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Health Services Research & Development

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HSR&D In Progress

March 2022

In This Issue: HSR&D Research on Social Determinants
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Enhancing Social Support to Improve Treatment Outcomes among Veterans with PTSD

Feature Article


Takeaway: There is a need for additional brief, primary care-based treatments for PTSD that also work to improve social support in traumatized Veterans. This study is expected to, in part, result in a protocol for routinely measuring social support to inform treatment, which will likely improve Veterans’ mental health and social relationships.


PTSD is a significant problem for Veterans, most of whom are initially treated for the disorder in VA’s Primary Care Mental Health Integration (PCMHI). Poor social support in this population is a risk factor for suicidal ideation, all-cause mortality, and worse treatment engagement and response. Preliminary research shows that approximately 60% of Veterans with PTSD present to specialty care intake appointments with poor social support. However, none of the existing PCMHI-based treatments for PTSD explicitly focus on social support generation or reengagement. Moreover, although the limited existing research suggests that the routine assessment of social support to guide treatment planning (also known as measurement-based care, or MBC) improves treatment outcomes in civilian populations, social support is not routinely monitored as part of evidence-based treatments for PTSD.

Primary Care Mental Health Integration (PC-MHI) refers to a set of mental and behavioral healthcare services that are provided to Veterans in collaboration with primary care providers.

This ongoing study (October 2020 – September 2025) will first identify an appropriate instrument for routinely measuring social support in the context of clinical care to improve PTSD treatment, and, subsequently, will evaluate a novel PCMHI-based PTSD treatment as part of a stepped-care model for Veterans who report poor social support and are at greater risk of PTSD treatment non-response. Specifically, study investigators will:

  • Select an instrument for measurement-based care of social support in clinical settings for Veterans with PTSD;
  • Pilot test a brief, PCMHI-based behavioral activation and social engagement intervention for PTSD based on key stakeholder (e.g., Veteran and PCMHI provider) feedback; and
  • Conduct a randomized clinical trial comparing the intervention to usual care in PCMHI.

Methods

Investigators will use quantitative data gathered in an online survey of Veterans to assess the degree to which five measures of social support (identified via systematic review and clinical utility ranking) are acceptable, reliable, and sensitive. They also will conduct qualitative interviews with key stakeholders to obtain data on participant acceptability, provider fidelity, and social-support-related measurement-based care. The pilot randomized controlled trial comparing the social support and PTSD intervention to usual care will evaluate the feasibility and acceptability of recruitment, randomization, intervention engagement, evaluation strategy, and outcome measurement of clinical outcomes (e.g., PTSD, depression symptoms, and social support), as well as mechanisms of change (e.g., disclosure) and multiple stepped-care outcomes (e.g., clinically indicated, evidence-based psychotherapy initiation and/or retention). 

Findings

To date, 303 Veterans have completed a national survey to obtain preliminary psychometric data on five social support instruments. All instruments demonstrated sound psychometric properties. The NIH PROMIS® social support short forms were preferred by Veterans who expressed a preference among the instruments. Preliminary qualitative interviews among racially- and gender-diverse PCMHI providers revealed: 1) favorable impressions of measurement-based care of social support in the context of treating PTSD as a “patient-centered” approach, and 2) behavioral activation and social engagement as “the ultimate goal of successful PTSD treatment.”

Created by the National Institutes of Health (NIH), the Patient-Reported Outcomes Measurement Information System (PROMIS®) is a publicly available system of “highly reliable, precise measures of patient-reported health status for physical, mental, and social wellbeing.”

Anticipated Impact

There is a need for additional brief, primary care-based treatments for PTSD that also work to improve social support in traumatized Veterans. This study is expected to result in a protocol for routinely measuring social support to inform treatment, which will likely improve Veterans’ mental health and social relationships. This work also will support future trials establishing effectiveness and implementation potential of the intervention, as well as a model of MBC of social support.

Principal Investigator:  Sarah Campbell, PhD, is part of HSR&D’s Denver/Seattle Center of Innovation for Veteran-Centered & Value-Driven Care in Seattle, WA.

Publications

None to report at this time.

View study abstract

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