Improving Healthcare for Veterans with PTSD
June is National PSTD Awareness Month. Post-traumatic stress disorder (PTSD) is a mental health problem that some people develop after experiencing or witnessing a life-threatening event, like combat, a natural disaster, a car accident, or sexual assault. The lifetime prevalence of post-traumatic stress disorder (PTSD) among the US population is 6%, which includes 8% of women and 4% of men. Among Veterans, the percentage of Veterans with PTSD varies by their service era:
- In a given year, approximately 11-20 out of every 100 Veterans (or between 11-20%) who served in Operations Iraqi Freedom (OIF) and Enduring Freedom (OEF) have PTSD.
- About 12 out of every 100 Gulf War Veterans (or 12%) have PTSD in a given year.
- It is estimated that approximately 30 out of every 100 (or 30%) Veterans who served in Vietnam have had PTSD in their lifetime.
Another cause of PTSD in the military can be military sexual trauma (MST). Of women who served in the military, 23% reported sexual assault and 55% of women and 38% of men experienced sexual harassment.1 In addition, one in four children exposed to trauma will develop PTSD by the age of 18. The odds of self-harm are 8 times higher in children with PTSD compared to those without PTSD, and the odds of suicide are 10 times higher.2
HSR&D Research on PTSD
HSR&D conducts a variety of research on PTSD – from studies on enhancing social support for Veterans with PTSD to optimizing treatment response in VA specialized intensive/inpatient PTSD program to promoting Veteran engagement in PTSD care, to name a few. The Research to Impact for VeteRans (RIVRs) program is a new HSR&D funding mechanism that gives researchers the opportunity to pursue a five-year impact goal. Each RIVR impact goal aligns with VA priority areas including PTSD. For example, Dr. Jeffrey Pyne, an investigator with HSR&D’s Center for Mental Healthcare and Outcomes Research (CeMHOR), is conducting a study with the goal of increasing rates of initiation and engagement in care for Veterans who have screening positive for PTSD and/or problem alcohol use in VA primary care. Investigators will identify barriers associated with the Veteran’s preferred mental health treatment and address them using a peer specialist (PS)-delivered treatment initiation and engagement intervention. Should it be shown to be effective, investigators will develop a toolkit to help scale up this intervention and will work with Peer Services leadership in VA’s Office of Mental Health and Suicide Prevention to add a community track for its advancement.
Another RIVR project funded by HSR&D and led by Dr. Nina Sayer, an investigator with HSR&D’s Center for Care Delivery and Outcomes Research (CCDOR), will measure and improve the reach of evidence-based psychotherapies (EBPs) for PTSD in collaboration with the Office of Mental Health and Suicide Prevention and VA’s National Center for PTSD. The project’s five-year goal is to increase the level of reach of evidence-based practices (EBPSs) for Veterans with PTSD nationally – and to reduce the number of VA PTSD clinics with low rates of EBP utilization for PTSD.
HSR&D’s Quality Enhancement Research Initiative (QUERI)
QUERI supports five programs that focus on mental health and suicide prevention as investigators work to advance optimal therapies for Veterans with PTSD. For example, the Virtual Care QUERI program is evaluating the effectiveness of more and less intensive (and expensive) implementation strategies for PTSD telemental health services, a mobile app supporting a treatment called “prolonged exposure” therapy for PTSD, and improved information exchange between VA and community care.
The following are just a few more HSR&D-funded research projects dedicated to the health and care of Veterans with PTSD.
PTSD-Multimorbidity Predicts Poor Social Functioning, Increasing Risk for Suicidal Ideation
A growing body of literature suggests that problems experienced by Veterans during their transition from military to civilian life confer significant risk for suicidal ideation. One of these problems is PTSD, which, along with chronic pain and sleep disturbance, can increase risk for suicidal ideation. Using longitudinal data on the self-reported disorders of 5,461 trauma-exposed Veterans from The Veterans Metrics Initiative Study, investigators in this HSR&D funded study assessed: 1) the extent to which PTSD co-occurs with sleep disturbance and chronic pain (PTSD-multimorbidity); 2) the impact of PTSD-multimorbidity on later social functioning and suicidal ideation; and 3) the extent to which social functioning mediates the impact of PTSD-multimorbidity on suicidal ideation.
At approximately 15 months post-separation, almost 91% of Veterans with probable PTSD also reported sleep disturbance and/or chronic pain. Relative to Veterans without probable PTSD, Veterans with all three conditions (n = 907) experienced the poorest social functioning and had greater risk for suicidal ideation. The impact of PTSD-multimorbidity on risk for suicidal ideation was partially explained by its negative effect on social functioning.
