Improving Function Through Primary Care Treatment of PTSD

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(格林伯格，西西茨基 等人的研究。1999年，Hoge，Terhakopian等人。2007)。兰特报告称，预计两年的成本为4.0至6.2美元 10亿美元用于目前伊拉克和阿富汗冲突的精神健康问题，并进一步 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)。即使创伤后应激障碍严重程度的轻微下降也与 增加了积极功能结果的概率(Smith等人2005)。长时间暴露(PE) 治疗(Foa等人)2000年，Foa等人。2005年，SchNurr等人。2007)是一种有效的一线治疗方法 创伤后应激障碍(IOM 2007，退伍军人事务部/DOD 2010)。虽然非常有效，但体育是在专门的心理健康领域提供的 设置通常为8到15次，每周90分钟的单独会话。患有创伤后应激障碍的退伍军人通常不情愿 寻求专门的精神健康护理，因此，许多人只在初级保健中接受治疗，而不是 能够获得这种有效的干预(PosSemato等人)2011年)。而国防部和退伍军人事务部则积极 将行为健康提供者整合到其初级保健诊所(Maguen等人)。2010年，Seal等人。 2011年)，目前初级保健中对创伤后应激障碍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年)。由于功能结果至关重要，我们 意欲超越评估PE-PC对临床结果的影响而发挥作用。因此，有一个 明确和迫切需要进一步开发、验证和传播循证心理疗法 创伤后应激障碍的综合VHA PC-MHI治疗，注重功能结果。来满足这一需求 和护理方面的差距研究人员开发了一种短暂的长期初级护理暴露(PE-PC) 治疗方案，4，30分钟疗程，用于阶梯式护理模式。军事上的一项先导研究 治疗机构发现PE-PC导致创伤后应激障碍的减少，并维持在6个月和12个月 后续行动(Cigang等人，2015年)。随机对照试验的初步结果(RCT；PI：Cigang； 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患者的创伤后应激障碍严重程度(由PCL测量)有显著更大的降低 大于MAC(组d=.78，p=.01)。这些初步发现的力度有限，因为缺乏 VHA的功能结果和影响检查。虽然服役人员和退伍军人有很多 治疗动机的相似性、潜在差异和其他因素可能会影响 该协议尤其是在检查功能变化时。拟议的研究将随机抽取120人 拉尔夫·H·约翰逊VAMC的退伍军人在初级保健中与创伤后应激障碍进行治疗，他们满足的程度最低 纳入/排除标准为6周的PE-PC或PC-MHI-照常治疗(TAU)。招聘将 发生在36个月以上。所有退伍军人将在随机化之前和之后完成基线评估- 随机化后6周、12周和24周的治疗随访评估。主要结果将是 在几个领域中被评估为自我报告的角色功能。此外，我们还将审查 与PE-PC或PCMHI-TAU相关的症状严重性和有效性、可接受性和利用率 在随机化前6个月和治疗完成后6个月。PE-PC可能允许 在VHA获得有效治疗和有效分配创伤后应激障碍专科治疗资源。 这一主题与退伍军人心理健康护理具有关键的相关性，并可以为HIGH提供一个新的切入点 优质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到改善。

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.