Veterans Affairs Posttraumatic Stress Disorder Research Articles

Unraveling PTSD: Symptom cluster change during and 1 year after veterans' residential PTSD treatment.

Although treatment of posttraumatic stress disorder (PTSD) is effective in reducing symptom severity, remission rates are low. One potential underlying reason for treatment ineffectiveness is differential response of specific PTSD symptom clusters. Using data from a national Veterans Affairs (VA) residential PTSD treatment cohort, we conducted a longitudinal study to examine changes in Diagnostic and Statistical Manual of Mental Disorders, fifth edition PTSD symptom clusters from admission to 1-year follow-up. PTSD symptom data were analyzed from a national cohort of veterans who completed VA PTSD residential treatment between October 2019 and September 2020 (n = 1,648; 13% women; median age 44.2 years). Endorsement (%) and severity (M[SD]) of PTSD clusters and individual symptoms were compared at admission, discharge, 4-month and 1-year follow-ups. Large magnitude reductions in all four PTSD symptom clusters were observed from admission to discharge and both follow-ups; however, endorsement of all symptom clusters remained high. Intrusions (Cluster B) were the most highly endorsed at discharge and follow-up, whereas avoidance symptoms (Cluster C) were the least highly endorsed. Differential patterns of change were observed among the 20 individual PTSD symptoms; for example, flashbacks decreased during treatment, but increased to near admission levels by 1-year postdischarge. Results suggest that intrusive symptoms may be more resistant to residential treatment for PTSD and contribute to lower likelihood of treatment success. Future work is needed to examine differential treatment response for PTSD clusters, to inform the improvement of current and creation of novel treatment interventions, and to better address intrusive symptoms to maximize PTSD treatment gains. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Factors Associated With Increased Substance Use Disorder Care in VA PTSD Specialty Outpatient Treatment

Objective Substance use disorders (SUDs) commonly co-occur with posttraumatic stress disorder (PTSD). Understanding PTSD clinics that serve higher percentages of patients with PTSD/SUD is crucial for improving SUD care in clinics with lower percentages of such patients. This study examined the differences between Veterans Affairs (VA) PTSD treatment sites with higher percentages ("High%") and lower percentages ("Low%") of patients with PTSD/SUD as well as exploring the roles of the PTSD/SUD specialists. Methods The study collected quantitative and qualitative data from 18 clinic directors and 21 specialists from 33 VA PTSD specialty outpatient clinics from 2014 to 2016. The clinics were chosen from the top and bottom quartiles based on two criteria: (1) the percentage of patients with PTSD/SUD and (2) the percentage of patients with PTSD/SUD who completed at least three SUD visits within the first month of their SUD treatment. The interviews sought to identify distinguishing characteristics between the High% and Low% clinics in terms of treatment access and practices for patients with PTSD/SUD. Results More of the High% clinics reported providing evidence-based, patient-centered, and integrated/concurrent PTSD/SUD treatment and had staff members with more up-to-date knowledge and skills than the Low% clinics. We also found the roles of the PTSD/SUD specialists were demanding and confusing, leading to high turnover rates. Conclusions The two groups of PTSD clinics differed in three key factors: Resources, knowledge and skills of staff members, and local policies. Future research should focus on addressing resource limitations, knowledge gaps, and local policy disparities in Low% clinics. By emulating the practices of High% clinics, VA PTSD clinics can improve SUD care for patients with PTSD/SUD.

Expected symptom change trajectories for the early identification of probable treatment nonresponse in VA PTSD specialty care clinics: A proof-of-concept.

