Center for Care Delivery and Outcomes Research
Goal: Improve health care, health care experience, and outcomes among Veterans with PTSD and other trauma-related disorders.
Background:PTSD is a psychiatric disorder that follows exposure to life-threatening or horrific experiences that disproportionally affects Veterans. Although the twelve-month prevalence of PTSD in the United States is estimated to be less than 4%, it approaches 25% among Veterans of recent wars and is even higher among Veterans with war-related physical injuries and among Veterans who use VA for medical care. In the absence of effective treatment, PTSD can become chronic and result in long-term impairments across major life domains.
Although PTSD is potentially disabling, there are effective treatments that reduce symptoms and improve functioning. However, the benefit of these treatments is limited by the following factors that CCDOR’s Trauma Recovery investigators have identified: (1) Most Veterans with PTSD do not receive evidence-based psychotherapy or pharmacotherapy. (2) Whether or not a Veteran with PTSD receives evidence-based treatment depends on the region in which he or she lives, the type of clinic in which PTSD is diagnosed, and whether or not the Veteran belongs to a racial or ethnic minority group. (3) Many Veterans who begin an evidence-based treatment do not fully engage or do not receive an adequate dose. The work of CCDOR’s Trauma Recovery research group addresses these problems and identifies treatment adaptations, new interventions, and implementation strategies to increase Veteran access to effective PTSD treatments.
As well, the Trauma Recovery research group’s expertise extends beyond PTSD to other trauma-related conditions, including traumatic brain injury, amputation, and post-deployment community reintegration. In addition, since PTSD does not occur in isolation, Trauma Recovery investigators examine clinical complexity among Veterans with trauma histories and collaborate with CCDOR’s Pain and Opioid Harms Reduction investigators to improve treatment and outcomes for Veterans with PTSD, pain, and opioid use disorders.
Expertise in Trauma Recovery: The Trauma Recovery research group is led by Dr. Nina Sayer, CCDOR Deputy Director, and includes 8 additional core investigators with a long history of successful collaboration. In addition to content expertise in traumatic stress, this research group has expertise in qualitative and mixed methods research, implementation science, survey methods, cohort studies, and an extensive understanding of the strengths and limitations of administrative data. Trauma Recovery investigators are recognized leaders in the field of traumatic stress studies. In large part due to strong partnerships, in particular with the VA’s Office of Mental Health and Suicide Prevention (OMHSP) and the National Center for PTSD (NCPTSD), this work has resulted in clinical and policy impacts and improvements in VA care delivery. Patient and provider educational products developed through prior Trauma Recovery research group projects have been integrated into VHA provider training and disseminated to the field.
- Dr. Sayer received funding for an implementation research project aimed at increasing the number of Veterans with PTSD who receive evidence-based psychotherapies for PTSD, and producing a toolkit and implementation strategy to improve evidence-based psychotherapy dissemination. If effective, Dr. Sayer will work with the NCPTSD to spread the implementation strategy to additional low-performing sites.
- Dr. Spoont evaluated a multi-component implementation strategy (comprised of online provider CME training, local Primary Care and Mental Health champions, CPRS consult template, and motivation enhancement) to increase the prescription rate of evidence-based pharmacotherapy for PTSD by primary care providers in community-based outpatient clinics. Findings indicate that this implementation strategy improves prescribing practices but could be improved to increase uptake. The tools developed through this project have already been disseminated to several VA health care systems and researchers.
- Variation in the quality of PTSD care is an issue of concern that has received little empirical attention. Sayer and colleagues are examining treatment fidelity and sources of variation in the quality of evidenced-based psychotherapies for PTSD across VHA. This research will inform provider- and system-level interventions to optimize the effectiveness and consistency of evidence-based psychotherapies for PTSD in practice.
- Dr. Kehle-Forbes, in collaboration with the NCPTSD investigators, submitted a research proposal to evaluate the integration of case formulation into Cognitive Processing Therapy to improve treatment effectiveness.
- Drs. Polusny and Erbes completed a high-impact series of longitudinal studies of National Guard Veterans who served in the wars in Iraq and Afghanistan, referred to as the Readiness and Resilience in National Guard Soldiers (RINGS) Project. The RINGS studies demonstrated the important role of family relationships in fostering resilience, and led to improvements in training programs for National Guard troops to enhance resilience through family communication and support. Most recently, Drs. Polusny and Erbes received NIH funding for a prospective study of the mechanisms of resilience in new military recruits. This work leverages findings from their prior RINGS work to inform the development of interventions to promote resilience among service members and Veterans who face hazardous duty.
- Trauma Recovery researchers also examine interventions developed outside of mainstream medicine to promote resilience and recovery. In the prior funding period, they examined mindfulness meditation for PTSD and expressive writing for reintegration problems. An ongoing study brings together the Trauma Recovery and the Pain and Opioid Harms Reduction groups to examine the development of chronic pain in Afghanistan and Iraq war Veterans, especially those with PTSD and co-occurring mental health problems, and their use of complementary and alternative medicine.
- Dr. Meis is conducting a multi-site trial to test if increasing family support for Prolonged Exposure, an evidence-based psychotherapy for PTSD, can improve Veteran engagement, retention, and treatment response.
- Based on findings from a recently completed study of drop out from evidence-based psychotherapies, Dr. Kehle-Forbes is testing the feasibility of a novel self-management program for Veterans who complete an evidence-based psychotherapy.
- Trauma Recovery researchers are pioneering new research methods to advance traumatic stress research. These methodological innovations are generally embedded in health services grants and then spread to other CCDOR projects through CCDOR’S Statistics and Data Management Core. As well, new methodologies developed in CCDOR are disseminated outside of CCDOR, to other VA facilities and partner agencies, through collaborations and mentoring. Prior methodological innovations include development of methods to identify evidence-based treatments and trauma-related disorders (e.g., traumatic brain injury and traumatic amputation) in VHA administrative records, reduce non-ignorable bias in mail surveys, identify risk factors for dropout, and conduct dyadic qualitative analysis.