Brian Shiner

Treatment-Seeking Barriers for Veterans of the Iraq and Afghanistan Conflicts Who Screen Positive for PTSD

OBJECTIVES Barriers associated with the decision not to seek treatment for symptoms of combat-related posttraumatic stress disorder (PTSD) were examined. METHODS Participants were 143 military men and women who served in Operation Enduring Freedom or Operation Iraqi Freedom (OEF/OIF) and who screened positive for posttraumatic stress disorder (PTSD), as assessed by the PTSD Checklist-Military Version, and who had not sought treatment for PTSD. During a cognitive-behavioral telephone intervention, participants were asked about their beliefs concerning seeking PTSD treatment. RESULTS Four categories of beliefs were associated with the decision to seek treatment, including concerns about treatment (40%), emotional readiness for treatment (35%), stigma (16%), and logistical issues (8%). CONCLUSIONS This work suggests areas for intervention efforts to minimize barriers to treatment for PTSD for OEF/OIF veterans.

Learning what matters for patients: qualitative evaluation of a health promotion program for those with serious mental illness

Sedentary lifestyle, poor dietary behaviors and metabolic alterations associated with psychiatric medications contribute to poor health and high rates of obesity among individuals with serious mental illness (SMI). Interventions that increase engagement in physical exercise, dietary modifications, lifestyle changes and preventive health care can provide health benefits across the lifespan. These interventions have led to substantial physical improvements in some persons with SMI, while others have not improved or have experienced worsening physical health. We set out to identify characteristics of a health promotion program that persons with SMI associated with physical health improvements. Interviews were conducted with eight participants from the In SHAPE health-promotion program who lost at least 10 pounds or diminished their waist circumference by at least 10 cm. Interviews aimed to determine which aspects of the program were perceived to be most helpful in promoting physical health improvement. Among successful participants, three themes emerged, highlighting the importance of: (i) individualized interventions promoting engagement in the program; (ii) relationships with health-promotion program employees and (iii) self-confidence resulting from program participation. Health-promotion programs that target these areas may have better success in achieving health benefits for persons with SMI.

Implementation of Evidence-Based Psychotherapies for Posttraumatic Stress Disorder in VA Specialty Clinics

OBJECTIVE The U.S. Department of Veterans Affairs (VA) has engaged in substantial efforts to promote the use of evidence-based psychotherapies for posttraumatic stress disorder (PTSD). The authors evaluated the effectiveness of these efforts. METHODS This study used a cross-sectional, mixed-methods evaluation of treatment provided by the VA at specialty PTSD clinics in New England during the first six months of fiscal year 2010. Natural language processing algorithms were applied to clinical notes to determine utilization of evidence-based psychotherapy (prolonged exposure therapy and cognitive-processing therapy) among patients who were newly diagnosed as having PTSD. Data regarding efforts to implement evidence-based psychotherapy and other clinic characteristics were obtained through qualitative interviews with clinical and administrative staff (N=30), and the Promoting Action on Research Implementation in Health Services framework was used to identify clinic factors associated with use of evidence-based psychotherapy. RESULTS Six percent of patients (N=1,924) received any sessions of an evidence-based psychotherapy for PTSD (median=five sessions). Several clinic factors were associated with an increased rate of implementation, including prior experience with use of the treatments, customization of training, and prolonged contact with the implementation and training team. Facilitation with broad training goals and clinics with highly organized systems of care were negatively associated with implementation. CONCLUSIONS Few patients with PTSD received evidence-based psychotherapy for PTSD during their first six months of treatment at a VA specialty PTSD clinic. The implementation framework poorly predicted factors associated with uptake of evidence-based psychotherapy. These results suggest that additional research is needed to understand implementation of evidence-based therapy in mental health settings.

Outcomes of a quality improvement project integrating mental health into primary care