The purpose of measurement-based care (MBC) is to detect treatment nonresponse sufficiently early in treatment to adjust treatment plans and prevent failure or dropout. Thus, the potential of MBC is to provide the infrastructure for a flexible, patient-centered approach to evidence-based care. However, MBC is underutilized across the Department of Veterans Affairs (VA) posttraumatic stress disorder (PTSD) specialty clinics, likely because no actionable, empirically determined guidelines for using repeated measurement effectively are currently available to clinicians. With data collected as part of routine care in VA PTSD specialty clinics across the United States in the year prior to COVID-19 (n = 2,182), we conducted a proof-of-concept for a method of generating session-by-session benchmarks of probable patient nonresponse to treatment, which can be visualized alongside individual patient data using the most common measure of PTSD symptoms used in VA specialty clinics, the PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (PCL-5). Using survival analysis, we first identified the probability of cases reaching clinically significant change at each session, as well as any significant moderators of treatment response. We then generated a multilevel model with initial symptom burden predicting the trajectory of PCL-5 scores across sessions. Finally, we determined the slowest changing 50% and 60% of all cases to generate benchmarks at each session for each level of the predictor(s) and then assessed the accuracy of these benchmarks at each session for classifying treatment responders and nonresponders. The final models were able to accurately identify nonresponders as early as the sixth session of treatment. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Worry differentially mediates posttraumatic cognition and posttraumatic stress symptom relationships among veterans seeking treatment associated with military sexual trauma.

Research has established negative posttraumatic cognitions (NPC) affect the development and course of posttraumatic stress symptoms (PTSS) following trauma exposure (L. A. Brown et al., 2019). Previous studies in civilian and combat veteran populations also suggest positive associations among worry, NPC (Beck et al., 2004; Bennett et al., 2009), and PTSS (Fergus & Bardeen, 2017). However, little research has investigated the prevalence of worry in veterans who have experienced military sexual trauma (MST), and no research has examined the role of worry in the relation between NPC and PTSS among veterans seeking treatment associated with MST. This project examined the prevalence of worry in a MST sample and whether worry mediated NPC-PTSS associations. Veterans (N = 91) seeking MST-related treatment presented to a Veterans Affairs Posttraumatic Stress Disorder specialty clinic for assessment and treatment recommendations. Veterans completed questionnaires assessing NPC, worry, and PTSS. Bootstrapped mediation analyses examined NPC-PTSS associations. Veterans reported similar levels of worry as nonveterans seeking treatment associated with generalized anxiety disorder. Mediation analyses showed worry significantly mediated NPC-PTSS relationships for beliefs about the world, self-blame, and coping competence but not for beliefs about the self or global NPC severity. Further, the degree of mediation differed by NPC type. Though a limitation of this study is the use of cross-sectional data, these results inform the use of clinical intervention strategies targeting worry in trauma-focused interventions and necessitate further research on whether trauma-focused interventions ameliorate co-occurring worry among veterans exposed to MST. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Examining bias in the award of Veterans Affairs (VA) disability benefits for posttraumatic stress disorder in women veterans: Analysis of evaluation reports and VA decisions.

Studies have raised concerns about possible inequities in the U.S. Department of Veterans Affairs (VA)'s awards of disability for posttraumatic stress disorder (PTSD) to women. However, the diagnoses and opinions made by disability examiners have not been studied. A sample of 270 initial PTSD examination reports and corresponding VA decisions were studied. Compared to men, women veterans were as likely to be diagnosed with a service-related mental disorder, χ2(1, N = 270) = 2.31, p =.129, odds ratio (OR) = 1.79, 95% CI [0.84, 3.80], and be granted service-connection, χ2(1, N = 270) = 0.49, p =.483, OR = 1.28, 95% CI [0.65, 2.51]. Women veterans were considered to have more psychiatric symptoms, Z = -2.05, p =.041, r =.16, and more psychiatric impairment, Z = -2.48, p =.013, r =.20, but the percentage of disability awarded by the VA did not differ, χ2(1, N = 270) = 0.49, p =.483; OR = 1.28, 95% CI [0.65, 2.51]. Secondary analyses implicate the role of military sexual trauma and premilitary trauma in explaining sex differences in symptoms and impairment. The findings indicate that neither opinions by examiners nor corresponding decisions by the VA regarding service connection reflect a negative bias toward women veterans. Results indicate that unbiased examinations lead to equitable VA claims decisions for women veterans. Future studies of the VA PTSD disability program nationally, including examination procedures and VA policies and implementation, will promote equity for women veterans in the PTSD claims process.

