Improving PTSD Service Delivery for Veterans with Severe Mental Illness

描述(由申请人提供)： 对退伍军人医疗保健的预期影响：与普通民众一样，退伍军人事务医学中心内没有明确的护理标准来治疗患有严重精神疾病的个人的创伤后应激障碍(PTSD)。这是一个相当大的问题，因为创伤、创伤后应激障碍和精神疾病的共病在退伍军人中特别常见，这种共病显然会加剧精神疾病的总体病程和严重程度。这项研究具有重要意义，因为它提出了对退伍军人中在退伍军人保健系统中接受治疗的创伤后应激障碍(PTSD)长期暴露的一线干预的有效性。在这方面，来自该项目的数据将被用来为患有创伤后应激障碍的严重精神疾病退伍军人建立一个明确和迫切需要的临床行动方案。背景：与普通人群相比，患有严重精神疾病(SMI；即双相情感障碍、精神分裂症)的个体的创伤和创伤后应激障碍的发生率更高。创伤，特别是性侵害和创伤后应激障碍也与精神障碍、生活质量下降和服务使用增加密切相关。尽管创伤后应激障碍的发生率很高，并且它对患有SMI的个体的功能产生了明显的负面影响，但关于如何有效地治疗这一患者群体中的创伤相关症状的经验数据很少。这在很大程度上是由于历史上将患有SMI的个体排除在创伤后应激障碍临床试验之外。然而，在临床环境中，临床医生不愿治疗患有SMI的患者的创伤和创伤后应激障碍，因为他们担心加剧他们的主要症状。因此，大多数精神创伤患者没有参与创伤/创伤后应激障碍的研究，在他们接受护理的公共部门环境中，他们的创伤/创伤后应激障碍症状没有得到治疗，因此，他们继续遭受与创伤后应激障碍相关的症状和痛苦。这个问题对于退伍军人来说尤其突出，他们通常患有创伤暴露、创伤后应激障碍和精神共病的比例高于一般人群。目的：本研究的主要目的是比较长期接受创伤后应激障碍(PE)加常规治疗(TAU)相对于单独接受TAU的相关卫生服务结果，如a)创伤后应激障碍的临床症状；b)生活质量和社会适应指数；c)过程结果，如治疗可信度、服务满意度、治疗联盟和治疗依从性；以及d)费用 指数。其他一些目标是：a)确定与单独使用TAU相比，PE+TAU对严重精神疾病的主要症状(即精神病、单相和/或双相抑郁症状)的影响，以及b)确定临床、生活质量和过程变量(即卫生服务变量)是否因城乡生活状况、种族、性别和/或严重精神疾病的初步诊断而异。总的来说，这些数据将为患有创伤后应激障碍和重度精神障碍的退伍军人建立一个明确的护理标准，他们在退伍军人管理局的医疗保健环境中接受治疗。方法：为了实现上述目标，我们将进行一项随机对照试验，比较PE+TAU和单独TAU对关键卫生服务结果的影响。具体地说，我们将从查尔斯顿退伍军人集中地区招募156名(每组78人)患有创伤后应激障碍和被诊断为SMI(即精神障碍、双相情感障碍或严重抑郁症)的不同种族的男性和女性退伍军人。招募和同意将在查尔斯顿退伍军人管理局或附属的社区门诊诊所(CBOC)进行。退伍军人将被随机分为PE+TAU组或单独TAU组，并在术后、3个月和6个月进行评估。处于PE+TAU状态的退伍军人除接受患有SMI的退伍军人的常规护理标准(TAU；即病例管理服务、精神药物管理)外，还将在查尔斯顿退伍军人医院接受12个疗程的PE。参与者年龄为21岁，患有创伤后应激障碍和精神障碍。最近有精神住院史或自杀意图和/或有积极药物滥用/依赖的退伍军人将被排除在参与范围之外。

DESCRIPTION (provided by applicant): Anticipated Impact on Veterans Health Care: As in the general population, there is no clear standard of care within Veterans Affairs Medical Centers for treating posttraumatic stress disorder (PTSD) among individuals with severe forms of mental illness. This is a considerable issue because trauma, PTSD, and psychiatric comorbidity are particularly common among Veterans and such comorbidity clearly exacerbates the overall course and severity of mental illness. This study is significant in that it proposes to establish the efficacy of a frontline intervention for PTSD, Prolonged Exposure, in Veterans treated within the VA healthcare system. In this regard, data from this project will be used to establish a clear, and much needed, clinical course of action for severely mentally ill Veterans suffering from PTSD. Background: Rates of trauma and PTSD are higher among individuals with severe mental illness (SMI; i.e., bipolar disorder, schizophrenia) relative to the general population. Trauma, particularly sexual victimization, and PTSD are also strongly correlated with psychiatric difficulties, decreased quality of life, and increased service use in this population. Despite the high rate of PTSD, and its clear negative impact on functioning among individuals with SMI, there are few empirical data on how to effectively treat trauma related symptoms in this patient population. This is due in large part to the historical exclusion of individuals with SMI from PTSD clinical trials. Within clinical settings as well, however, clinicians are reluctant to treat trauma and PTSD among their patients with SMI for fear of exacerbating their primary symptoms. As such, most individuals with SMI do not participate in trauma/PTSD research, are not treated for their trauma/PTSD symptoms within the public sector settings where they are cared for, and as such, continue to suffer from PTSD related symptoms and distress. This issue is particularly salient for Veterans who typically suffer from high rates of trauma exposure, PTSD, and psychiatric comorbidity relative to the general population. Objectives: The primary objectives of this study are to compare Prolonged Exposure for PTSD (PE) plus treatment as usual (TAU) relative to TAU alone across relevant health services outcomes such as a) clinical symptoms of PTSD; b) indices of quality of life and social adjustment; c) process outcomes, such as treatment credibility, satisfaction with services, therapeutic alliance, and treatment adherence; and d) cost indices. Some additional objectives are to a) determine the impact of PE+TAU on the primary symptoms of severe mental illness (i.e., psychosis, unipolar and/or bipolar depressive symptoms) relative to TAU alone and b) to determine if clinical, quality of life, and process variables (i.e., health services variables) vary by rural/urban living status, race, gender, and/ o primary diagnosis of severe mental illness. Collectively, these data will establish a clear standard of care for Veterans with PTSD and SMI who are treated within VA healthcare settings. Method: To achieve the above objectives, we will conduct a randomized controlled trial comparing PE+TAU to TAU alone across critical health services outcomes. Specifically, we will enroll 156 (n=78 per group) ethnically diverse male and female Veterans with PTSD and a diagnosis of SMI (i.e., a psychotic disorder, bipolar disorder, or severe depression) from the Charleston VA catchment area. Recruitment and consent will take place at the Charleston VA or affiliated community-based outpatient clinics (CBOCs). Veterans will be randomized to PE+TAU or TAU alone and evaluated at post, 3, and 6 months. Veterans in the PE+TAU condition will receive12 sessions of PE at the Charleston VA in addition to the regular standard of care for Veterans with SMI (TAU; i.e., case management services, psychotropic medication management). Participants will be > 21 with PTSD and SMI. Veterans with a recent history of psychiatric hospitalization or suicidal intent and/or who have active substance abuse/dependence will be excluded from participation.