Empowering Veterans to Self-Manage PTSD Symptoms Following Completion of Trauma-Focused Therapy

背景近90%完成创伤集中治疗（TFT）的退伍军人 治疗需要。在TFT之后的六个月内，成功完成的公司仍然是使用率最高的公司之一 VA精神卫生服务，尽管临床上有意义的症状改善。我们之前的工作表明 退伍军人谁受益于TFT的主要后TFT治疗需求的做法和应用 在治疗过程中学到的技能，以维持或建立在治疗收益的目标。退伍军人 在没有治疗师支持的情况下，对实现这些目标表现出较低的自我效能感， 停滞或复发，没有持续的接触。因此，我们开发并测试了一个治疗师， 辅助自我管理计划的TFT完成者（EMPOWER）设计为一个步骤，从主动 psychotherapy.可行性开放试验表明，EMPOWER是可行的， 患者此外，研究结果表明，干预是成功的，帮助退伍军人维持或 提高PTSD相关收益，同时降低他们的心理健康服务利用率。这些有希望的发现 进行随机评估。意义满足退伍军人TFT后治疗需求的干预措施 是迫切需要的。心理健康提供者正在为这一高优先级队列提供持续的治疗。 退伍军人没有证据来指导他们的治疗计划。此外，高于预期的TFT后水平 精神卫生保健的利用威胁到这些高效治疗的持续实施。为 所有退伍军人都有机会获得最有效的治疗创伤后应激障碍，我们必须评估和实施 准备并使成功的TFT完成者能够退出积极治疗的干预措施。 创新这项拟议的研究是第一个大规模的TFT后护理研究，也是第一个严格的 评估自我管理计划，从积极的心理健康服务逐步减少到维持性心理健康服务 进行积极的心理治疗更广泛地说，我们认为这是第一次直接干预 促进一种精神卫生保健的情景模式。具体目标：1）估计后验概率分布 的影响，并建立这些影响的可能范围相比，后TFT TAU为 退伍军人的MH服务利用率和自我报告的创伤后应激障碍症状。随后的混合RCT将是 在评估了在一系列样本量中检测到EMPOWER效应的可能性后设计 使用Go/No Go和总功率方法。2)探索EMPOWER与TFT后TAU相比的影响 退伍军人（a）管理PTSD症状的自我效能，（B）对TFT后护理的满意度，（c）幸福感 （d）抑郁症，（e）二次利用结果。3)进行半结构化面试 与退伍军人和供应商，以情境化定量调查结果，并确定潜在的障碍，促进者， 和战略，以促进今后实施增强妇女权能方案。方法论：我们提出了一个务实的 随机对照试验（RCT），其中36名PE和CPT提供者将被随机分配以支持退伍军人， 他们参与了EMPOWER自我管理计划或协助TAU。参与者将是以下患者： 最近完成了PE/CPT课程的研究提供者，在此期间他们经历了临床 PTSD症状显著减轻（n=90）。主要结果将是精神卫生服务利用率 （总体和PE/CPT提供者）和自我报告的PTSD症状，在9个月内测量4次 期对提供者（n=18）和退伍军人（n=24）的定性访谈侧重于提供者对 治疗效果、实施挑战/潜在策略以及退伍军人对治疗的看法 有效性下一步：与国家创伤后应激障碍中心和心理健康办公室的合作伙伴， 自杀预防，我们将确定是否需要后续的混合I型或II型RCT。

Background. Nearly 90% of Veterans who complete trauma-focused therapy (TFT) for PTSD have remaining treatment needs. In the six-months following TFT, successful completers remain some of the highest utilizers of VA mental health services despite clinically meaningful symptom improvement. Our prior work demonstrated that Veterans who benefitted from TFT's primary post-TFT treatment needs were the practice and application of skills learned during therapy, with the goal of maintaining or building upon treatment gains. Veterans expressed low self-efficacy for meeting these goals without the support of their therapists and feared stagnation or relapse without ongoing contact. As such, we developed and feasibility-tested a therapist- assisted self-management program for TFT completers (EMPOWER) designed as a step down from active psychotherapy. The feasibility open trial demonstrated that EMPOWER is feasible and highly acceptable to patients. Further, findings suggest that the intervention was successful in helping Veterans maintain or enhance PTSD-related gains while reducing their mental health service utilization. These promising findings warrant a randomized evaluation. Significance. Interventions that meet Veterans' post-TFT treatment needs are urgently needed. Mental health providers are delivering ongoing treatment to this high priority cohort of Veterans without evidence to guide their treatment plan. Further, higher than expected levels of post-TFT mental health care utilization threatens the continued implementation of these highly effective treatments. For all Veterans to have access to the most effective treatments for PTSD, we must evaluate and implement interventions that prepare and enable successful TFT completers to step down from active therapy. Innovation. The proposed study is the first large-scale study of post-TFT care and the first to rigorously evaluate a self-management program to step-down from active to maintenance mental health services following a course of active psychotherapy. More broadly, we believe it to be the first intervention to directly facilitate an episodic model of mental health care. Specific Aims: 1) Estimate posterior probability distributions of EMPOWER's effects and establish likely ranges for those effects as compared to post-TFT TAU for Veterans' MH service utilization and self-reported PTSD symptoms. The subsequent Hybrid RCT will be designed after assessing the likelihood of detecting an effect for EMPOWER across a range of sample sizes using Go/No Go and Overall Power methods. 2) Explore the impact of EMPOWER compared to post-TFT TAU on Veterans'(a) self-efficacy for managing PTSD symptoms, (b) satisfaction with post-TFT care, (c) well-being & functioning (d) depression, and (e) secondary utilization outcomes. 3) Conduct semi-structured interviews with Veterans and providers to contextualize quantitative findings and identify potential barriers, facilitators, and strategies to facilitate future implementation of EMPOWER. Methodology: We are proposing a pragmatic randomized control trial (RCT) in which 36 PE and CPT providers will be randomized to support Veterans as they participate in the EMPOWER self-management program or facilitate TAU. Participants will be patients of the study providers who recently completed a course of PE/CPT during which they experienced clinically meaningful reductions in PTSD symptoms (n=90). Primary outcomes will be mental health service utilization (overall and with PE/CPT providers) and self-reported PTSD symptoms measured four times over a 9-month period. Qualitative interviews with providers (n=18) and Veterans (n=24) focused on providers' impressions of treatment effectiveness, implementation challenges/potential strategies, and Veterans' perception of treatment effectiveness. Next Steps: With partners at the National Center for PTSD and the Office of Mental Health & Suicide Prevention, we will determine whether a subsequent Hybrid Type I or II RCT is warranted.