Yoga vs Cognitive Processing Therapy for Military Sexual Trauma–Related Posttraumatic Stress Disorder

First-line treatment for posttraumatic stress disorder (PTSD) in the US Department of Veterans Affairs (VA), ie, trauma-focused therapy, while effective, is limited by low treatment initiation, high dropout, and high treatment refraction. To evaluate the effectiveness of Trauma Center Trauma-Sensitive Yoga (TCTSY) vs first-line cognitive processing therapy (CPT) in women veterans with PTSD related to military sexual trauma (MST) and the hypothesis that PTSD outcomes would differ between the interventions. This multisite randomized clinical trial was conducted from December 1, 2015, to April 30, 2022, within 2 VA health care systems located in the southeast and northwest. Women veterans aged 22 to 71 years with MST-related PTSD were enrolled and randomized to TCTSY or CPT. The TCTSY intervention (Hatha-style yoga focusing on interoception and empowerment) consisted of 10 weekly, 60-minute group sessions, and the CPT intervention (cognitive-based therapy targeting modification of negative posttraumatic thoughts) consisted of 12 weekly, 90-minute group sessions. Sociodemographic data were collected via self-report survey. The primary outcome, PTSD symptom severity, was assessed using the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) and PTSD Checklist for DSM-5 (PCL-5). Assessments were conducted at baseline, midintervention, 2 weeks post intervention, and 3 months post intervention. Of 200 women veterans who consented to participate, the intent-to-treat sample comprised 131 participants (mean [SD] age, 48.2 [11.2] years), with 72 randomized to TCTSY and 59 randomized to CPT. Treatment was completed by 47 participants (65.3%) in the TCTSY group and 27 (45.8%) in the CPT group, a 42.6% higher treatment completion rate in the TCTSY group (P = .03). Both treatment groups improved over time on the CAPS-5 (mean [SD] scores at baseline: 36.73 [8.79] for TCTSY and 35.52 [7.49] for CPT; mean [SD] scores at 3 months: 24.03 [11.55] for TCTSY and 22.15 [13.56]) and the PCL-5 (mean [SD] scores at baseline: 49.62 [12.19] for TCTSY and 48.69 [13.62] for CPT; mean [SD] scores at 3 months: 36.97 [17.74] for TCTSY and 31.76 [12.47]) (P < .001 for time effects). None of the group effects or group-by-time effects were significant. Equivalence analyses of change scores were not significantly different between the TCTSY and CPT groups, and the two one-sided test intervals fell within the equivalence bounds of plus or minus 10 for CAPS-5 for all follow-up time points. In this comparative effectiveness randomized clinical trial, TCTSY was equivalent to CPT in reducing PTSD symptom severity, with both groups improving significantly. The higher treatment completion rate for TCTSY indicates its higher acceptability as an effective and acceptable PTSD treatment for women veterans with PTSD related to MST that could address current VA PTSD treatment limitations. ClinicalTrials.gov Identifier: NCT02640690.

Clinical outcomes of veterans affairs residential PTSD treatment for PTSD and depressive symptoms: 1-year follow-up outcomes and gender differences.

The long-term effectiveness of Department of Veterans Affairs (VA) residential treatment for posttraumatic stress disorder (PTSD), and how it may vary for men and women veterans, is unknown. This is the first national investigation of symptom change from admission, discharge, 4 months, and 1-year postdischarge from VA PTSD residential rehabilitation treatment programs (RRTPs). Participants included all veterans discharged from 40 VA PTSD RRTPs October 1, 2017-September 30, 2020 (n = 2,937; 14.3% women). Linear mixed models examined PTSD and depressive symptoms across time points; it was hypothesized that women veterans would experience greater symptom reduction during and after treatment. Overall, veterans reported large-sized reductions of PTSD symptoms at all time points (Cohen's d: discharge = 1.23, 4-month follow-up d = 0.97, 1-year follow-up d = 1.51). Treatment effects for depressive symptoms were large-sized at all time points (Cohen's d; discharge = 1.03, 4-month follow-up d = 0.94, 1-year follow-up d = 1.05). Women veterans showed greater improvement in PTSD and depressive symptom severity (p < .001) than men at discharge, but not at 4-month or 1-year follow-ups. Veterans reported significant reductions in PTSD and depressive symptoms, and treatment gains were maintained one year postdischarge. Women experienced greater benefit during, but not after, treatment. Results not only provide support for the effectiveness of VA residential treatment for PTSD but also highlight the continued need for strategies to maximize and maintain treatment gains. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Factor structure and psychometric performance of the PCL-5 in a clinical sample of veterans seeking treatment in a VA PTSD outpatient clinic.

