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A top priority for the Veteran’s Healthcare Administration is improving access to high-quality mental healthcare. Mobile and telemental healthcare are a vital component of increasing access for veterans. The Veteran’s Healthcare Administration is making efforts to further broaden how veterans receive their care through VA Video Connect, which allows veterans to connect with their provider from their residence or workplace. In this mixed-methods study, successes and challenges associated with the rapid implementation of VA Video Connect telemental health appointments are examined through (1) administrative data and (2) qualitative interviews at one medical center. Within 1 year of the telehealth initiative, the number of providers experienced with telemental health increased from 15% to 85%, and telehealth appointments increased from 5376 to 14,210. Provider reported barriers included administrative challenges and concerns regarding care. Having an implementation model of telehealth champions and a team of experienced mental health providers allowed for rapid adoption of telehealth. Utilizing a similar model in other settings will further enable more veterans with depression and anxiety to have access to evidence-based psychotherapy, regardless of location or national crisis. With the dramatic increase in both training for providers as well as veteran use of telemental healthcare during the COVID-19 pandemic response, future research should aim to better understand which teams were able to switch to telehealth easily versus those which struggled, along with examining system-wide and provider-level factors that facilitated continued use of telehealth after social distancing requirements related to COVID-19 were relaxed. Electronic supplementary material The online version of this article (10.1007/s41347-020-00161-8) contains supplementary material, which is available to authorized users.

Objective Despite the availability of evidence-based psychotherapy (EBP) for posttraumatic stress disorder (PTSD) in the Veterans Health Administration, treatment completion rates are low and not all veterans benefit from these treatments. Understanding factors associated with PTSD EBP completion and symptom improvement is critical to improving completion rates and effectiveness. Method This chart review study used the Andersen Behavioral Model to examine whether predisposing characteristics (nonmodifiable characteristics such as demographics), enabling factors (modifiable logistic variables that can facilitate or impede treatment use), and need factors (clinical characteristics such as symptom severity or comorbidities) predicted treatment completion or symptom improvement following PTSD EBP treatment among 82 Iraq and Afghanistan combat veterans. Logistic regression was used to examine treatment completion, and repeated measures analysis of variance was used to examine changes in PTSD and depression symptoms following treatment. Results EBP completers had greater improvement in PTSD symptoms than did EBP dropouts. Need factors (lack of comorbid substance use disorders and having problems with family members/significant others) were related to treatment completion, whereas enabling resources (receiving individual rather than group treatment) were related to symptom improvement. Conclusions This is one the first studies to use a comprehensive model to examine factors relevant to treatment completion and symptom improvement. Results suggest that nonmodifiable predisposing characteristics do not drive treatment completion and symptom improvement, underscoring the potential importance of targeting enabling resources and needs factors for intervention. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Objective: To evaluate the efficacy of psychosocial treatments for posttraumatic stress disorder (PTSD) among individuals with a comorbid severe mental illness (SMI; ie, schizophrenia, bipolar disorder, major depressive disorder). Data Sources: PubMed, PsycINFO, CINAHL, and Cochrane Library were searched from January 1998 to March 2020 using keywords related to PTSD, treatment, and severe mental illness. Study Selection: All clinical trials for PTSD psychotherapy among individuals with SMI were included. From 38 potentially eligible studies, a total of 14 clinical trials across 684 individuals with comorbid SMI and PTSD were identified and included in the analysis. Data Extraction: Data on demographic, SMI diagnosis, symptom severity, sample attrition, and treatment protocol received were extracted. Effect size calculations and subsequent meta-analyses were conducted using the Meta-Analysis Package for R (metafor) version 2.1-0 in R (3.6.0). Results: PTSD treatments had a large effect on PTSD outcomes among individuals with SMI, with patients experiencing a standard deviation reduction in PTSD symptomatology pre- to post-treatment (g = -1.009, P

