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）是一种使人衰弱且代价高昂的心理健康问题（Greenberg，Sisitsky 等人，1999年; Hoge，Terhakopian等人，2007年）。兰德公司报告说，估计两年的成本为4.0至6.2美元 10亿美元用于目前伊拉克和阿富汗冲突中的心理健康问题， 估计为创伤后应激障碍和抑郁症提供循证治疗可以节省估计的 8，620万美元（Tanielian等人，2008年）。即使PTSD严重程度的轻微降低也与 积极功能结局的概率增加（Smith等人，2005）。长期暴露（PE） 治疗（Foa，et al. 2000，Foa，et al. 2005，Schnurr，et al. 2007）是一种有效的一线治疗， 创伤后应激障碍（IOM 2007，VA/DOD 2010）。虽然非常有效，但体育课程在专业心理健康领域提供 设置通常在8至15，每周90分钟的个人会议。患有创伤后应激障碍的退伍军人通常不愿意 寻求专业精神健康护理，因此，许多人只在初级保健中接受治疗， 获得这种有效的干预措施（Possemato等人，2011年）。尽管国防部和退伍军人事务部积极地 将行为健康提供者整合到他们的初级保健诊所中（Maguen等人，2010年，Seal等人， 2011），目前在初级保健中对PTSD的行为干预往往与临床不一致。 实践指南和/或无效（Possemato等人，2011）。由于功能结果至关重要，我们 旨在将评估PE-PC对临床结局的影响扩展到功能。由此可见，有一 明确和迫切需要进一步发展，验证和传播循证心理治疗 在综合VHA PC-MHI中治疗PTSD，重点关注功能结局。为了满足这种需求 和护理差距，研究人员开发了一种短期长期暴露于初级保健（PE-PC） 治疗方案与4，30分钟的会议中使用的阶梯护理模式。一项军事试点研究 治疗机构发现，PE-PC导致PTSD的减少，并在6个月和12个月时保持不变。 随访（Jumrang等人，2015）。随机对照试验（RCT）的初步结果; PI：Cigrang; COI：Rauch）与最小注意力控制（MAC，包括任何PC的延续）相比 开始治疗）发现PE-PC组PTSD严重程度（以PCL测量）显著降低 MAC（组间d = .78，p = .01）。这些初步调查结果的力度受到缺乏 VHA中的功能结局和影响检查。虽然军人和退伍军人有许多 相似性，治疗动机和其他因素的潜在差异可能会影响疗效， 特别是在检查功能变化时。这项拟议的研究将随机抽取120名 拉尔夫·H的退伍军人。约翰逊VAMC在初级保健与创伤后应激障碍谁满足最低 入选/排除标准至PE-PC或PC-MHI治疗6周（TAU）。招聘将 发生在36个月以上。所有退伍军人将在随机化前和随机化后完成基线评估。 随机化后第6、12和24周的治疗随访评估。主要结局将是 在几个领域被评估为自我报告的角色功能。此外，我们将研究 与PE-PC或PCMHI-TAU相关的症状严重程度和有效性、可接受性和利用率 随机化前6个月和治疗完成后6个月。PE-PC可以允许 获得有效的治疗和有效分配创伤后应激障碍专科治疗资源的VHA。 这一主题与退伍军人精神卫生保健密切相关，可以为高水平的精神卫生保健提供新的切入点。 高质量的创伤后应激障碍护理，以改善功能，让更多的退伍军人体验改善。