There is a clear need to improve the measurement of posttraumatic symptoms in veterans seeking trauma-focused treatment. We evaluated the structure and psychometric performance of the Posttraumatic Stress Disorder (PTSD) Checklist for the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (PCL-5) in a naturalistic sample of veterans engaging in evidence-based therapy in a Veterans Affairs (VA) PTSD outpatient clinic. We collected data from 500 sequential patients at the beginning and end of treatment, evaluating the PCL-5 factor structure followed by psychometric analyses. Results align with recent research following rigorous methods and advanced statistical techniques in suggesting a unidimensional factor structure for the PCL-5, with indications for its items representing a general factor with no clear support for multiple factors or subscales aligned with specific symptom clusters. In addition, psychometric analyses suggest a wider range of potential cutoff scores predicting PTSD diagnosis that may be specific to this population or setting. Given the remaining research questions surrounding the PCL-5 and its structure and functioning specifically, as well as the evolving conceptualizations of PTSD as a psychological disorder, further research is needed to guide clinical practice and future research. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Comparative effectiveness of evidence-based psychotherapies for PTSD delivered in VA residential PTSD treatment.

Cognitive Processing Therapy (CPT) and Prolonged Exposure (PE) are first-line treatments for posttraumatic stress disorder (PTSD). There have been few direct comparisons of CPT and PE intended to determine their comparative effectiveness, none of which have examined outcomes among military veterans receiving these treatments in a residential setting such as the Department of Veterans Affairs (VA) residential rehabilitation treatment programs (RRTPs). Such work is essential given that these veterans are among the most complex and severely symptomatic patients with PTSD treated in VA. In this study we compared changes in PTSD and depressive symptoms across admission, discharge, four months and 12 months following discharge among veterans who received CPT or PE within VA RRTPs. Using linear mixed models conducted on program evaluation data derived from the electronic medical record and follow-up surveys, we compared self-reported PTSD and depressive symptom outcomes among 1130 veterans with PTSD who were treated with individual CPT (n = 832, 73.5%) or PE (n = 297, 26.5%) in VA PTSD RRTPs in fiscal years 2018-2020. PTSD and depressive symptom severity did not significantly differ at any time points. The CPT and PE groups both showed large-sized reductions in PTSD (CPT d = 1.41, PE d = 1.51) and depression (CPT d = 1.01, PE d = 1.09) from baseline to 12-month follow-up. Outcomes for PE and CPT do not differ among a highly complex population of veterans with severe PTSD and several comorbid conditions that can make it difficult to engage in treatment.

Economic costs of implementing evidence-based telemedicine outreach for posttraumatic stress disorder in VA.

Telemedicine outreach for posttraumatic stress disorder (TOP) is a virtual evidence-based practice (EBP) involving telephone care management and telepsychology that engages rural patients in trauma-focused psychotherapy. This evaluation examined implementation and intervention costs attributable to deploying TOP from a health system perspective. Costs were ascertained as part of a stepped wedge cluster randomized trial at five sites within the Veterans Affairs (VA) Healthcare System. All sites initially received a standard implementation strategy, which included internal facilitation, dissemination of an internal facilitators operational guide, funded care manager, care managing training, and technical support. A subset of clinics that failed to meet performance metrics were subsequently randomized to enhanced implementation, which added external facilitation that focused on incorporating TOP clinical processes into existing clinic workflow. We measured site-level implementation activities using project records and structured activity logs tracking personnel-level time devoted to all implementation activities. We monetized time devoted to implementation activities by applying an opportunity cost approach. Intervention costs were measured as accounting-based costs for telepsychiatry/telepsychology and care manager visits, ascertained using VA administrative data. We conducted descriptive analyses of strategy-specific implementation costs across five sites. Descriptive analyses were conducted instead of population-level cost-effectiveness analysis because previous research found enhanced implementation was not more successful than the standard implementation in improving uptake of TOP. Over the 40-month study period, four of five sites received enhanced implementation. Mean site-level implementation cost per month was $919 (SD = $238) during standard implementation and increased to $1,651 (SD = $460) during enhanced implementation. Mean site-level intervention cost per patient-month was $46 (SD = $28) during standard implementation and $31 (SD = $21) during enhanced implementation. Project findings inform the expected cost of implementing TOP, which represents one factor health systems should consider in the decision to broadly adopt this EBP. Plain Language Summary: What is already known about the topic: Trauma-focused psychotherapy delivered through telemedicine has been demonstrated as an effective approach for the treatment of post-traumatic stress disorder (PTSD). However, uptake of this evidence-based approach by integrated health systems such as the Veterans Affairs (VA) Health Care System is low. What does this paper add: This paper presents new findings on the costs of two implementation approaches designed to increase adoption telemedicine outreach for PTSD from a health system perspective. What are the implications for practice, research, and policy: Cost estimates from this paper can be used by health systems to inform the relative value of candidate implementation strategies to increase adoption of evidence-based treatments for PTSD or other mental health conditions.

