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2023 HSR&D/QUERI National Conference Abstract

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1071 — Results from a Pragmatic Randomized Clinical Trial of Clinician Supported PTSD Coach in VA Primary Care Patients

Lead/Presenter: Kyle Possemato,  VA Center for Integrated Healthcare
All Authors: Possemato K (VA Center for Integrated Healthcare), Johnson EM (VA Center for Integrated Healthcare, Syracuse) Barrie, K (VA Center for Integrated Healthcare, Syracuse) Puran, D (National Center for PTSD, Palo Alto) Ghaus, S (National Center for PTSD, Palo Alto) Rosen, C (National Center for PTSD, Palo Alto & Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine) Cloitre, M ((National Center for PTSD, Palo Alto & Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine) Owen, J (National Center for PTSD, Palo Alto) Jain, S (National Center for PTSD, Palo Alto & Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine) Beehler, G (VA Center for Integrated Healthcare, Syracuse) Prins, A (National Center for PTSD, Palo Alto) Seal, K (San Francisco VA Health Care System & Departments of Medicine and Psychiatry, U of California, San Francisco) Kuhn, E (National Center for PTSD, Palo Alto & Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine)

Objectives:
PTSD is common in VA primary care patients; however, evidence-based treatments are typically only offered in specialty mental health settings and often not accessed by Veterans due to patient and system-level barriers. This study tested whether a brief, scalable treatment in primary care increased access to effective PTSD treatment. Clinician Supported PTSD Coach (CS PTSD Coach) was designed to be implemented in VA’s Primary Care Mental Health Integration (PCMHI) system and combines mental health clinician support with the widely used “PTSD Coach” VA mobile app. We hypothesized that CS PTSD Coach would be superior to PCMHI Treatment as Usual (TAU) in 1) reducing PTSD (measured by clinician-rated and self-report assessments), 2) engaging Veterans in initial and continued mental health care (measured by engagement in two sessions of specialty care post-study intervention) and 3) patient satisfaction with care.

Methods:
A multi-site randomized pragmatic clinical trial of CS PTSD Coach vs. PCMHI TAU enrolled a diverse sample of 233 Veterans with PTSD who were not currently accessing PTSD treatment. CS PTSD Coach is intended to be delivered in four 30-minute sessions and encourages daily use of symptom management strategies guided by the app. CS PTSD Coach was designed to match patient preferences for a flexible approach that can be delivered in person or virtually, and respects Veterans’ desire for self-reliance. It uses the VHA stepped-care model: Veterans who continue to have PTSD symptoms (PTSD Checklist-5 [PCL-5] ? 33) after 4 sessions are offered facilitated referrals to specialty mental health services. Outcomes were measured at 2 (post-treatment), 4, and 6 months.

Results:
Clinician-rated PTSD symptoms did not significantly differ by condition at post-treatment. However, Veterans randomized to CS PTSD Coach were more likely to 1) drop below 33 on the PCL-5 (Coach 41%, TAU 26%, p = .014), 2) have larger decreases in patient-reported PTSD symptoms at post-treatment (Coach M[SD] = 9.9 [12.8] points, TAU M[SD] = 6.5 points, p < . 05) and 3) maintain symptom gains though 6-month follow-up compared to PCMHI TAU. Veterans randomized to CS PTSD Coach were more likely to access mental health care during the intervention period (p = .019) and continued to have more engagement in care than TAU in the follow-up period (p < .001). Among participants who continued to have significant symptoms of PTSD at post-treatment, 36% of CS PTSD Coach participants and 25% of TAU participants engaged in two specialty mental health care visits post study intervention (p = .097). Patients reported significantly higher treatment satisfaction with CS PTSD Coach than TAU (p < .001).

Implications:
A structured 4-session intervention that matches Veteran preferences for care resulted in high patient satisfaction, better initial and continued mental health access and more self-reported symptom relief but not a larger reduction in clinician-rated PTSD symptoms compared to treatment as usual.

Impacts:
Brief mental health interventions for PTSD can be provided in VA primary care. Clinician Supported PTSD Coach results in greater patient-report PTSD symptom relief and more engagement in mental health care than PCMHI Treatment as Usual.