Improving PTSD Service Delivery for Veterans with Severe Mental Illness

改善患有严重精神疾病的退伍军人的创伤后应激障碍（PTSD）服务

• 批准号: 8278139
• 负责人: ANOUK L GRUBAUGH
• 金额: --
• 依托单位: RALPH H JOHNSON VA MEDICAL CENTER
• 依托单位国家: 美国
• 财政年份: 2012
• 资助国家: 美国
• 起止时间: 2012-04-01 至 2016-03-31
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/8278139
• 关键词: Acute; Address; Adult; Aftercare; Age; Ambulatory Care Facilities; Area; Beds; Bipolar Disorder; Caring; Case Management; Catchment Area; Clinical; Clinical Trials; Cognitive Therapy; Communities; Community Mental Health Centers; Comorbidity; Consent; Data; Dependence; Diagnosis; Distress; Enrollment; Exclusion; Female; Fright; Gender; General Population; Health Services; Healthcare; Healthcare Systems; Hospitalization; Individual; Intervention; K-Series Research Career Programs; Life; Literature; Living Costs; Medical center; Medication Management; Mental Depression; Mental Health; Mental disorders; Mentally Ill Persons; Methods; Mission; Outcome; Participant; Patients; Population; Post-Traumatic Stress Disorders; Process; Psyche structure; Psychotic Disorders; Public Hospitals; Public Sector; Quality of life; Race; Randomized; Randomized Controlled Trials; Recording of previous events; Relative (related person); Research; Rural; Schizophrenia; Services; Severities; Social Adjustment; Substance abuse problem; Symptoms; Therapeutic; Trauma; Veterans; Victimization; base; behavioral health; comparative efficacy; cost; cost effectiveness; depressive symptoms; effective therapy; evidence base; follow-up; group intervention; health administration; improved; indexing; intervention effect; male; patient population; satisfaction; severe mental illness; standard of care; success; suicidal; treatment adherence; treatment as usual; trial comparing

DESCRIPTION (provided by applicant): Anticipated Impact on Veterans Health Care: As in the general population, there is no clear standard of care within Veterans Affairs Medical Centers for treating posttraumatic stress disorder (PTSD) among individuals with severe forms of mental illness. This is a considerable issue because trauma, PTSD, and psychiatric comorbidity are particularly common among Veterans and such comorbidity clearly exacerbates the overall course and severity of mental illness. This study is significant in that it proposes to establish the efficacy of a frontline intervention for PTSD, Prolonged Exposure, in Veterans treated within the VA healthcare system. In this regard, data from this project will be used to establish a clear, and much needed, clinical course of action for severely mentally ill Veterans suffering from PTSD. Background: Rates of trauma and PTSD are higher among individuals with severe mental illness (SMI; i.e., bipolar disorder, schizophrenia) relative to the general population. Trauma, particularly sexual victimization, and PTSD are also strongly correlated with psychiatric difficulties, decreased quality of life, and increased service use in this population. Despite the high rate of PTSD, and its clear negative impact on functioning among individuals with SMI, there are few empirical data on how to effectively treat trauma related symptoms in this patient population. This is due in large part to the historical exclusion of individuals with SMI from PTSD clinical trials. Within clinical settings as well, however, clinicians are reluctant to treat trauma and PTSD among their patients with SMI for fear of exacerbating their primary symptoms. As such, most individuals with SMI do not participate in trauma/PTSD research, are not treated for their trauma/PTSD symptoms within the public sector settings where they are cared for, and as such, continue to suffer from PTSD related symptoms and distress. This issue is particularly salient for Veterans who typically suffer from high rates of trauma exposure, PTSD, and psychiatric comorbidity relative to the general population. Objectives: The primary objectives of this study are to compare Prolonged Exposure for PTSD (PE) plus treatment as usual (TAU) relative to TAU alone across relevant health services outcomes such as a) clinical symptoms of PTSD; b) indices of quality of life and social adjustment; c) process outcomes, such as treatment credibility, satisfaction with services, therapeutic alliance, and treatment adherence; and d) cost indices. Some additional objectives are to a) determine the impact of PE+TAU on the primary symptoms of severe mental illness (i.e., psychosis, unipolar and/or bipolar depressive symptoms) relative to TAU alone and b) to determine if clinical, quality of life, and process variables (i.e., health services variables) vary by rural/urban living status, race, gender, and/ o primary diagnosis of severe mental illness. Collectively, these data will establish a clear standard of care for Veterans with PTSD and SMI who are treated within VA healthcare settings. Method: To achieve the above objectives, we will conduct a randomized controlled trial comparing PE+TAU to TAU alone across critical health services outcomes. Specifically, we will enroll 156 (n=78 per group) ethnically diverse male and female Veterans with PTSD and a diagnosis of SMI (i.e., a psychotic disorder, bipolar disorder, or severe depression) from the Charleston VA catchment area. Recruitment and consent will take place at the Charleston VA or affiliated community-based outpatient clinics (CBOCs). Veterans will be randomized to PE+TAU or TAU alone and evaluated at post, 3, and 6 months. Veterans in the PE+TAU condition will receive12 sessions of PE at the Charleston VA in addition to the regular standard of care for Veterans with SMI (TAU; i.e., case management services, psychotropic medication management). Participants will be > 21 with PTSD and SMI. Veterans with a recent history of psychiatric hospitalization or suicidal intent and/or who have active substance abuse/dependence will be excluded from participation.