Effectiveness of cognitive behavioral conjoint therapy for posttraumatic stress disorder (PTSD) in a U.S. Veterans Affairs PTSD clinic.

Cognitive behavioral conjoint therapy (CBCT) for posttraumatic stress disorder (PTSD) is a 15-session conjoint treatment for PTSD designed to improve PTSD symptoms and enhance intimate relationship functioning. Numerous studies of CBCT for PTSD document improvements in patient PTSD and comorbid symptoms, partner mental health, and relationship adjustment. However, little is known about its effectiveness in real-world clinical settings. Using an intention-to-treat sample of couples who participated in CBCT for PTSD in an outpatient U.S. Veterans Affairs (VA) PTSD clinic (N = 113), trajectories of session-by-session reports of veterans' PTSD symptoms and both partners' relationship happiness were examined. Across sessions, there were significant reductions in veteran-rated PTSD symptoms, d = -0.69, and significant increases in veteran- and partner-rated relationship happiness, ds = 0.36 and 0.35, respectively. Partner ratings of veterans' PTSD symptoms increased before significantly decreasing, d = -0.24. Secondary outcomes of veteran and partner relationship satisfaction, ds = 0.30 and 0.42, respectively; veteran and partner depressive symptoms, ds = -0.75 and -0.29, respectively; and partner accommodation of PTSD symptoms, d = -0.44, also significantly improved from pre- to posttreatment. The findings suggest that CBCT for PTSD was effective for decreasing PTSD and comorbid symptoms in veterans, as well as for improving relationship functioning and partners' mental health, among a sample of real-world couples seeking treatment in a VA PTSD specialty clinic.

Racial Disparities in Clinical Outcomes of Veterans Affairs Residential PTSD Treatment Between Black and White Veterans.

Racial disparities across various domains of health care are a long-standing public health issue that affect a variety of clinical services and health outcomes. Mental health research has shown that prevalence rates of posttraumatic stress disorder (PTSD) are high for Black veterans compared with White veterans, and some studies suggest poorer clinical outcomes for Black veterans with PTSD. The aim of this study was to examine the impact of racial disparities longitudinally in the U.S. Department of Veterans Affairs (VA) residential rehabilitation treatment programs (RRTPs). Participants included 2,870 veterans treated nationally in VA PTSD RRTPs in fiscal year 2017. Veterans provided demographic data upon admission to the program. Symptoms of PTSD and depression were collected at admission, discharge, and 4-month follow-up. Hierarchical linear modeling was used to examine symptom change throughout and after treatment. Black veterans experienced attenuated PTSD symptom reduction during treatment as well as greater depression symptom recurrence 4 months after discharge, relative to White veterans. This study adds to the body of literature that has documented poorer treatment outcomes for Black compared with White veterans with PTSD. Although both Black and White veterans had an overall reduction in symptoms, future research should focus on understanding the causes, mechanisms, and potential solutions to reduce racial disparities in mental health treatment.

Latent classes of PTSD symptoms in veterans undergoing residential PTSD treatment.

