Talk to the Veterans Crisis Line now
U.S. flag
An official website of the United States government

Health Services Research & Development

Go to the ORD website
Go to the QUERI website
HSRD Conference Logo



2023 HSR&D/QUERI National Conference Abstract

Printable View

1135 — Advancing Health Equity by Understanding Race and Other Factors Associated with PTSD Symptom Improvement Following Evidence-Based Psychotherapy

Lead/Presenter: Shira Maguen,  San Francisco VA Heath Care System
All Authors: Maguen S (San Francisco VA Health Care System and University of California, San Francisco), Batten AJ (San Francisco VA Health Care System), Hubbard A (San Francisco VA Health Care System and University of California, San Francisco), Holder N (San Francisco VA Health Care System and University of California, San Francisco), Burkman K (San Francisco VA Health Care System and University of California, San Francisco), Cottonham DP (San Francisco VA Health Care System and University of California, San Francisco), Purcell N (San Francisco VA Health Care System and University of California, San Francisco), Mehlman H (San Francisco VA Health Care System and University of California, San Francisco), Shiner B (White River Junction VA Medical Center and Geisel School of Medicine at Dartmouth College)

Objectives:
Several VHA studies have found that Black Veterans demonstrate less posttraumatic stress disorder (PTSD) symptom improvement than their White counterparts following PTSD evidence-based psychotherapies (EBPs; e.g., Maguen et al., 2020; Lamp et al., 2019). We aimed to understand this disparity among Veterans receiving EBPs by identifying associated demographic, clinical, and service utilization factors.

Methods:
Using retrospective analysis of VHA electronic health records, we identified Iraq and Afghanistan War Veterans who had a post-deployment PTSD diagnosis from 1/1/08 to 7/1/19, initiated a PTSD EBP, and completed a PTSD symptom checklist pre- and post-EBP (N = 21,751). Demographics, clinical data , and service utilization variables were obtained from the Corporate Data Warehouse. We used hierarchical Bayesian logistic regression to model the probability of PTSD symptom improvement, using a minimum of 10-point improvement on a PTSD symptom measure as marker of clinically relevant change. We adjusted for demographic and military variables (age, gender, marital status, military branch, rank, number of tours, and military component). We also examined rurality, comorbid mental health diagnoses (anxiety, bipolar disorder, depression, substance use disorders, TBI, and schizophrenia/psychosis), military sexual trauma, smoking status, and suicide ideation/attempt. We included clinical utilization measures predicted to impact EBP improvement: psychotherapy visits prior to first EBP, the number of days from the first mental health visit post-discharge to the first EBP, the number of visits to a PTSD clinic, PTSD medication, location of EBP visit (e.g., PTSD clinic, inpatient, etc.), whether the EBP was received in a group or individual setting, the total number of EBP visits, the average time between EBP visits, the type of treatment on the first EBP visit (Prolonged Exposure Therapy [PE] or Cognitive Processing Therapy), and number of EBP visits within 16 weeks of the first EBP visit. Each utilization variable was also examined as an interaction term with Black race.

Results:
Black race was associated with less PTSD improvement, as was male gender, PTSD medication receipt, TBI, and EBP in group therapy format (vs. individual therapy). Factors associated with PTSD improvement included PE receipt, EBP treatment density (within 16 weeks), Reserves (vs. active duty), and comorbid substance disorder diagnosis.

Implications:
Black Veterans continue to evidence disparities in PTSD EBP improvement, and disparities cannot be explained by service utilization differences (e.g., EBP engagement, dropout). Consequently, it is important to conduct mixed methods research to better understand these disparities. Understanding experiences that impact Black Veterans, such as race-based trauma and the impact of ongoing racism and discrimination, is critical so that we can provide Black Veterans with the most effective care for PTSD and related traumas.

Impacts:
Health services, patient characteristics, and clinical factors only moderately attenuate the disparities in PTSD improvement experienced by Black Veterans. Qualitative studies are needed to understand the impact of race-based trauma, discrimination, and other experiences that may differentially impact Black Veterans. Other modifiable factors can assist with PTSD symptom improvement, including provision of PTSD EBPs in an individual (vs. group) format as well as attending to EBP treatment density (completing treatment in 16 weeks).