Findings from this study indicate that clinicians treating post-9/11 Veterans with PTSD should also assess co-occurring chronic pain and sleep disturbance and their impact on functioning. Further, given the additional risk for suicidal ideation associated with poor social functioning, clinicians should be mindful to not only support Veterans' efforts to seek social support, but also to monitor the quality of support received and integrate social functioning aims into treatment planning.
Shor R, Borowski S, Zelkowitz R, et al. The transition to civilian life: Impact of comorbid PTSD, chronic pain, and sleep disturbance on Veterans’ social functioning and suicidal ideation. Psychological Trauma: Theory, Research, Practice, and Policy. June 2, 2022; online ahead of print.
Study Shows High Economic Burden of PTSD
PTSD is associated with an increased risk of substance use disorder, disability, unemployment, and premature mortality, all of which contribute to a substantial clinical burden. PTSD also is associated with a substantial economic burden. However, there is limited literature describing the total economic burden of PTSD in the United States. Led by an HSR&D investigator, this study sought to estimate the economic burden of PTSD in the U.S. civilian and military (i.e., military and Veterans) populations from a societal perspective. Investigators used insurance claims data, academic literature, and governmental publications to estimate the total excess costs of PTSD in 2018. They also assessed direct healthcare costs (pharmacy and medical), direct non-healthcare costs (substance use, homelessness, disability, psychotherapy), and indirect costs (unemployment, productivity loss, premature mortality).
Results of this study show that the economic burden of PTSD goes beyond direct healthcare costs and has been found to rival costs for other expensive mental health conditions. The total excess economic burden of PTSD in the US was estimated at $232 billion for 2018 ($19,630 per individual with PTSD). A larger proportion of total excess costs was attributed to the civilian population ($190 billion, or 82%) than the military/Veteran population ($43 billion, or 18%). However, excess costs per individual with PTSD are lower for the civilian population ($18,640) than the military/Veteran population ($25,684).
Moreover, in the military/Veteran population, the annual all-cause mortality rate for those with PTSD was estimated to be 80% higher than those without PTSD, resulting in estimated excess costs of $1 billion annually.
Findings warrant an increased awareness of PTSD and expansion of evidence-based interventions.
Davis L, Schein J, Cloutier M, et al. The economic burden of post-traumatic stress disorder in the United States from a societal perspective. Journal of Clinical Psychiatry. April 25, 2022;83(3).
VA Screening Tool for PTSD is Accurate and Acceptable
To ensure that individuals with PTSD are identified and provided with appropriate treatment services, in the VA system and in other settings, PTSD screening is conducted in primary care clinics because individuals with mental health symptoms are more likely to initially seek medical care. Thus, VA uses the Primary Care PTSD Screen (PC-PTSD) – a questionnaire designed for use in a primary care setting, which is based on criteria in the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition). In 2013, the American Psychiatric Association presented revised PTSD diagnostic criteria in the DSM Fifth Edition (DSM-5). The PC-PTSD screen was then revised as the PC-PTSD-5 to reflect DSM-5 criteria. This HSR&D-funded study sought to determine whether the PC-PTSD-5 is a diagnostically accurate and acceptable measure for use in VA primary care clinics. Investigators enrolled Veterans (n=396, of which 333 were male) from two VA medical centers, who were screened using the PC-PTSD-5 and then interviewed using a well-validated, structured diagnostic interview for PTSD. Investigators then examined the accuracy of the PC-PTSD-5 against the diagnostic interview.
The PC-PTSD-5 is an accurate and acceptable screening tool for use in VA primary care settings. Further, most Veterans felt comfortable completing the screening, with a preference for administration by the individual’s own primary care practitioner.
The PC-PTSD-5 has demonstrated utility in screening for PTSD in VA primary care settings. The prevalence of PTSD among patients seeking primary care –15% of men and 29% of women in this study cohort – underscores the importance of screening.
Bovin M, Kimerling R, Weathers F, et al. Diagnostic accuracy and acceptability of the primary care post-traumatic stress disorder screen for the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) among US Veterans. JAMA Network Open. February 4, 2020;4(2).
Approximately 1 in 10 Veterans have PTSD and most (80% or more) do not receive first-line treatments – evidence-based psychotherapies – despite significant VA investment to increase access to these treatments. Clinicians often struggle to engage Veterans in evidence-based psychotherapies because they can be emotionally challenging treatments. Engagement could be catalyzed by mental health providers integrated into primary care (i.e., VA’s Primary Care-Mental Health Integration, or PC-MHI) to maximize the reach of engagement efforts beyond specialty PTSD settings. Shared decision-making, a process by which the patient and provider collaboratively discuss treatment options, may address patient and provider barriers to evidence-based psychotherapies. However, no study has tested a full shared decision-making intervention for primary care patients with PTSD.