描述（由申请人提供）： 对退伍军人医疗保健的预期影响：与一般人群一样，退伍军人事务医疗中心对于治疗患有严重精神疾病的个人的创伤后应激障碍 (PTSD) 没有明确的护理标准。这是一个相当大的问题，因为创伤、创伤后应激障碍和精神合并症在退伍军人中尤其常见，而且这种合并症明显加剧了精神疾病的整体病程和严重程度。这项研究的意义重大，因为它建议在 VA 医疗系统内接受治疗的退伍军人中建立针对 PTSD（长期暴露）的一线干预措施的有效性。在这方面，该项目的数据将用于为患有创伤后应激障碍（PTSD）的严重精神疾病退伍军人制定明确且急需的临床行动方案。背景：与一般人群相比，严重精神疾病（SMI；即双相情感障碍、精神分裂症）患者的创伤和创伤后应激障碍（PTSD）发生率较高。创伤，特别是性受害和创伤后应激障碍也与该人群的精神困难、生活质量下降和服务使用增加密切相关。尽管 PTSD 的发病率很高，而且它对 SMI 患者的功能有明显的负面影响，但关于如何有效治疗该患者群体的创伤相关症状的经验数据却很少。这在很大程度上是由于历史上将患有 SMI 的个体排除在 PTSD 临床试验之外。然而，在临床环境中，临床医生也不愿意治疗 SMI 患者的创伤和 PTSD，因为担心会加剧他们的主要症状。因此，大多数 SMI 患者没有参与创伤/PTSD 研究，也没有在他们接受护理的公共部门环境中接受创伤/PTSD 症状的治疗，因此继续遭受 PTSD 相关症状和痛苦。对于退伍军人来说，这个问题尤其突出，与普通人群相比，他们通常遭受创伤暴露、创伤后应激障碍和精神共病的比例较高。目的：本研究的主要目的是比较长期暴露 PTSD (PE) 加照常治疗 (TAU) 与单独 TAU 的相关卫生服务结果，例如 a) PTSD 的临床症状； b) 生活质量和社会适应指数； c) 处理结果，例如治疗可信度、服务满意度、治疗联盟和治疗依从性； d) 成本 指数。一些额外的目标是 a) 确定 PE+TAU 相对于单独 TAU 对严重精神疾病主要症状（即精神病、单相和/或双相抑郁症状）的影响，以及 b) 确定临床、生活质量是否和过程变量（即卫生服务变量）因农村/城市生活状况、种族、性别和/或严重精神疾病的初步诊断而异。总的来说，这些数据将为在 VA 医疗机构中接受治疗的患有 PTSD 和 SMI 的退伍军人建立明确的护理标准。方法：为了实现上述目标，我们将进行一项随机对照试验，比较 PE+TAU 与单独 TAU 的关键卫生服务结果。具体来说，我们将从查尔斯顿弗吉尼亚州学区招募 156 名（每组 78 名）患有 PTSD 并诊断为 SMI（即精神障碍、双相情感障碍或严重抑郁症）的不同种族的男性和女性退伍军人。招募和同意将在查尔斯顿退伍军人管理局或附属社区门诊诊所 (CBOC) 进行。退伍军人将被随机分配接受 PE+TAU 或单独 TAU，并在术后、3 个月和 6 个月时进行评估。除了 SMI 退伍军人的常规标准护理（TAU；即病例管理服务、精神药物管理）之外，处于 PE+TAU 状况的退伍军人还将在查尔斯顿 VA 接受 12 次 PE 治疗。参与者年龄 > 21 岁，患有 PTSD 和 SMI。最近有精神病住院史或有自杀倾向和/或有活性物质滥用/依赖性的退伍军人将被排除在参与之外。