Although most veterans in the Department of Veterans Affairs (VA) health system are treated for posttraumatic stress disorder (PTSD) in the outpatient setting, the VA has approximately 40 residential PTSD treatment facilities across the country for those requiring more intensive care. The symptom profiles of these veterans are poorly understood. Thus, the current study was designed to characterize classes of PTSD symptoms in a national sample of veterans undergoing residential treatment. We analyzed latent classes of PTSD symptoms among 2,452 veterans entering VA PTSD residential treatment in fiscal year 2013. The model with the best fit was a 4-class model comprising a low symptom class, moderate symptom class with high reexperiencing symptoms, a moderate symptom class with high emotional numbing, and a high symptom class. Compared to classes identified in outpatient samples, these classes were similar in type but greater in severity. Classes differed by age, race/ethnicity, trauma type, co-occurring medical conditions, co-occurring psychiatric conditions, and social functioning. Compared to the moderate class with high emotional numbing, those in the moderate class with high reexperiencing symptoms were more likely to be non-White, have greater pain severity, greater sleep problems, and were less likely to be depressed. Our findings suggest that veterans in residential treatment who have more severe PTSD symptoms also experience other medical and psychosocial stressors. A better understanding of symptom profiles may help to create more individualized treatment planning and thus potentially improve care for these veterans. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Comparing the effectiveness of VA residential PTSD treatment for veterans who do and do not report a history of MST: A national investigation

The Department of Veterans Affairs (VA) has implemented initiatives to promote veterans’ recovery from the health sequelae of military sexual trauma (MST), including posttraumatic stress disorder (PTSD). MST can impact emotion regulation, interpersonal functioning, and perceptions of trust and safety, as well as increase risk for psychiatric comorbidity, which may impede PTSD treatment.. VA PTSD Residential Rehabilitation Treatment Programs (RRTPs) may facilitate the therapeutic process by offering increased structure, support, and adjunctive services. Limited research has examined the effect of MST on PTSD RRTP outcomes. Utilizing data from 7918 men and women veterans participating in a VA PTSD RRTP, the impact of the experience of MST on rates of program completion and changes in PTSD symptoms during and after treatment were examined. Rates of program completion were similar between those who did and did not report experiencing MST. Multilevel modeling was utilized to examine the impact of MST on PTSD symptoms after accounting for gender, age, race/ethnicity, and program completion. MST survivors endorsed more severe PTSD symptoms at admission; however, PTSD symptom severity scores were similar to those who did not report experiencing MST by discharge. Additionally, MST survivors had larger initial reductions in PTSD symptoms, followed by a greater recurrence of PTSD symptoms over time, compared to those who did not report experiencing MST. MST survivors appear able to participate in and benefit from PTSD RRTPs. Nonetheless, the increased recurrence of PTSD symptoms following discharge from residential treatment indicates the need for strategies to maintain post-treatment gains among MST survivors.

Changes in Post-traumatic Stress Disorder Service Connection Among Veterans Under Age 55: An 18-Year Ecological Cohort Study.

Mandatory, age-based re-evaluations for post-traumatic stress disorder (PTSD) service connection contribute substantially to the Veterans Benefits Administration's work load, accounting for almost 43% of the 168,013 assessments for PTSD disability done in Fiscal Year 2017 alone. The impact of these re-evaluations on Veterans' disability benefits has not been described. The study is an 18-year, ecological, ambispective cohort of 620 men and 970 women receiving Department of Veterans Affairs PTSD disability benefits. Veterans were representatively sampled within gender; all were eligible for PTSD disability re-evaluations at least once because of age. Outcomes included the percentage whose PTSD service connection was discontinued, reduced, re-instated, or restored. We also examined total disability ratings among those with discontinued or reduced PTSD service connection. Subgroup analyses examined potential predictors of discontinued PTSD service connection, including service era, race/ethnicity, trauma exposure type, and chart diagnoses of PTSD or serious mental illness. Our institution's Internal Review Board reviewed and approved the study. Over the 18 years, 32 (5.2%) men and 180 (18.6%) women had their PTSD service connection discontinued; among them, the reinstatement rate was 50% for men and 34.3% for women. Six men (1%) and 23 (2.4%) women had their PTSD disability ratings reduced; ratings were restored for 50.0% of men and 57.1% of women. Overall, Veterans who lost their PTSD service connection tended to maintain or increase their total disability rating. Predictors of discontinued PTSD service connection for men were service after the Vietnam Conflict and not having a Veterans Health Administration chart diagnosis of PTSD; for women, predictors were African American or black race, Hispanic ethnicity, no combat or military sexual assault history, no chart diagnosis of PTSD, and persistent serious mental illness. However, compared to other women who lost their PTSD service connection, African American and Hispanic women, women with no combat or military sexual assault history, and women with persistent serious illness had higher mean total disability ratings. For both men and women who lost their PTSD service connection, those without a PTSD chart diagnosis had lower mean total disability ratings than did their counterparts. Particularly for men, discontinuing or reducing PTSD service connection in this cohort was rare and often reversed. Regardless of gender, most Veterans with discontinued PTSD service connection did not experience reductions in their overall, total disability rating. Cost-benefit analyses could help determine if mandated, age-based re-evaluations of PTSD service connection are cost-effective.

