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The National Center for Posttraumatic Stress Disorder (PTSD)

The National Center for Posttraumatic Stress Disorder (PTSD). Paula P. Schnurr, PhD Acting Executive Director Research Professor of Psychiatry, Geisel School of Medicine at Dartmouth

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The National Center for Posttraumatic Stress Disorder (PTSD)

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  1. The National Center for Posttraumatic Stress Disorder (PTSD) Paula P. Schnurr, PhD Acting Executive Director Research Professor of Psychiatry, Geisel School of Medicine at Dartmouth Presentation to the Institute of Medicine Committee to Evaluate the Department of Veterans Affairs Mental Health Services June 5, 2014

  2. Overview of the National Center for PTSD • Congressional Mandate, Public Law 98-528 98 Stat. 2686 (1984) • “carry out and promote the training of health care and related personnel in, and research into, the causes and diagnosis of PTSD and the treatment of Veterans for PTSD” • “serve as a resource center for, and promote and seek to coordinate the exchange of information regarding all research and training activities carried out by the Veterans’ Administration, and by other Federal and non-Federal entities, with respect to PTSD” • Mission: To promote the best clinical care and functional status of Veterans through research, education, and training related to the etiology, diagnosis, and treatment of PTSD and stress-related disorders • Center activities • Research, education, and consultation; no direct patient care • Majority of efforts are relevant to Veterans of all eras; some OEF/OIF/OND specific

  3. Our Organization • Opened in August 1989

  4. Hub-and-Spoke Organization

  5. Research Related to PTSD in Veterans of Operation Enduring Freedom/ Operation Iraqi Freedom /Operation New Dawn (OEF/OIF/OND)

  6. CSP # 566: Neuropsychological and Mental Health Outcomes of Operation Iraqi Freedom (OIF): A Longitudinal Cohort Study (Vasterling) • N = 961 male and female active-duty Army soldiers assessed 2003 and again 2005 • 654 deployed between assessments; 307 not deployed • Initial paper found deployment was associated with mild deficits in sustained attention and visual-spatial memory and enhanced reaction time • Related grant: Family Adaptation to OIF Deployment (Vasterling & Taft)

  7. Project VALOR: Veterans After-Discharge Longitudinal Registry (Keane) • N = 1,600 male and female OEF/OIF/OND Veterans • 1,200 w/medical record-based PTSD diagnosis • 400 w/o medical record-based PTSD diagnosis • Recent paper reported on agreement between VA administrative diagnoses and the Structured Clinical Interview for Diagnostic and Statistical Manual-IV; good agreement but some discrepancies

  8. Randomized Controlled Trial of Acceptance and Commitment Therapy (ACT) for Distress and Impairment in OEF/OIF Veterans (Lang & Schnurr) N = 160 male and female OEF/OIF Veterans randomized to ACT or present-centered therapy Statistically significant change over time (Cohen’s d = .78) but ACT was not more effective than present-centered therapy Clinical Caseness

  9. Predicting Post-Deployment Mental Health Substance Abuse and Services Needs(Eisen; Vogt, co-Investigator) • N = 596 male and female OEF/OIF Veterans surveyed 3-12 months after return from deployment • Major paper reported a lack of gender differences in response to combat

  10. Web-based Behavioral Intervention for Returning Veterans with Risky Alcohol Use (Keane) • VetChange: Randomized clinical trial of a self-management web intervention for 600 OEF/OIF/OND Veterans with alcohol abuse found that the intervention was effective for both alcohol use and PTSD symptoms (Brief et al., 2013)

  11. Improving Knowledge and Assessment of PTSD and Related Issues • Consortium to Alleviate PTSD (CAP) (Peterson & Keane) • Partnership between VA and Department of Defense (DoD); continues ongoing collaboration w/DoD in STRONG STAR • Assessment • VA DSM-IV to DSM-5 Crosswalk Study (75% OEF/OIF/OND; Miller) • Deployment Risk and Resilience Inventory-2 (Vogt) updated to ensure relevance to OEF/OIF/OND • Updated Center’s PTSD assessment instruments for DSM-5: Primary Care PTSD Screen (PC-PTSD); PTSD Checklist (PCL); Clinician Administered PTSD Scale (CAPS) • Intimate Partner Violence Screening Tool (Iverson) • Work and Family Functioning in Women Veterans (Vogt & Smith) • PTSD, Traumatic Brain Injury, and Neuropsychological Factors in Partner Violence Among Veterans (Taft)

  12. Optimizing Treatment Efficiency and Supporting Implementation of Evidence-based Care • Comparative effectiveness • CSP #591: CERV-PTSD: Comparative Effectiveness Research in Veterans with PTSD (Schnurr, Chard, & Ruzek) • Trazodone Hydrochloride as an Adjunct to Antidepressants for Treatment of Combat-Related PTSD in OIF/OEF/OND Servicemembers and Veterans (Krystal & Wynn, pending) • Treatment format • Group Cognitive Behavioral Therapy for Chronic PTSD: A Randomized Clinical Trial (Sloan) • Variable Length Cognitive Processing Therapy for Combat-Related PTSD (Resick & Wachen) • Evidenced-based treatment implementation • Sustained Use Of Evidence-Based PTSD Treatment in VA Residential Settings (Cook) • Promoting Effective, Routine, and Sustained Implementation of Stress Treatments (Sayer& Rosen) • Initiative to address over-prescribing of benzodiazepines in PTSD (Bernardy)