Objective: Depression is commonly seen, but infrequently adequately treated, in primary care clinics. Improving access to depression care in primary care clinics has improved outcomes in clinical trials; however, these interventions are largely unstudied in clinical settings. This study examined the effectiveness of a quality improvement project improving access to mental healthcare in a large primary care clinic. Methods: A before–after study evaluating the efficacy of the integration of a primary mental healthcare (PMHC) clinic into a large primary care clinic at the White River Junction, Vermont Veterans Affairs Medical Center (VAMC). In the before period (2003), a traditional referral and schedule model was used to access mental healthcare services. Patients who had screened positive for depression using a depression screen for 6 months after entry into either model were retrospectively followed. VA clinics without a PMHC were used as a control. The proportion of patients who received any depression treatment and guideline-adhering depression treatment in each model was compared, as well as the volume of patients seen in mental health clinics and the wait time to be seen by mental health personnel. Results: 383 and 287 patients screened positive for depression at VAMC and the community-based outreach clinic, respectively. Demographics of the before and after cohorts did not differ. The PMHC model was associated with a greater proportion of patients who had screened positive for depression obtaining some depression treatment (52.3% vs 37.8%; p<0.001), an increase in guideline-adherent depression treatment for depression (11% vs 1%; p<0.001). Conclusions: Implementation of the PMHC model was associated with more rapid and improved treatment for depression in the population of patients who screened positive for depression. More widespread implementation of this model should be investigated.

It Is Time to Address the Crisis in the Pharmacotherapy of Posttraumatic Stress Disorder: A Consensus Statement of the PTSD Psychopharmacology Working Group

There is an urgent need to address a critical lack of advancement in the psychopharmacologic treatment of posttraumatic stress disorder (PTSD). The clinical, social, and financial burden of ineffectively treated PTSD is enormous (1–6). The impact of PTSD morbidity and mortality is further magnified by its substantial disruptions in family, workplace, and societal contexts (7). For the Department of Veterans Affairs (VA) and Department of Defense (DoD), i.e., institutions that are vehicles for the expression of the national debt to military personnel who developed PTSD as a consequence of their military service, the need to help these people has taken on significant priority. One in 10 VA healthcare users have the diagnosis of PTSD, which includes one in four treatment-seeking veterans of the recent wars in Iraq and Afghanistan (8). The prevalence of PTSD in the general population for lifetime is approximately 8% (8) and just under 4% for the current year, making it the fifth most prevalent mental disorder in the United States (9–11). Despite this high prevalence and costly impact, there seems to be no visible horizon for advancements in medications that treat symptoms or enhance outcomes in persons with a diagnosis of PTSD. The nature of this PTSD pharmacotherapy crisis is threefold. First, there are only two medications currently approved for the treatment of PTSD by the U.S. Food and Drug Administration (FDA), sertraline (Zoloft) and paroxetine (Paxil). These medications are helpful but are believed to work via the same mechanism of action (12), and both produce reduction in symptom severity rather than remission of PTSD symptoms (13,14). This efficacy gap may be particularly great for patients treated in VA settings (13). Second, the limited efficacy of the FDA-approved treatments for PTSD has necessitated polypharmacy for the vast majority of patients treated. These offlabel medications, as monotherapy or in combination with other medications, have not been studied adequately for the treatment of PTSD. Therefore, most patients are treated with medications or combinations for which there is little empirical guidance regarding benefits and risks. Third, research and development of new medications for the treatment of PTSD has stalled and there is a void in new drug development. There has not been a medication approved for the treatment of PTSD since 2001, despite the significant need. In a survey of ClinicalTrials.gov, there were few pharmaceutical industrysponsored clinical trials for PTSD that have enrolled patients since 2006: one Phase III clinical trial, four Phase II clinical trials, and no Phase I clinical trials (see The Limited Research Portfolio, below). There is no doubt that there is a deficient pipeline of new PTSD medications and it is uncertain about how to best identify new targets for medication development. Even if there were a more robust investment in PTSD research, questions would remain regarding the optimal design for these studies. The past decade of investments from VA and other

Inclusion and exclusion criteria in randomized controlled trials of psychotherapy for PTSD.