Clinical, Empirical, and Theoretical Rationale for Selection of Accelerated Resolution Therapy for Treatment of Post-traumatic Stress Disorder in VA and DoD Facilities.

Post-traumatic stress disorder (PTSD) is a chronic, disabling psychiatric disorder prevalent among U.S. service members and veterans. First-line treatments for PTSD endorsed in the 2017 Veterans Affairs (VA)/Department of Defense (DoD) Clinical Practice Guideline for PTSD emphasize individual, manualized trauma-focused psychotherapies that have a primary component of exposure and/or cognitive restructuring. These include prolonged exposure (PE) therapy, cognitive processing therapy (CPT), eye movement desensitization and reprocessing (EMDR), and others. Accelerated resolution therapy (ART) is an emerging trauma-focused therapy not specifically referenced in the guideline, but one that is consistent with the recommendations and is derived directly from EMDR. One randomized clinical trial and multiple observational studies have suggested that ART can be delivered in an average of just four treatment sessions. This commentary reviews the clinical, empirical, and theoretical rationale for use of ART as a potential first-line PTSD treatment modality in VA and DoD facilities. The clinical protocol of ART is summarized into discrete procedural steps. The theoretical rationale as to how ART may help clients process traumatic memories and resolve symptoms of PTSD is also discussed, including how repeated sets of smooth pursuit horizontal eye movements may facilitate a relaxation response and assist with processing emotionally intrusive memories. Herein, we review primary treatment results from four published studies of ART, including mean symptom score reductions on the 17-item PCL (PTSD checklist) after treatment with ART, along with effect sizes and percentage of treatment responders. Finally, the ART protocol is compared directly against specific recommended elements of trauma-focused therapy described in the VA/DoD Clinical Practice Guideline. The four published studies of ART reviewed (n = 291) included adult civilians and service members/veterans; the mean age was 42.3 ± 12.3 yr and 28.9% were female. Among 237 treatment completers (81.4% of the combined cohort), the mean number of ART sessions received was 3.9 ± 1.1. Across the four studies, mean treatment-related reductions in PCL scores ranged from 15.6 ± 13.2 to 25.6 ± 11.3, with a pooled mean reduction on the PCL of 20.6 ± 15.0. Effect sizes were large and ranged from 1.18 to 2.26 (p< 0.0005) across studies, with a pooled effect size of 1.38 (95% confidence interval: 1.20-1.56, p < 0.0001). Using the clinical cutpoint of >10-point reduction on the PCL instrument, clinically significant change (response) ranged from 63.8% to 100.0% across the four studies, with a pooled treatment response rate of 74.7%. Results were nominally attenuated when conservatively assuming no treatment response for non-completers. The ART protocol contains the core therapeutic elements and aligns closely with the current VA/DoD Clinical Practice Guideline. It has a plausible theoretical rationale and an evolving empirical research base that includes four studies with peer-reviewed publications, one of which was a randomized controlled trial. These features, along with the brevity of the treatment protocol, no requirement for narration, and high provider satisfaction rates, provide a rationale for the potential use of ART as a first-line PTSD treatment modality for active duty and veteran military personnel.

Examination of the World Health Organization Disability Assessment System as a Measure of Disability Severity Among Veterans Receiving Cognitive Processing Therapy.