  13. Using Technology to Increase Treatment Reach and Engagement • Group Cognitive Processing Therapy (CPT) delivered to veterans via telehealth (Morland et al., 2011): First randomized clinical trial evaluating CPT via video teleconferencing compared to in-person modality • Results showed feasibility, safety, and efficacy • TelementalHealth and CPT for Rural Combat Veterans with PTSD (Morland) • Telephone case monitoring of Veterans following discharge from PTSD treatment (Rosen) • Helping Families Help Veterans with PTSD and Alcohol Abuse: A Randomized Clinical Trial of VA Community Reinforcement and Family Training (Erbes & Kuhn)

  14. Using Technology to Increase Treatment Reach and Engagement PTSD Coach Online: Evaluation (in progress) in large nationally-representative sample with various PTSD severity suggests immediate positive effects on stress and coping

  15. Using Technology to Increase Treatment Reach and Engagement • PTSD Coach Mobile Phone App: Veterans were very satisfied with the app and found it helpful for education, coping, and accessing resources (Kuhn et al., 2014) • In progress: • Telephone and Mobile Apps Intervention for Patients in Primary Care and PTSD Outpatient (Tiet, Rosen, & Leyva) • Study of CBT-Insomnia Coach app for student Veterans to improve sleep, other mental health symptoms, and academic functioning (in preparation; McCaslin)

  16. Educational Initiatives Related to PTSD in OEF/OIF/OND Veterans

  17. Initiatives for Veterans Veteran Outreach and Engagement Returning from the War Zone AboutFace Whiteboard videos Veteran Self-Help and Treatment Support Self-help and Support Apps VetChange PTSD Coach Online

  18. Initiatives for Providers and Others PTSD 101 Clinical Skills Training Iraq War Clinician Guide War Zone to the Home Front ToolkitsPTSD Awareness video

  19. Implementation and Evaluation of the Work of the National Center for PTSD (NCPTSD) within VA

  20. Improving PTSD Diagnosis and Assessment • Use of NCPTSD assessment tools within VA • Primary Care-PTSD screen is a mandated performance measure • PCLused in EBT national trainings and planned measurement-based care • Clinician Administered PTSD Scale (CAPS) used in research and clinical care and planned for use by in Compensation and Pension (C&P) exams • Intimate partner violence (IPV) screen allows VA providers to efficiently detect possible IPV and provide appropriate care • Dissemination and training in NCPTSD assessment tools • Developing CAPS-5 overview course and extensive CAPS-5 online training for VA C&P and non-C&P providers • NCPTSD guideline and White Paper on use of standardized assessment in C&P Exams • Randomized clinical trial of standardized assessment and efforts to implement CAPS in C&P exams

  21. Improving PTSD Care • Practice guidelines and consensus/training conferences • Lead role in development of VA/DoD Clinical Practice Guideline for PTSD (2004, 2010) and revisions • Major role in PTSD/TBI/Pain and PTSD/Substance Use Disorder Consensus Conferences (2009); developed best practice recommendations for assessment and treatment • Iraq War Clinician Guide (2003) helped prepare VA and DoD to serve personnel returning from Iraq • Coordinated VA PTSD/Primary Care Summit with VA Headquarters (1999) • Co-sponsored first national training conference on African-American Veterans and PTSD (1994) • Results of risperidone study (CSP #504) led to change in VA/DoD Practice Guideline for PTSD

  22. Improving PTSD Care • Research on Cognitive Processing Therapy (CPT) led to VA national training in CPT (initiated 2006) • 5,069 VA and Vet Center clinicians have attended the CPT training • Research on Prolonged Exposure (PE) led to VA national training in PE (initiated 2007) • 1,667 VA clinicians have attended the PE training • Program evaluation data show clinically meaningful improvement in PTSD in Vietnam, OEF/OIF/OND, and Persian Gulf Veterans (Chard et al., 2012; Eftekhari et al., 2013)

  23. PTSD Outcomes among Veterans Treated in VA’s National Training Initiative of Prolonged Exposure —Eftekhari et al., 2013; N = 1,888; data presented are from intention-to-treat analysis.

  24. Supporting Evidence-based PTSD Care via VA Program and Provider Support • VA Mentoring Program (Created 2008) • Provides guidance on administrative challenges to encourage implementation of evidence-based treatment for PTSD within PTSD specialized clinics • 2013 evaluation: Mentors found program helpful in connecting to other PCTs and clinicians, informing about VA leadership goals and priorities, learning about innovations in PTSD care, and meeting VA PTSD performance standards • VA PTSD Consultation Program (Created 2011) • Advises VA clinicians on PTSD, with major emphasis on effective use of the 2010 VA/DoD Clinical Practice Guideline for PTSD and use of evidence-based treatment • Includes monthly training webinar, with up to 800 attendees per month

  25. Challenges to Providing Adequate Mental Health Services to OEF/OIF/OND Veterans • Stigma and negative beliefs about mental health treatment hold back Veterans not yet in VA care from seeking mental health care • Veterans already in VA may wait to seek MH care or remain in treatment only when problems are severe • Diversity within the cohort and with prior cohorts in characteristics and needs (e.g., women with combat exposure, expanded hours for working Veterans) • Preference for psychotherapy over medications requires adequate number of providers trained in evidence-based psychotherapy • Provider misperceptions that OEF/OIF/OND Veterans not appropriate for Cognitive Processing Therapy or Prolonged Exposure (e.g., due to acute problems or TBI)

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