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

背景：创伤后应激障碍对退伍军人来说是一个重大问题，他们中的大多数人最初都是在创伤后接受治疗的 初级保健精神卫生集成(PCMHI)中的应激障碍(PTSD)在这方面，社会支持很差 人口是自杀意念、全因死亡率和较差的治疗参与度的危险因素 回应。初步研究表明，约60%患有创伤后应激障碍的退伍军人会去专科就诊 社会支持较差的护理收容预约。然而，现有的基于PCMHI的治疗方法中没有一种是 创伤后应激障碍明确关注社会支持的产生或重新投入。此外，虽然现有的有限 研究表明，常规的社会支持评估可以指导治疗计划(也称为 基于测量的护理(MBC)改善了平民人口的治疗结果，但社会支持并没有 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，这个CDA-2将首先识别一个 在临床护理背景下常规测量社会支持以改善创伤后应激障碍的适当工具 治疗，并随后评估一种新的基于PCMHI的创伤后应激障碍治疗作为阶梯式护理模式的一部分 对于退伍军人来说，他们报告的社会支持很差，并且有很大的创伤后应激障碍的风险，治疗没有反应。 重要性/影响：拟议的研究涉及几个HSR&D研究优先事项，包括 评价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；以及对脆弱的退伍军人进行干预 有创伤后应激障碍和自杀风险。通过衡量和改善社会支持以加强创伤后应激障碍的治疗， 拟议的研究计划明确解决了阻碍敏感疾病治疗结果的关键因素 退伍军人人数。创新：尽管社会支持不佳被广泛认为是最强的 创伤后应激障碍发生和维持的预测因素，现有的基于PCMHI的创伤后应激障碍治疗方法 以社会支持为目标或衡量，作为主要治疗重点。因此，拟议的CDA-2研究具有很高的 小说。无论是过去还是现在，高铁和研发资助的研究都没有测试过监测或改善社会责任的方法 对退伍军人创伤后应激障碍患者基于PCMHI治疗的支持，尽管它与糟糕的临床相关 结果。具体目标：1)编制退伍军人临床环境社会支持量表 患有创伤后应激障碍。2)反复细化和执行单臂试点测试基于PCMHI的简短行为激活 以及基于关键利益相关者(例如，退伍军人和PCMHI提供者)对创伤后应激障碍的社交参与干预 反馈。3)进行双臂试点随机临床试验(RCT)，将干预与常规护理进行比较 在盈科重工。方法：AIM 1将使用从210名退伍军人在线调查中收集的定量数据 评估社会支持的四个衡量标准(通过系统回顾和临床效用确定)的程度 排名)是可接受的，可靠的，敏感的，并选择最佳的衡量标准用于目标2‘S试点。目标2将 包括反复完善创伤后应激障碍和社会支持干预，然后， 与关键利益相关者进行定性访谈。目标2将获得关于参与者可接受性、提供商忠诚度、 以及与社会支持相关的MBC。社会支持和创伤后应激障碍干预与平时对照研究 目标3中的护理将评估招募、随机、干预的可行性和可接受性 临床结果的参与度、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)，以及改变的机制(例如，披露)和多重分步护理 结果(例如，临床指示的循证心理治疗开始/保留)。下一首 步骤/执行：这项工作将支持今后确定有效性和执行情况的试验 干预的潜力，以及社会支持的MBC模式。未来的研究将探索MBC 以及以PCMHI为基础的干预措施，以帮助相关条件下的贫困社会支持。

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.