Cognitive processing therapy (CPT) is effective for reducing posttraumatic stress disorder (PTSD) and depression among military veterans. However, studies have not examined whether CPT is associated with reductions in disability severity. The current study examines the association between disability severity and PTSD and depression among U.S. veterans who are receiving CPT. Veterans completed measures at pre- and posttreatment and received CPT through a Veterans Affairs PTSD outpatient (n = 155) or residential (n = 177) program. The World Health Organization Disability Assessment Schedule (WHODAS) 2.0 was used to assess disability severity. The WHODAS 2.0 scores were positively correlated with clinician- and veteran-rated PTSD and veteran-rated depression at pre- and posttreatment (r = .22 to. 60). Compared with outpatients, veterans in residential treatment had worse scores on the WHODAS Mobility scale (ηp2 = .03), but on no other WHODAS 2.0 scales. Pre- to posttreatment reductions were found on all WHODAS 2.0 subscales (ηp2 = .03 to .15). Reductions in PTSD and depression were positively associated with improvements on the WHODAS 2.0 Summary scale and most subscales (r = .22 to. 52). Findings suggest that the WHODAS 2.0 is a promising disability severity measure for veterans in PTSD treatment. Findings also suggest that CPT may help veterans to achieve reductions in disability severity.

Impacts of the 2010 VA PTSD Rule Change on Veterans’ Disability Compensation and Reported Cognitive Disability

In July 2010, the Department of Veterans Affairs (VA) simplified the process of obtaining veterans’ disability compensation (DC) for veterans with posttraumatic stress disorder (PTSD) who served in...

The influence of veteran race and psychometric testing on veterans affairs posttraumatic stress disorder (PTSD) disability exam outcomes.

This study examined the influence of veterans' race and examiners' use of psychometric testing during a Department of Veterans Affairs posttraumatic stress disorder (PTSD) disability examination on diagnostic and service connection status outcomes. Participants were 764 veterans enrolled in a national longitudinal registry. Current and lifetime PTSD diagnostic status was determined with the Structured Clinical Interview for DSM-IV (SCID) and was compared with PTSD diagnosis conferred upon veterans by their compensation and pension (C&P) examiners as well as with ultimate Veterans Affairs (VA) PTSD service connected status. The concordance rate between independent SCID current PTSD diagnosis and PTSD disability examination diagnosis was 70.4%, and between SCID lifetime PTSD diagnosis and PTSD disability examination diagnosis was 77.7%. Among veterans with current SCID diagnosed PTSD, Black veterans were significantly less likely than White veterans to receive a PTSD diagnosis from their C&P examiner (odds ratio [OR] = .39, p = .003, confidence interval [CI] = .20-.73). Among veterans without current SCID diagnosed PTSD, White veterans were significantly more likely than Black veterans to receive a PTSD diagnosis from their C&P examiner (OR = 4.07, p = .005, CI = 1.51-10.92). Splitting the sample by use of psychometric testing revealed that examinations that did not include psychometric testing demonstrated the same relation between veteran race and diagnostic concordance. However, for examinations in which psychometric testing was used, the racial disparity between SCID PTSD status and disability exam PTSD status was no longer significant. Results suggest that psychometric testing may reduce disparities in VA PTSD disability exam outcomes. (PsycINFO Database Record

Childhood trauma and posttraumatic stress disorder in a real-world Veterans Affairs clinic: Examining treatment preferences and dropout.

The Department of Veterans Affairs (VA) has promoted large-scale dissemination efforts of evidence-based psychotherapies (EBPs) for posttraumatic stress disorder (PTSD). In spite of efforts to make gold-standard treatments available to veterans, few veterans with PTSD receive a full course of psychotherapy. It is unclear if type of trauma experienced is related to treatment initiation and completion. This study aimed to identify patient factors, including experiencing childhood trauma that related to treatment preferences and dropout in a real-world VA PTSD clinic. A chart review was conducted for veterans who were referred for individual EBPs for PTSD (N = 199). Extracted variables included demographics, PTSD symptoms, treatment preferences, and treatment completion/dropout. Veterans choose to engage in individual EBP (48%), group treatment (11%), nontrauma focused psychotherapy (15%), or no psychotherapy (26%). Slightly over half of the veterans who began individual EBP completed it, with no statistical differences in completion rates for prolonged exposure and cognitive processing therapy. Childhood trauma was the second-most common type of trauma experienced, next to combat exposure. Those who completed EBP had higher rates of combat trauma (88%) than noncompleters (70%), and noncompleters (50%) had higher rates of childhood trauma than completers (29%). Regardless of trauma experienced, those who completed an EBP experienced substantial reductions in PTSD symptoms. Assessing veterans for childhood trauma and emotion regulation difficulties may be beneficial even in VA clinics where treatment is most often focused on combat trauma. (PsycINFO Database Record