Improving Function Through Primary Care Treatment of PTSD

通过 PTSD 的初级保健治疗改善功能

• 批准号: 10268183
• 负责人: SHEILA A.M. RAUCH
• 金额: --
• 依托单位: VETERANS HEALTH ADMINISTRATION
• 依托单位国家: 美国
• 财政年份: 2018
• 资助国家: 美国
• 起止时间: 2018-10-01 至 2023-09-30
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/10268183
• 关键词: Address; Afghanistan; Aftercare; Behavior Therapy; Caring; Chronic Post Traumatic Stress Disorder; Clinic; Clinical; Clinical Practice Guideline; Clinical Research; Conflict (Psychology); Diagnosis; Diagnostic; Effectiveness; Event; Evidence based treatment; Exclusion Criteria; Exposure to; Goals; Health; Health Personnel; Health Services Accessibility; Health Surveys; Healthcare; Individual; Infrastructure; Intention; Intervention; Iraq; Life; Measures; Medication Management; Mental Depression; Mental Health; Military Personnel; Modeling; Monitor; Motivation; Outcome; Patient Self-Report; Patients; Pharmaceutical Preparations; Pilot Projects; Post-Traumatic Stress Disorders; Primary Health Care; Probability; Protocols documentation; Psychotherapy; Quality of life; Questionnaires; Randomized; Randomized Clinical Trials; Randomized Controlled Trials; Recovery; Reporting; Research; Research Design; Research Personnel; Research Priority; Resources; Role; Services; Severities; Symptoms; Testing; Training; Translating; Treatment Protocols; Veterans; Work; World Health Organization Disability Assessment Schedule; attentional control; base; behavioral health; brief intervention; care seeking; combat; cost; effective intervention; effective therapy; evidence base; experience; follow up assessment; follow-up; functional disability; functional outcomes; implementation strategy; improved; improved functioning; medical specialties; meetings; military treatment facility; primary outcome; recruit; seal; service member; standard of care; treatment as usual; treatment choice

Posttraumatic stress disorder (PTSD) is a debilitating and costly mental health issue (Greenberg, Sisitsky et al. 1999, Hoge, Terhakopian et al. 2007). RAND reported an estimated two-year cost of $4.0 to $6.2 billion US dollars for mental health issues from the current conflicts in Iraq and Afghanistan and further estimated that providing evidence-based treatments for PTSD and depression could save an estimated $86.2 million (Tanielian, et al. 2008). Even modest reductions in PTSD severity have been related to increased probability of positive function outcomes (Smith, et al. 2005). Prolonged Exposure (PE) therapy (Foa, et al. 2000, Foa, et al. 2005, Schnurr, et al. 2007) is an effective, first-line treatment for PTSD (IOM 2007, VA/DOD 2010). While highly effective, PE is provided in specialty mental health settings typically in 8 to 15, weekly 90 minute individual sessions. Veterans with PTSD are often reluctant to seek care in specialty mental health, and, as a result, many are treated solely in primary care and do not have access to this effective intervention (Possemato, et al. 2011). While the DoD and VA have actively integrated behavioral health providers into their primary care clinics (Maguen, et al. 2010, Seal, et al. 2011), current behavioral interventions for PTSD in primary care are often inconsistent with clinical practice guidelines and/or not effective (Possemato, et al. 2011). Since functional outcomes are critical, we intend to extend beyond assessing the impact of PE-PC on clinical outcomes to function. Thus, there is a clear and urgent need to further develop, validate, and disseminate evidence-based psychotherapeutic treatments for PTSD in integrated VHA PC-MHI with a focus on functional outcomes. To fill this need and gap in care the study investigators developed a Brief Prolonged Exposure for Primary Care (PE-PC) treatment protocol with 4, 30-minute sessions for use in a stepped care model. A pilot study in military treatment facilities found PE-PC resulted in reductions in PTSD that were maintained at 6- and 12-month follow-up (Cigrang, et al, 2015). Preliminary results from a randomized controlled trial (RCT; PI: Cigrang; CoI: Rauch) of PE-PC compared to minimal attention control (MAC, including continuation of any PC initiated treatment) found a significantly larger reduction in PTSD severity (measured by PCL) in PE-PC than MAC (between group d = .78, p = .01). The strength of these initial findings is limited by lack of functional outcomes and examination of impact in VHA. While Service Members and Veterans have many similarities, potential differences in motivation for treatment and other factors may influence the efficacy of the protocol especially when examining changes in function. The proposed study will randomize 120 Veterans at Ralph H. Johnson VAMC presenting in primary care with PTSD who meet minimal inclusion/exclusion criteria to 6 weeks of PE-PC or PC-MHI-treatment as usual (TAU). Recruitment will occur over 36 months. All Veterans will complete a baseline assessment prior to randomization and post- treatment follow-up assessments at Weeks 6, 12, and 24 post-randomization. Primary outcome will be function assessed as self-reported role function in several domains. In addition, we will examine symptoms severity and effectiveness, acceptability, and utilization associated with PE-PC or PCMHI-TAU in the 6 months prior to randomization and 6 months following treatment completion. PE-PC may allow access to effective treatment and efficient allocation of PTSD specialty treatment resources in the VHA. This topic is of key relevance to Veteran mental health care and can provide a new access point for high quality PTSD care to improve function allowing many more Veterans to experience improvement.

