visited a PTSD specialty clinic operated by the VA in the Pacific Northwest at least once within a year of screening positive. RESULTS: A total of 286 (33%) of the 852 veterans for whom complete data were available received minimally adequate specialty treatment; OEF-OIF veterans were less likely than non-OEF-OIF veterans to receive minimally adequate specialty treatment (29% versus 36%, p=.021) and attended fewer mean±SD visits to a PTSD clinic (8.2±11.4 versus 9.9±13.5, p=.045). Predictors of receiving minimally adequate specialty treatment included attending a PTSD clinic visit within 30 days of a positive screen, living in an urban location, and having psychiatric comorbidities. CONCLUSIONS: Most veterans with new PTSD diagnoses who initiated VA PTSD specialty care did not receive minimally adequate specialty treatment. Future studies should examine factors that lead to premature discontinuation of PTSD treatment and to what extent specialty treatment for PTSD is necessary.