HSR&D Home » Research » CRE 12-039 – HSR&D Study
Web and Shared Decision Making for Reserve/National Guard Women's PTSD Care
Anne G. Sadler, PhD RN
Iowa City VA Health Care System, Iowa City, IA
Iowa City, IA
Funding Period: May 2013 - March 2017
Women and OEF/OIF/OND Reserve/National Guard (RNG) war Veterans are among the fastest growing groups of new VHA users. PTSD is highly prevalent in this group of Veterans yet most choose not to seek care. This gap between need for and use of VA PTSD care shows barriers to engaging Veterans in mental health (MH) care persist. Removing these barriers requires new approaches to support Veterans post-deployment adjustment to mediate the severity of post-deployment MH conditions, alleviate concerns over MH diagnoses, and interrupt the cycle of chronicity found in many with PTSD.
1) Identify perceptions, preferences, barriers and facilitators to accessing VHA MH services and EBP for PTSD (including cognitive processing therapies (CPT) and prolonged exposure therapy (PE)) of a community sample of recent VHA users among PTSD+ OEF/OIF/OND RNG female war Veterans.
2) Evaluate study participants' perceptions of and satisfaction with a web-based interface (WEB-ED, developed in QUERI-funded studies) that screens for post-deployment readjustment and MH concerns and provides immediate tailored education.
3) Evaluate and test differences in VHA initiation and use, for those who screen positive for PTSD on the web-based interface randomly assigned to: A) Study nurse case manager (NCM) or B) existing outreach.
Our study population of OEF/OIF/OND female Veterans, recently returned from Iraq/Afghanistan, were identified by VA/DoD Identity Repository. Participants were selected from the Women's Practice Based Research Network founder sites (California, North Carolina, Iowa) and the Evidence-Based Therapy for PTSD CREATE leadership site (Minnesota). In Phase 1, we interviewed OEF/OIF/OND RNG female war Veterans' who screened PTSD+ on an online VA PTSD screener to assess their preferences, barriers and facilitators to accessing VHA MH services and evidence based psychotherapy (EBP) for PTSD. This information was used to refine this team's existing WEB-ED. Phase 2 implemented the revised WEB-ED and assessed Veteran satisfaction with it. Phase 3 recruited participants who screened PTSD+ on WEB-ED and were randomly assigned to: A) Study NCM who facilitated use of a PTSD decision aid and shared decision-making (SDM)to assist with VHA MH evaluation and treatment; or B) existing outreach (current care). Phase 4 included follow-up assessments conducted at 6 and 12 months to compare the efficacy of two approaches to promote VHA MH initiation.
1) Phase 1 qualitative interviews were conducted with a community sample of RNG servicewomen who met the following criteria: returned from Iraq/Afghanistan in the preceding 36 months; screened PTSD+ with an online VA screen and had a VHA encounter within the prior 18 months (N=19). Most (74%) had no EBP treatment. Veterans with no EBP reported numerous care barriers (shame, career concerns, time constraints, concerns about RNG access to VA, perception of insufficient VA staffing) and 80% indicated no provider education or SDM about PTSD treatment options.
2) Phase 2, 577 RNG servicewomen returning from Iraq/Afghanistan deployment within prior 60 months completed on-line screening/tailored education (WEB-ED) about post-deployment MH conditions. Half (49%) screened PTSD+. Among those screening PTSD+, most had one or more trauma exposures: combat (87%), military sexual trauma (67%), head injury (25%). Many screened positive for other post-deployment conditions: depression (29%), substance use disorder (50%), prescription drug misuse (49%), family readjustment (21%), intimate partner violence (9%), anger (60%). Veterans reported satisfaction with WEB-ED:80% indicating they would recommend WEB-ED to a peer and 67% learned information not received otherwise. 60% reported as a direct result of WEB-ED, they would subsequently seek MH care.
3) In Phase 3, PTSD+ Veterans who continued RCT study participation were randomly assigned to the NCM treatment (n=85) and existing outreach (n=86) arms. Using the Patient Activation Measure, we found that PCL-5 PTSD+ Veterans had significantly lower patient activation scores than PTSD- peers, indicating PTSD+ Veterans felt disengaged/overwhelmed (60%) whereas PTSD- (most with other MH+ screens) reported high activation (taking action/pushing further (71%)). Participants reported PTSD treatment avoidance given: fear will make life worse, not wanting to relive traumas, privacy concerns, and disbelief therapy helps. Those in the NCM treatment arm reported high satisfaction with the Iowa PTSD treatment option grid (e.g.,100% liked/felt useful). They reported benefits of the option grid included 1) new information, 2) conciseness, and 3) support for doctor-patient communication. Veterans found SDM to be useful (88%) and that a lot/every effort was made to include what matters most to them in choosing what to do next (96%). Participants liked: "talking to a person and not a computer" and "felt listened to, my own words were important".
Phase 4 documented more than half (58%) obtained MH treatment for PTSD. Among those who got care, approximately half received EBP (42% CPT; 11% PE). The majority sought VHA care (85%). RCT participants had similar rates of MH engagement regardless of their treatment arm.
This study provides valuable insights about female RNG war Veterans' need for and decisions to seek MH services and EBP for PTSD. Study interventions focused on moving information and not people, addressing the needs of a high-risk population that might delay or not otherwise access PTSD treatment or VHA care, and providing Veteran-centered approaches. However, the subgroup of PTSD+ Veterans with low patient-activation scores represent a special population requiring additional support for engaging in needed MH care. The study provides important information regarding the efficacy of relatively inexpensive and resource-sparing interventions that can be readily implemented within existing models of patient care delivery and illustrating that one-size does not fit all. Participants reported high satisfaction with these approaches, suggesting Veteran usability and spread potential. Next steps include engaging providers with PTSD decision aid/SDM use, refining interventions to further focus on Veteran-provider partnership, eg, Veteran self-management collaboration. While this web interface and SDM intervention is currently directed at RNG women Veterans' post-deployment, there are clear implications for expansion to other populations and health/MH concerns as well. Findings have important policy implications for operational partners invested in the improved access and delivery of evidence-based MH care for Veterans with PTSD.
External Links for this Project
NIH ReporterGrant Number: I01HX000937-01
Dimensions for VADimensions for VA is a web-based tool available to VA staff that enables detailed searches of published research and research projects.
If you have VA-Intranet access, click here for more information vaww.hsrd.research.va.gov/dimensions/
VA staff not currently on the VA network can access Dimensions by registering for an account using their VA email address. Search Dimensions for this project
DRA: Mental, Cognitive and Behavioral Disorders
DRE: Treatment - Efficacy/Effectiveness Clinical Trial
MeSH Terms: none