The COVID-19 pandemic has caused many Veterans Healthcare Administration providers working with veterans diagnosed with posttraumatic stress disorder to question the feasibility and appropriateness of continuing to provide trauma-focused treatment during this crisis. The Veterans Healthcare Administration is in a unique position to continue to provide trauma-informed care because of its capacity to offer telemental health services. Data from a Veterans Affairs medical center's posttraumatic stress disorder clinical team suggest that not only are veterans interested in continuing with treatment but also that the treatments can be modified to accommodate the current climate. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Background Posttraumatic stress disorder (PTSD) rarely remits over time, and if left untreated, leads to significant distress, functional impairment, and increased health care costs. Fortunately, effective evidence-based treatments (EBTs) for PTSD, such as Prolonged Exposure (PE), exist. Despite their availability and efficacy, a significant number of individuals with PTSD do not initiate treatment when offered or dropout prematurely. One proposed theory suggests that the emotional-numbing symptoms of PTSD (e.g., blunted affect, apathy) can serve as a barrier to engaging in, and successfully completing, treatment; and the broad human-animal interaction (HAI) literature available suggests that HAI can potentially reduce emotional numbing related to PTSD. Accordingly, this manuscript describes an ongoing, federally funded, randomized controlled trial testing the efficacy of RESCUE, an HAI intervention, as a viable adjunctive treatment component for PE. Methods/design The study will include 70 veterans with PTSD treated at a Southeastern Veterans Affairs Medical Center (VAMC). All participants in the trial receive up to 12 sessions of PE. Participants are randomly assigned 1:1 to (1) volunteer at a local animal shelter or (2) volunteer at a community agency of their choice as part of their in-vivo exposure exercises for PE. Outcomes will be examined via standard clinical interviews, self-report questionnaires, and thematic interviews. Discussion It is hypothesized that participants in the HAI condition will report greater decreases in emotional-numbing symptoms and increased treatment compliance and completion rates relative to those in the community volunteer condition. If successful, RESCUE, could be easily incorporated into standard PE and broadly disseminated. Trial registration ClinicalTrials.gov. ID: NCT03504722. Retrospectively registered on 2 May 2017.

ObjectiveThe aim of this study was to systematically review variables associated with initiation of trauma-centered cognitive-behavioral therapy (TC-CBT) among individuals with posttraumatic stress disorder (PTSD).MethodsPubMed, PsycINFO, Web of Science, Published International Literature on Traumatic Stress (PILOTS), and Scopus were searched in a systematic manner up to 2018, and 26 relevant studies were recovered and analyzed.ResultsThe average weighted initiation rate was 6% in larger hospital systems with a high rate of trauma and 28% in outpatient mental health settings (range 4%-83%). Older age (odds ratio [OR]=1.56, 95% confidence interval [CI]=0.51-1.61), female gender (OR=1.18, 95% CI=1.08-1.27), black or other racial-ethnic minority group (OR=1.16, 95% CI=1.03-1.28), Veterans Affairs PTSD service connection status (OR=2.30, 95% CI=2.18-2.42), mental health referral (OR=2.28, 95% CI=1.05-3.50), greater staff exposure to TC-CBT (OR=2.30, 95% CI=2.09-2.52), adaptability of TC-CBT to staff workflow (OR=4.66, 95% CI=1.60-7.72), greater PTSD severity (OR=1.46, 95% CI=1.13-1.78), and comorbid depression (OR=1.21, 95% CI=1.14-1.29) increased the likelihood of TC-CBT initiation, whereas delayed treatment reduced the likelihood of TC-CBT initiation (OR=0.93, 95% CI=0.92-0.95). Qualitative studies showed that mental health beliefs (stigma and lack of readiness), provider organizational factors (low availability, privacy issues), and patient lack of time (logistics) were perceived as barriers to initiation by patients and providers.ConclusionsTC-CBT initiation increased among patients who were older and female. Initiation was also higher among providers who had more exposure to TC-CBT in their work environment and when TC-CBT fit into their existing workflow.

Prolonged exposure therapy (PE) is effective in reducing posttraumatic stress disorder (PTSD) symptoms among individuals with comorbid substance use disorder (SUD) and PTSD. However, concerns that PE will lead to negative outcomes such as dropout and relapse remain a barrier to high-risk individuals, such as those warranting residential SUD care, receiving PE. The goal of this study was to gather information on feasibility, acceptability, and efficacy of offering PE in residential SUD treatment. Study therapists conducted PE (3 times/week, up to 15 sessions) with 9 patients admitted to a residential SUD treatment program at a Veterans Affairs (VA) hospital. Participants completed the PTSD Symptom Checklist (PCL-S) and Patient Health Questionnaire (PHQ-9) at admission, at discharge from the 4- to 6-week program, and 3-months postdischarge follow-up. Patients who were offered PE tolerated and engaged in PE as indicated by completion of the protocol, high satisfaction scores, and clinically significant decreases in PTSD and depression symptom severity. Symptom reduction at follow-up was significantly greater among patients who received PE than those who did not ( n = 21). This preliminary data provides initial support for further investigation of the efficacy of PE in residential SUD care.