Led by Jessica Chen, PhD, an investigator with HSR&D’s Denver/Seattle Center of Innovation for Veteran-Centered & Value-Driven Care, this study developed and refined a shared decision-making intervention for PTSD—Patient Readiness for Improvement through Motivation, Engagement, and Decision-making (PRIMED)—using input from Veterans with diverse perspectives, PC-MHI providers, and VA operational partners to better optimize integration of shared decision-making into routine clinical care. Dr. Chen conducted qualitative interviews with Veterans diagnosed with PTSD, oversampling women and racial/ethnic minorities to refine the PRIMED intervention and center inclusive practices. Using human-centered design, her team developed an electronic health record template to guide PC-MHI providers through the steps of the PRIMED intervention, which prioritizes education about evidence-based treatments that are supported by VA clinical practice guidelines.
VA primary care patients with PTSD described having collaborative experiences with PC-MHI providers when initiating PTSD treatment. They reported that their providers presented treatment options, listened to patient preferences, and shared agency and decision-making power to allow patients to decide to what do next. An emergent theme was Veterans’ beliefs that PTSD is a lifelong condition and how such beliefs serve as a barrier pursuing evidence-based treatment. Most Veterans expressed skepticism that they would no longer have PTSD after participating in an evidence-based psychotherapy, which caused them to question the validity of these treatments. Based on these findings, Dr. Chen and her team plan to develop guidance for VA mental health clinicians regarding encouraging vs. discouraging language for discussing PTSD treatment options.
In addition, investigators created a clinical documentation template that incorporates shared decision-making (SDM) into the initial intake appointment conducted by PC-MHI providers. Their analysis of the initial PC-MHI visit identified areas where SDM can happen naturally while also highlighting barriers: clinician’s lack of understanding of SDM and lack of time available for patient discussion (maximum 3-4 minutes). The visit template marries the requirements of the PC-MHI assessment with SDM goals and guides clinicians toward a patient-centered conversation about treatment options. The template was developed with PC-MHI clinicians and has been added to the CPRS (computerized patient record system) catalog for general use. Adaptations will be made for Cerner.
Dr. Chen seeks to work with operational partners to deploy the PRIMED electronic health record template in PC-MHI clinics and evaluate the impact of PRIMED on treatment engagement and clinical outcomes, with a goal of increasing the use of first-line PTSD treatments and improving the quality of life for Veterans with PTSD.
Chen JA, Matson TE, Lehavot K, et al. Provider perspectives on implementing shared decision making for PTSD treatment in VA primary care. Administration and Policy in Mental Health. 2021;48(6):1046-1054.
Chen JA, Jakupcak M, McCann R, et al. Posttraumatic stress disorder collaborative care: A quality improvement study in Veterans Affairs primary care. Families, Systems & Health. 2021;39(2):198-211.
Evidence-based psychotherapies, such as Prolonged Exposure (PE), result in clinically significant symptom relief for many, yet adherence to these treatments (i.e., session attendance and homework compliance) can be poor. Engaging families in Veterans' treatment may provide a powerful method for promoting EBP adherence. The goal of this ongoing study (September 2017 to June 2022) is to evaluate the effectiveness of improving family support as a tool to improve Veterans' EBP adherence.
Led by Laura Meis, PhD, an investigator with HSR&D’s Center for Care Delivery and Outcomes Research (CCDOR), this ongoing randomized controlled trial is comparing Veteran adherence to PE with and without family attendance at PE's educational sessions. Investigators also will work to identify facilitators and barriers to family involvement in PE within VA. Study participants include Veterans with clinically significant symptoms of PTSD, plus a family member or friend of the Veteran. Primary outcomes to be examined include session attendance and therapist ratings of homework compliance. Secondary outcomes include treatment satisfaction, relationship functioning, quality of life, and PTSD severity measured before and after treatment. Key social influences, targeted by family-involvement strategies, are being assessed through brief weekly self-reports.
If effective, this approach could help resolve national calls for routine inclusion of family involvement in PTSD treatment. Once demonstrated for PTSD, these strategies could be used for other conditions and problems relevant to Veteran populations (i.e., suicide prevention, traumatic brain injury rehabilitation) and stimulate shifts across practice and policy to improve the involvement of families in care.
Meis L, Glynn S, Spoont M, et al. Can families help Veterans get more from PTSD treatment? A randomized clinical trial examining Prolonged Exposure with and without family involvement. Trials. 2022 Mar 30; 23(1):243
- VA’s National Center for PTSD. How common is PTSD in adults?
- Danese A, McLaughlin K, Samara M, and Stover C. Psychopathology in children exposed to trauma: Detection and intervention needed to reduce downstream burden. British Medical Journal. November 19, 2020;m3073.