Objective. Posttraumatic stress disorder (PTSD) is a prevalent and often disabling condition. Fortunately, effective psychological treatments for PTSD are available. However, research indicates that these treatments may be underutilized in clinical practice. One reason for this underutilization may be clinicians’ unwarranted exclusion of patients from these treatments based on their understanding of exclusion criteria used in clinical trials of psychological treatments for PTSD. There is no comprehensive and up-to-date review of inclusion and exclusion criteria used in randomized clinical trials (RCTs) of psychological treatments for PTSD. Therefore, our objective was to better understand how patients were excluded from such RCTs in order to provide guidance to clinicians regarding clinical populations likely to benefit from these treatments. Methods. We conducted a comprehensive literature review of RCTs of psychological treatments for PTSD from January 1, 1980 through April 1, 2012. We categorized these clinical trials according to the types of psychotherapy discussed in the major guidelines for treatment of PTSD and reviewed all treatments that were studied in at least two RCTs (N=64 published studies with 75 intervention arms since some studies compared two or more interventions). We abstracted and tabulated information concerning exclusion criteria for each type of psychotherapy for PTSD. Results. We identified multiple RCTs of cognitive behavioral therapy (n=56), eye movement desensitization and reprocessing (n=11), and group psychotherapy (n=8) for PTSD. The most common exclusions were psychosis, substance abuse and dependence, bipolar disorder, and suicidal ideation. Clinical trials varied in how stringently these criteria were applied. It is important to note that no exclusion criterion was used in all studies and there was at least one study of each type of therapy that included patients from each of the commonly excluded groups. A paucity of evidence exists concerning the treatment of patients with PTSD and four comorbidities: alcohol and substance abuse or dependence with current use, current psychosis, current mania, and suicidal ideation with current intent. Conclusions. Psychological treatments for PTSD have been studied in broad and representative clinical populations. It appears that more liberal use of these treatments regardless of comorbidities is warranted. (Journal of Psychiatric Practice 2014;20:25–37)

Automated classification of psychotherapy note text: implications for quality assessment in PTSD care.

In recent years, studies have attempted to use various methods to characterize the quality of care for post-traumatic stress disorder (PTSD) delivered in United States Veterans Administration (VA) outpatient clinics. Dieperink et al. used manual chart review to characterize care for 150 veterans at three VA medical centres during the 2001 fiscal year [1]. They found wide variation in the types of social services, psychotherapy and pharmacotherapy received in the 6 months following entry into specialized PTSD programmes. For example, clinics in Minneapolis and Memphis tended to provide pharmacotherapy while clinics in Boston tended to provide psychotherapy. As a result, there was wide variation in the amount of care received; veterans in Minneapolis received an average of seven mental health contacts per year (visits with a psychiatrist, psychologist, social worker or other mental health practitioner) while veterans in Boston received an average of 16 mental health contacts per year. Although it was not clear which approach was superior, it was clear that PTSD care was not standardized among the three VA facilities. In order to include more sites and be able to generalize across sites, further studies on the quality of care for PTSD in the VA have attempted to use national administrative data rather than chart review to capture information about the process of care. This work has relied on a combination of Current Procedural Technology (CPT) codes, International Classification of Diseases, Ninth Revision (ICD-9) codes, and pharmacy data. Cully et al. used administrative data to examine the receipt of psychotherapy in the VA nationally for the 12 months following initial diagnoses of PTSD, anxiety and depression in the 2004 fiscal year [2]. While the 77 743 veterans with new diagnoses of PTSD had a higher chance of receiving psychotherapy than veterans with anxiety or depression, the amount of psychotherapy was still very low; only 10% received an adequate number of sessions (defined as eight in this study), and the median wait to start psychotherapy was 50 days. Two studies using similar methods were published in 2010. Using stricter inclusion criteria, Spoont et al. examined care for 20 284 veterans with a new diagnosis of PTSD from the 2004 mid-fiscal year through the 2005 mid-fiscal year [3]. They evaluated whether veterans received a large enough medication supply that they could have gotten an adequate trial of pharmacotherapy or whether they received enough psychotherapy visits that they could have received an adequate trial of psychotherapy (defined, again, as eight visits). Based on this resource utilization, they concluded that, at most 33%, of veterans could have received an adequate trial of evidence-based treatment for PTSD. Seal et al. examined all mental health visits over the year following a new PTSD diagnosis in veterans returning from Iraq and Afghanistan [4]. The study included 49 425 veterans enrolling in VA care from the 2002 mid-fiscal year through the 2008 mid-fiscal year. They asserted that delivery of evidence-based psychotherapies endorsed in the VA Mental Health Uniformed Services Package [5] (prolonged exposure [6] and cognitive processing therapy [7]) required at least nine sessions over 15 weeks and found that only 9.5% received this level of service. A key limitation in these three studies is that they tell us only the best possible scenario about the amount of psychotherapy that could have been delivered based on the number of visits – we do not know whether veterans actually received psychotherapy during these visits. Therefore, it is possible that these studies overestimate the amount of psychotherapy actually delivered to veterans with PTSD. Researchers and policy makers wishing to understand care delivery for PTSD are left with a dilemma. Manual medical record review can generate detailed information about clinical processes, including psychotherapists’ reports of the specific techniques they used in a session. However, the method is time-consuming and difficult to apply on a large scale. Administrative review techniques are applicable on a large scale, but are limited in the granularity of the information they provide. We learn how much of a given service practitioners report providing, but because we do not read the notes, we have little information about the content of those services. Automated text-based information retrieval technologies, such as natural language processing (NLP) have the potential to bridge this gap by extracting detailed information found in a medical record review on the larger scale permitted by administrative review. NLP is an effort to have computers draw specific information from free text. The application of NLP has traditionally been limited by the need to customize programming for each new application. However, modern NLP applications can use a technique known as machine learning to ‘teach’ a computer to recognize patterns in documents [8,9]. Through the recognition of language patterns within a document the NLP application can help users make inferences about the content of the text. We sought to understand whether using administrative data to determine the number of psychotherapy sessions veterans receive is equivalent to manual medical records review. We thought it was possible that psychotherapy billing codes might sometimes be misapplied to other services delivered by psychotherapy-oriented practitioners, such as psychologists and social workers. These might include intakes, psychological testing and case management. Alternatively, administrative data review might be accurate, making manual or automated review of note text an unnecessary method. Our primary hypothesis was that administrative data overestimates the number of psychotherapy sessions delivered to veterans when compared to manual chart review (as some sessions administratively coded as psychotherapy are actually used for other purposes). Our secondary hypothesis was that if administrative data review was inaccurate, our manual medical record review could be approximated using an automated NLP programme, creating the potential for a more accurate method to be efficiently applied to large-scale treatment studies.

