Multisite RCT of STEP-Home: A transdiagnostic skill-based community reintegration workshop

9/11后，来自持久自由和伊拉克自由行动（OEF/OIF）的退伍军人代表了一个临床 复杂的群体，他们需要非污名化和多学科干预，有效地针对他们的 许多合并症与轻度创伤性脑损伤和创伤后应激障碍有关。研究表明，A 大多数退伍军人在从战场上回来后，很难重新适应平民生活 包括关系困难，冲动和危险行为，增加物质使用， 愤怒控制问题心理健康问题经常被认为是造成这些困难的原因。不幸的是， 这群退伍军人也被证明对心理健康治疗有很强的抵抗力， 很难参与，显示出高比率的预约不出现和调度困难。我们建议 越来越多的退伍军人需要综合的、跨诊断的干预措施， 适合他们提出的一系列治疗挑战，同时也是可口和迷人的。到 为了解决这一治疗差距，我们为退伍军人开发了STEP-Home研讨会， 在最近完成的RR & D SPiRE奖（2014- 2016）。在这份绩效审查提案中，我们建议在这些发现的基础上， 在多中心随机对照试验中，将STEP-Home重返工作坊应用于疗效阶段。步骤- 家庭是一个为期12周，每周2小时的重返社会讲习班，旨在帮助所有后9/11退伍军人（与和 没有精神病和/或神经病诊断史），并发展技能，以提高他们的 帮助他们控制愤怒/冲动，并协助他们在退伍后重新融入平民生活和工作生活。核心技能和 该计划的内容是新颖的，在他们的集体使用，并没有被应用到退伍军人人口之前， 我们的SPiRE可行性研究我们将进行一项多中心（TRACTS Boston; TRACTS Houston）随机 STEP-Home对照试验（26个研讨会; 8名退伍军人/研讨会;总数= 208）。我们有两个主要目标， 这个提议。首先，我们将检查STEP-Home对主要结局的治疗效果， 主动控制条件（当前中心组治疗）。第二，我们会评估 治疗效果的主要结果。作为一个探索性的目标，我们将检查STEP的治疗效果- 家庭心理健康，功能和职业状况以及认知次要结果的测量 在工作坊中，间接。最后，在第二个探索性目标中，我们将确定 对主要结果的治疗是通过获得核心技能/关键成分（问题 解决、情绪调节、注意力训练）。成功地实现所提出的目标， 有可能显著提高技能，促进9/11后退伍军人重返平民社会。而且 STEP-Home SPiRE可行性研究表明，该研讨会也可作为退伍军人的门户 他们不愿意参加传统的心理健康治疗，以促进开放和参与， 额外的，急需的，VA服务。鉴于该队列中治疗耐药率较高， 可接受的干预措施，促进治疗参与和保留，并为未来的VA打开大门 护理，是必要的，以改善功能状态，并减少长期的医疗保健费用未经治疗的精神 健康疾病。

Post-9/11 Veterans from Operations Enduring Freedom and Iraqi Freedom (OEF/OIF) represent a clinically complex group who require non-stigmatizing and multidisciplinary interventions that effectively target their many comorbidities associated with mild TBI and posttraumatic stress disorder. Research indicates that a majority of combat Veterans experience difficulty in readjusting to civilian life after returning from combat including relationship difficulties, impulsive and dangerous behavior, increased substance use, and increased anger control problems. Mental health problems are frequently cited as driving these difficulties. Unfortunately, this group of Veterans has also been demonstrated to be highly resistant to mental health treatment and difficult to engage, showing high rates of appointment no-shows and scheduling difficulties. We propose this growing group of Veterans requires integrative, transdiagnostic (across diagnoses) interventions that will be appropriate for the range of treatment challenges they present while also being palatable and engaging. To address this treatment gap, we have developed the STEP-Home workshop for returning Veterans and demonstrated its feasibility and preliminary effectiveness in a recently completed RR&D SPiRE award (2014- 2016). In this Merit Review proposal, we propose to build on those findings and advance the development of the STEP-Home reintegration workshop to the efficacy stage in a multisite randomized controlled trial. STEP- Home is a 12-week, 2 hour/week reintegration workshop designed to assist all post-9/11 Veterans (with and without a history of psychiatric and/or neurologic diagnoses) with developing skills to improve their anger/impulse control and assist their reintegration to civilian and work life after the military. The core skills and content of the program are novel in their collective use and have not been applied to a Veteran population prior to our SPiRE feasibility study. We will conduct a multisite (TRACTS Boston; TRACTS Houston), randomized controlled trial of STEP-Home (26 workshops; 8 Veterans/workshop; total=208). We have two primary aims in this proposal. First, we will examine the treatment effects of STEP-Home on primary outcomes relative to an active control condition (Present Centered Group Therapy). Second, we will assess the maintenance of treatment effects for our primary outcomes. As an exploratory aim, we will examine treatment effects of STEP- Home on measures of mental health, functional and vocational status and cognitive secondary outcomes targeted indirectly in the workshop. Last, in a second exploratory aim, we will determine if the effect of treatment on the primary outcomes is mediated by the acquisition of core skills/key ingredients (problem solving, emotional regulation, attention training). The successful completion of the aims proposed has the potential to significantly improve skills to foster civilian reintegration in post-9/11Veterans. Furthermore, the STEP-Home SPiRE feasibility study demonstrated that the workshop also serves as a gateway for Veterans who are hesitant to participate in traditional mental health treatments to promote openness and engagement in additional, critically needed, VA services. Given the high rate of treatment resistance in this cohort, developing acceptable interventions that promote treatment engagement and retention, and open the door to future VA care, is necessary to improve functional status and to reduce long-term healthcare costs of untreated mental health illnesses.