创伤后应激障碍（PTSD）是一个令人衰弱且昂贵的心理健康问题（Sisitsky Greenberg，Sisitsky 等。 1999年，Hoge，Terhakopian等。 2007）。兰德报告说，估计为4.0美元至6.2美元的两年成本 伊拉克和阿富汗目前的冲突以及进一步的进一步的心理健康问题的十亿美元 估计为PTSD和抑郁症提供基于证据的治疗可以节省估计的 8620万美元（Tanielian等人，2008年）。即使是PTSD严重程度的适度降低也与 正功能结果的可能性增加（Smith等，2005）。长时间暴露（PE） 治疗（FOA等，2000，FOA等，2005； Schnurr等人2007）是一种有效的一线治疗方法 PTSD（IOM 2007，VA/DOD 2010）。虽然非常有效，但在特种心理健康中提供了PE 设置通常在8至15个，每周90分钟的个人会议中。具有PTSD的退伍军人通常不愿 寻求专业心理健康的护理，结果，许多人仅在初级保健中受到治疗 可以使用这种有效的干预措施（Possemato等，2011）。国防部和弗吉尼亚州积极 综合行为健康提供者进入其初级保健诊所（Maguen等，2010，Seal等。 2011年），初级保健中PTSD的当前行为干预通常与临床不一致 实践指南和/或无效（Possemato等，2011）。由于功能结果至关重要，我们 打算扩展超出评估PE-PC对临床结果功能的影响。因此，有一个 明确而迫切的需要进一步发展，验证和传播基于证据的心理治疗 在综合VHA PC-MHI中的PTSD处理，重点是功能结果。满足这一需求 研究人员的差距研究人员在初级保健（PE-PC）的长时间暴露中开发了一个短暂的暴露。 在阶梯护理模型中使用4个，30分钟的课程。一项军事试点研究 治疗设施发现PE-PC导致PTSD降低，该PTSD保持在6个月和12个月 随访（Cigrang等人，2015年）。从随机对照试验（RCT； PI：Cigrang）的初步结果； PE-PC的COI：RAUCH）与最少的注意力控制（MAC，包括任何PC的延续） 开始治疗）发现PE-PC中PTSD严重程度的降低明显更大（由PCL衡量） 比MAC（d = .78组之间，p = .01）。这些初步发现的优势受到缺乏的限制 功能结果和VHA影响的检查。服务成员和退伍军人有很多 相似性，治疗动机的潜在差异和其他因素可能会影响 该协议尤其是在检查功能变化时。拟议的研究将随机化120 拉尔夫·H·约翰逊·瓦姆（Ralph H. 像往常一样（tau）将包含/排除标准限制在PE-PC或PC-MHI-6周。招聘会 发生36个月。所有退伍军人将在随机分组之前完成基线评估 在随机后第6、12和24周的治疗随访评估。主要结果将是 在多个领域中评估为自我报告的角色功能的功能。此外，我们将检查 与PE-PC或PCMHI-TAU相关的症状严重性和有效性，可接受性和利用率 在随机分组前的6个月和治疗完成后6个月。 PE-PC可能允许 在VHA中获得有效的治疗和有效分配PTSD专业治疗资源。 该主题与资深心理保健的关键相关，可以为高高提供一个新的访问点 优质的PTSD护理可以提高功能，从而使更多的退伍军人得到改善。