Access to VA Services for Returning Veterans With PTSD

OBJECTIVE In order to understand access to treatment services for post-traumatic stress disorder (PTSD) in the Veterans Health Administration (VHA), we reviewed existing literature to estimate the proportion of Iraq and Afghanistan veterans who have used VHA services. METHODS We reviewed studies regarding the prevalence of PTSD among Iraq and Afghanistan War veterans to estimate the need for treatment. We then compared need to Veterans Affairs utilization in order to estimate the proportion accessing care. RESULTS Access to VHA services is high, with 58% of the estimated population of Iraq and Afghanistan veterans accessing some PTSD-related service. However, there is insufficient information about the quality of these services. CONCLUSIONS The Veterans Affairs has been successful in providing access to treatment services for Iraq and Afghanistan Veterans with PTSD. Additional studies are needed to further characterize the quality of services provided.

Clinicians’ Perception of Patient Readiness for Treatment: An Emerging Theme in Implementation Science?

Despite a training program to help veterans administration (VA) clinicians implement evidence-based psychotherapies (EBPs) for posttraumatic stress disorder (PTSD), uptake has been limited. To understand clinicians’ implementation challenges, we performed thematic analysis of semi-structured telephone interviews guided by the Promoting Action on Research Implementation in Health Services framework. Our sample included 22 psychotherapists in VA PTSD clinics in one region. We identified a theme not captured by our implementation framework: clinicians’ perceptions about their patients’ readiness for treatment. Clinician perception of patient readiness may be important to the uptake of EBPs and should be considered in mental health implementation work.

Examination of the effectiveness of the Mental Health Environment of Care Checklist in reducing suicide on inpatient mental health units.

CONTEXT Suicide is one of the leading causes of death in the United States. While suicides occurring during psychiatric hospitalization represent a very small proportion of the total number of suicides, these events are highly preventable owing to the controlled nature of the environment. Many methods have been proposed, but no interventions have been tested. OBJECTIVE To evaluate the effect of identification and abatement of hazards on inpatient suicides in the Veterans Health Administration (VHA). DESIGN, SETTING, AND PATIENTS The effect of implementation of a checklist (the Mental Health Environment of Care Checklist) and abatement process designed to remove suicide hazards from inpatient mental health units in all VHA hospitals was examined by measuring change in the rate of suicides before and after the intervention. INTERVENTION Implementation of the Mental Health Environment of Care Checklist. MAIN OUTCOME MEASURE The number of completed suicides on inpatient mental health units in VHA hospitals. RESULTS Implementation of the Mental Health Environment of Care Checklist was associated with a reduction in the rate of completed inpatient suicide in VHA hospitals nationally. This reduction remained present when controlling for number of admissions (2.64 per 100 000 admissions before to 0.87 per 100 000 admissions after implementation; P < .001) and bed days of care (2.08 per 1 million bed days before to 0.79 per 1 million bed days after implementation; P < .001). CONCLUSIONS Use of the Mental Health Environment of Care Checklist was associated with a substantial reduction in the inpatient suicide rate occurring on VHA mental health units. Use of the checklist in non-VHA hospitals may be warranted.