Assessing and Enhancing Social Support to Improve Treatment Outcomes Among Veterans with PTSD

背景：创伤后应激障碍是退伍军人的一个重要问题，他们中的大多数人最初接受创伤后应激障碍治疗。 压力障碍（PTSD）在初级保健心理健康整合（PCMHI）。在这方面社会支持不佳 人群是自杀意念、全因死亡率和更差治疗参与的风险因素， 反应初步研究表明，大约60%的创伤后应激障碍退伍军人目前的专业 社会支持不足的护理预约。然而，现有的基于PCMHI的治疗方法 PTSD明确地关注社会支持的产生或重新参与。此外，尽管现有的有限 研究表明，指导治疗计划的社会支持的常规评估（也称为 基于测量的护理（MBC）可以改善平民人群的治疗结果，但社会支持不能 作为创伤后应激障碍循证治疗的一部分进行常规监测。因此，该CDA-2将首先识别 在临床护理中常规测量社会支持以改善PTSD的适当工具 治疗，并随后评估一种新的基于PCMHI的PTSD治疗作为阶梯式护理模式的一部分 为退伍军人谁报告穷人的社会支持和创伤后应激障碍治疗无反应的风险很大。 意义/影响：拟议的研究解决了几个HSR&D研究优先事项，包括 评估健康的社会决定因素，即社会支持，对健康的质量和结果的影响， 护理;测试新的精神卫生保健模式，以改善结果;并与脆弱的退伍军人进行干预 创伤后应激障碍和自杀风险通过测量和改善社会支持来加强创伤后应激障碍的治疗， 拟议的研究计划明确解决了一个关键因素，阻碍治疗结果的敏感 退伍军人的人口。创新：尽管社会支持不足被广泛认为是最强的 PTSD发展和维持的预测因子，现有的基于PCMHI的PTSD治疗方法 将社会支持作为主要治疗重点。因此，拟议的CDA-2研究具有很高的 小说过去或现在都没有HSR& D资助的研究测试了监测或改善社会的方法。 支持基于PCMHI的治疗退伍军人创伤后应激障碍，尽管它与临床表现不佳有关， 结果。具体目标：1）选择一个工具，用于退伍军人临床环境中的社会支持MBC 创伤后应激障碍2)迭代地完善并进行一个简单的、基于PCMHI的行为激活的单臂试点测试 和基于关键利益相关者的PTSD社会参与干预（例如，资深和PCMHI供应商） 反馈3)进行一项两组试点随机临床试验（RCT），比较干预与常规护理 在PCMHI。方法：目标1将使用从210名退伍军人中收集的在线调查的定量数据， 评估社会支持的四项指标（通过系统回顾和临床效用确定） 排名）是可接受的，可靠的，敏感的，并选择最好的措施，用于目标2的试点。目标2将 涉及创伤后应激障碍和社会支持干预的反复完善，然后， 与主要利益相关者进行定性访谈。目标2将获得有关参与者可接受性、提供者忠诚度、 和社会支持相关的MBC。社会支持和PTSD干预与常规干预的比较 目标3中的护理将评估招募、随机化、干预的可行性和可接受性 临床结果的参与、评估策略和结果测量（例如，创伤后应激障碍抑郁症 症状和社会支持），以及变化机制（例如，披露）和多步护理 结果（例如，临床指示的基于证据的心理治疗开始/保持）。下 步骤/实施：这项工作将支持未来的试验，以确定有效性和实施 干预的潜力，以及社会支持的MBC模型。未来的研究将探索MBC 和PCMHI为基础的干预措施，为穷人的社会支持，在相关的条件。

Background: PTSD is a significant problem for Veterans, most of whom are initially treated for posttraumatic stress disorder (PTSD) in Primary Care Mental Health Integration (PCMHI). Poor social support in this population is a risk factor for suicidal ideation, all-cause mortality, and worse treatment engagement and response. Preliminary research shows that approximately 60% of Veterans with PTSD present to specialty care intake appointments with poor social support. However, none of the existing PCMHI-based treatments for PTSD explicitly focus on social support generation or reengagement. Moreover, although the limited existing research suggests that the routine assessment of social support to guide treatment planning (also known as measurement-based care, or MBC) improves treatment outcomes in civilian populations, social support is not routinely monitored as part of evidence-based treatments for PTSD. Thus, this CDA-2 will first identify an appropriate instrument for routinely measuring social support in the context of clinical care to improve PTSD treatment, and, subsequently, evaluate a novel PCMHI-based PTSD treatment as part of a stepped care model for Veterans who report poor social support and are at great risk of PTSD treatment non-response. Significance/Impact: The proposed research addresses several HSR&D research priorities, including evaluating the impact of social determinants of health, namely, social support, on the quality and outcomes of care; testing new models of mental health care to improve outcomes; and intervening with vulnerable Veterans with PTSD and suicide risk. By measuring and improving social support to enhance PTSD treatment, the proposed research plan explicitly addresses a key factor that impedes treatment outcomes for a sensitive population of Veterans. Innovation: Although poor social support is widely recognized as among the strongest predictors of PTSD development and maintenance, none of the existing PCMHI-based treatments for PTSD target or measure social support as a primary treatment focus. The proposed CDA-2 research is thus highly novel. No past or present HSR&D-funded studies have tested methods for monitoring or improving social support in PCMHI-based treatment among Veterans with PTSD, despite its association with poor clinical outcomes. Specific Aims: 1) Select an instrument for MBC of social support in clinical settings for Veterans with PTSD. 2) Iteratively refine and conduct a one-arm pilot test a brief, PCMHI-based behavioral activation and social engagement intervention for PTSD based on key stakeholder (e.g., Veteran and PCMHI provider) feedback. 3) Conduct a two-arm pilot randomized clinical trial (RCT) comparing the intervention to usual care in PCMHI. Methodology: Aim 1 will use quantitative data gathered in an online survey from 210 Veterans to assess the degree to which four measures of social support (identified via systematic review and clinical utility ranking) are acceptable, reliable, and sensitive, and select the best measure for use in Aim 2’s pilot. Aim 2 will involve the iterative refinement of the PTSD and social support intervention following, and followed by, qualitative interviews with key stakeholders. Aim 2 will obtain data on participant acceptability, provider fidelity, and social-support-related MBC. The pilot RCT comparing the social support and PTSD intervention to usual care in Aim 3 will evaluate the feasibility and acceptability of recruitment, randomization, intervention engagement, evaluation strategy, and outcome measurement of clinical outcomes (e.g., PTSD, depression symptoms, and social support), as well as mechanisms of change (e.g., disclosure) and multiple stepped-care outcomes (e.g., clinically-indicated evidence-based psychotherapy initiation/retention). Next Steps/Implementation: This work will support future trials establishing effectiveness and implementation potential of the intervention, as well as a model of MBC of social support. Future research will explore MBC and PCMHI-based interventions for poor social support in related conditions.