Addressing Mental Health Comorbidities: Integrated CBT to Improve Functioning in Veterans with Co-Occurring Anxiety and Substance Use

背景和意义：共同发生的危险饮酒和精神健康障碍，特别是 焦虑症，是部署的退伍军人经历的一种特别有问题的组合。尽管退伍军人事务部 作为提供循证精神健康治疗的领导者，我们对如何 最好地促进患有焦虑和危险饮酒的退伍军人的心理社会恢复。退伍军人 那些已经被部署的人在运作和重返社会方面遇到问题的风险特别大 与精神健康障碍和饮酒有关。共发焦虑、创伤后应激障碍 创伤后应激障碍(PTSD)和危险饮酒严重影响心理社会功能(包括职业和 关系运作)和生活质量。认知行为疗法(CBT)是一种循证医学 针对焦虑症和危险饮酒的心理治疗(EBP)可以促进改善 功能和生活质量。然而，许多退伍军人没有接受CBT治疗焦虑症和/或SUD。 使用CBT治疗焦虑症或SUD的一个重大挑战是，提供者最常治疗的是 疾病是分开的，通常在不同的诊所。这会导致处理过程效率低下，从而导致质量不佳 结果。统一协议(UP)是一种跨诊断CBT协议，可有效治疗 同时出现多种情绪障碍。调整UP以满足部署的退伍军人的需求 正在发生的焦虑、创伤后应激障碍和危险饮酒有可能更有效地改善 发挥功能，减轻症状。考虑到焦虑、创伤后应激障碍和危险饮酒在 退伍军人，这项RR&D CDA-2提案的研究目标支持UP的改编使用 在有危险饮酒的部署退伍军人中进行调查，并检查其可行性、可接受性和 初步疗效。研究计划：目标1：调整UP以治疗焦虑症/创伤后应激障碍和 退伍军人中的危险饮酒(UP-A)。这将使用已建立的迭代来实现 干预发展战略，包括将利益攸关方反馈纳入制定 干预。利益相关者的反馈将包括定性访谈关键利益相关者(临床医生、 退伍军人)。目标2：通过非随机试点试验(N)评估部署的退伍军人使用UP-A的体验 =10)和对退伍军人的定性访谈，并根据调查结果修改干预措施，以确保 以退伍军人为中心，退伍军人满意度，可行性和可接受性。退伍军人将从退伍军人管理局招募 治疗环境和研究临床医生提供的UP-A。退伍军人将完成功能和功能的测量 接受干预前后的症状变化。目标3：探索可行性、可接受性和 UP-A对功能结局、焦虑和创伤后应激障碍症状以及酒精使用的初步影响 先导随机对照试验。部署的退伍军人(N=40)将随机接受UP-A或问题 解决治疗控制问题。结果将在基线、治疗后和三个月后收集。 治疗。退伍军人还将完成定性访谈，以获得对可行性和可接受性的反馈。 职业规划：埃克尔博士将接受在高需求退伍军人中进行康复研究的培训 人口(例如，部署后健康)、临床试验研究和与成为 独立资助的退伍军人事务部研究员。这些培训目标将通过多方面的 战略，包括与导师的研究，正式的课程作业，培训/研讨会/会议，以及 咨询导师团队。培训将支持成功实施 建议的研究和进行研究以改善退伍军人功能的长期职业目标 有复杂的精神卫生保健需求。

Background and significance: Co-occurring hazardous drinking and mental health disorders, particularly anxiety disorders, is an especially problematic combination experienced by deployed Veterans. Although VA is a leader in delivering evidence-based mental health treatment, gaps remain in our understanding of how to best promote psychosocial recovery for Veterans with co-occurring anxiety and hazardous drinking. Veterans who have been deployed are at particular risk for experiencing problems in functioning and reintegration related to mental health disorders and alcohol use. Co-occurring anxiety, posttraumatic stress disorder (PTSD), and hazardous drinking heavily impact psychosocial functioning (including occupational and relationship functioning) and quality of life. Cognitive behavior therapy (CBT) is an evidence-based psychotherapy (EBP) for anxiety disorders and hazardous drinking that can promote improvements in functioning and quality of life. However, many Veterans do not receive CBT for anxiety disorders and/or SUD. A significant challenge in treating an anxiety disorder or SUD with CBT is that providers most often treat each disorder separately, often in separate clinics. This results in an inefficient treatment process that leads to poor outcomes. The Unified Protocol (UP) is a transdiagnostic CBT protocol that effectively treats symptoms of multiple emotional disorders simultaneously. Adapting the UP to meet the needs of deployed Veterans with co- occurring anxiety, PTSD, and hazardous drinking has the potential to more efficiently and effectively improve functioning and reduce symptoms. Given the impact of anxiety, PTSD, and hazardous drinking among returning Veterans, the research goals of this RR&D CDA-2 proposal support the adaptation of the UP for use among deployed Veterans with hazardous drinking and examination of its feasibility, acceptability, and preliminary efficacy. Research Plan: Aim 1: Adapt the UP for treatment of anxiety disorders/PTSD and hazardous drinking among deployed Veterans (UP-A). This will be achieved using established iterative intervention development strategies, including incorporating stakeholder feedback in the development of the intervention. Feedback from stakeholders will include qualitative interviews key stakeholders (clinicians, Veterans). Aim 2: Evaluate deployed Veterans’ experience using UP-A through a non-randomized pilot trial (N = 10) and qualitative interviews with Veterans and revising the intervention based on findings to ensure Veteran-centricity, Veteran satisfaction, feasibility, and acceptability. Veterans will be recruited from VA treatment settings and provided UP-A by study clinicians. Veterans will complete measures of functioning and symptoms before and after receiving the intervention. Aim 3: Explore the feasibility, acceptability, and preliminary effect of UP-A on functioning outcomes, anxiety and PTSD symptoms, and alcohol use through a pilot randomized controlled trial. Deployed Veterans (N=40) will be randomized to receive UP-A or a problem solving therapy control. Outcomes will be collected at baseline, post-treatment, and three months post- treatment. Veterans will also complete qualitative interviews to obtain feedback on feasibility and acceptability. Career Plan: Dr. Ecker will receive training in conducting rehabilitation research among high-need Veteran populations (e.g., post-deployment health), clinical trial research, and training related to becoming an independently-funded VA researcher. These training objectives will be achieved through a multifaceted strategy that includes research with mentors, formal coursework, trainings/seminars/conferences, and consultation with the mentor team. Training will support the immediate goals of successfully conducting the proposed research and the long-term career goal of conducting research to improve functioning in Veterans with complex mental health care needs.