This study examined: (a) the relationship between self-reported posttraumatic stress disorder (PTSD) symptoms and risk of obstructive sleep apnea (OSA) in a younger, Iraq and Afghanistan (OEF/OIF/OND) veteran sample seeking treatment for PTSD; and (b) the relationships between PTSD symptom scores and each risk factor of OSA (snoring, fatigue, high blood pressure/BMI).Participants were 195 Iraq and Afghanistan veterans presenting to a VA outpatient PTSD clinic for evaluation. Veterans were 21 to 59 years old (mean 33.40, SD 8.35) and 93.3% male (n = 182). Logistic regressions were run to examine whether veterans with greater PTSD symptom severity had an increased probability of screening as high risk for OSA, even after controlling for known risk factors (older age, positive smoking status, and use of CNS depressants).Of 159 veterans screened, 69.2% were assessed as being at high risk for OSA. PTSD symptom severity increased the risk of screening positive for OSA. PTSD symptom severity increased risk of screening positive for snoring and fatigue, but not high blood pressure/BMI.OEF/OIF/OND veterans with PTSD screen as high risk for OSA at much higher rates than those seen in community studies and may not show all classic predictors of OSA (i.e., older and higher BMI). This study is the first to suggest that the Berlin may be a useful screener for OSA in a younger OEF/OIF/OND veteran population with PTSD. Screening of younger veterans with PTSD for OSA should be standard care, and polysomnography and OSA interventions should be readily available to younger veterans.

IMPORTANCE: Co-occurrence of posttraumatic stress disorder (PTSD) and alcohol use disorder (AUD) is common and associated with psychiatric and functional problems. Understanding whether exposure therapy is tolerable and efficacious for treating PTSD and AUD is critical to ensure that best practice treatments are available. OBJECTIVE: To compare the efficacy of integrated (ie, targeting both PTSD and alcohol use) prolonged exposure (I-PE) therapy with present-centered integrated coping skills (I-CS) therapy, a more commonly available treatment, in reducing PTSD symptoms and alcohol use. DESIGN, SETTING, AND PARTICIPANTS: This prospective randomized clinical trial with masked assessments considered 186 veterans seeking Veterans Affairs mental health services. A total of 119 veterans with PTSD and AUD were randomized. Data were collected from February 1, 2013, to May 31, 2017, before treatment, after treatment, and at 3- and 6-month follow-ups. Intention-to-treat analyses were performed. INTERVENTIONS: Veterans underwent I-PE (Concurrent Treatment of PTSD and Substance Use Disorder Using Prolonged Exposure) or I-CS (Seeking Safety) therapy. MAIN OUTCOMES AND MEASURES: A priori planned outcomes were PTSD symptoms (Clinician Administered PTSD Scale for DSM-5) and percentage of heavy drinking days (Timeline Follow-Back) before treatment, after treatment, and at 3- and 6-month follow-ups. RESULTS: A total of 119 veterans (mean [SD] age, 41.6 [12.6] years; 107 [89.9%] male) were randomized. Linear mixture models found that PTSD symptoms decreased in both conditions, with a significantly greater decrease for I-PE treatment compared with I-CS treatment (treatment × time interaction, −2.83; F(3,233.1) = 4.92; Cohen d = 0.41; P = .002). The percentage of heavy drinking days improved in both conditions but was not statistically different between I-PE and I-CS treatment (treatment × time interaction, 1.8%; F(3,209.9) = 0.18; Cohen d = 0.04; P = .91). CONCLUSIONS AND RELEVANCE: The I-PE arm had a greater reduction in PTSD symptoms than the I-CS arm and comparable drinking decreases. The study provides evidence that exposure therapy is more efficacious in treating PTSD than a more commonly available integrated treatment without exposure for comorbid PTSD and AUD. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT01601067