Psychological Services 2014, Vol. 11, No. 2, 179 –184
In the public domain DOI: 10.1037/a0035077
Treatment Utilization Among OEF/OIF Veterans Referred for Psychotherapy for PTSD Jason C. DeViva Veterans Affairs Connecticut Health Care System, Yale School of Medicine Despite high levels of positive screening for mental health complaints, research indicates that veterans of Operations Enduring Freedom and Iraqi Freedom (OEF/OIF) seek mental health care at low rates. The purpose of this study was to examine treatment utilization in 200 consecutive OEF/OIF referrals to a PTSD specialist for psychotherapy. This study also examined the relationships between treatment engagement/completion and numerous demographic and clinical variables. This chart-review study identified whether referrals were seen at all and whether they completed psychotherapy (as defined by documented mutual agreement between therapist and referral). Chi-square analyses and t tests were performed to determine whether engagement and completion were related to gender, age, marital status, race, employment, school enrollment, branch of service, time since most recent deployment, number of deployments, service-connection rating, medication prescription, substance use and depressive disorder comorbidity, referral source, TBI screening results, and presence of pain problems and legal issues. Of 200 consecutively referred OEF/OIF veterans, 75 were never seen, 86 were seen at least once without completing, and 24 completed psychotherapy. Being married and employed and older age were associated with higher likelihood of completing therapy. Completers received significantly more sessions of psychotherapy than those who were seen without completing, but the 2 groups did not differ in the types of therapy received. Keywords: military, psychotherapy, retention, veteran
the national VA system between 2002 and 2008 and were diagnosed with PTSD, 80% had at least one follow-up visit specifically for PTSD. Seal et al. determined that nine sessions of treatment would allow for delivery of a minimum adequate dosage of an evidence-based psychotherapy for PTSD; they reported that 27% of their sample had nine or more visits targeting PTSD within the year after diagnosis, and only 9% of the sample received those nine sessions within a 15-week time period. Maguen, Madden, Cohen, Bertenthal, and Seal (2012) examined the records of more than 290,000 OEF/OIF veterans with at least one of several mental health diagnoses common to that population and found that the median time from end of deployment to the first primary care visit was about a year and a half, with more than two years to the first mental health visit. Maguen et al. also defined receiving eight or more mental health visits in a 12-month period as “minimally adequate mental health care” (p. 1206), and found that by three years postdeployment only about a quarter of the population examined had received minimally adequate mental health care. On a smaller scale, Lu, Duckert, O’Malley, and Dobscha (2011) found that among more than 800 veterans who screened positive for PTSD in VA primary care visits over an approximately 2-year period from 2006 –2008 across four VA facilities in the Pacific Northwest, OEF/OIF veterans received an average of 8 visits to specialty PTSD clinics in the year after screening, with only 29% of OEF/OIF veterans receiving 9 or more sessions in the year after screening, which constituted “minimally adequate specialty treatment” (p. 944). Both statistics were significantly lower than those of non-OEF/OIF veterans diagnosed with PTSD. Erbes, Curry, and Leskela (2009) reported that 106 OEF/OIF veterans referred to an outpatient VA PTSD program were scheduled for an average of 11
Research indicates that substantial proportions of service members returning from deployment to Iraq or Afghanistan screen positive for anxiety, depression, or posttraumatic stress disorder (PTSD; Hoge, Auchterlonie, & Milliken, 2006; Hoge et al., 2004; Hoge, Terhakopian, Castro, Messer, & Engel, 2007). Exposure to combat and PTSD among veterans of Operations Enduring Freedom (OEF) and Iraqi Freedom (OIF) have been associated with increased functional impairment, including greater levels of alcohol use (Jacobson et al., 2008), health problems (Hoge et al., 2007), and relationship problems (Renshaw, Rodrigues, & Jones, 2009). Research on treatment utilization among OEF/OIF veterans suggests that health care providers in the Department of Veterans Affairs (VA) engage these veterans in mental health care at low rates. Three studies have examined engagement in treatment within the VA system at the national level. Harpaz-Rotem and Rosenheck (2011) found that, among a national sample of over 29,000 OEF/OIF veterans, VA clinicians provided an average of about 7 encounters with PTSD listed as a primary or secondary diagnosis over the year after initial diagnosis, with an average of 221 days between the first and last visits. Seal et al. (2010) reported that of more than 84,000 OEF/OIF veterans who entered
This article was published Online First December 23, 2013. Jason C. DeViva, Veterans Affairs Connecticut Health Care System, Yale School of Medicine. Correspondence concerning this article should be addressed to Jason C. DeViva, VA Connecticut Health Care System, 950 Campbell Avenue, West Haven, CT 06516. E-mail: [email protected] 179
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mental health appointments but kept an average of 6, which was a significantly lower proportion than Vietnam veterans referred to the same program. Numerous factors appear to correlate with measures of treatment utilization. Studies have found that variables such as older age, female gender, service connection benefits from the VA, higher income, receiving services in a specialty mental health clinic, comorbid depression, and urban residence were associated with greater treatment utilization (Harpaz-Rotem & Rosenheck, 2011; Lu et al., 2011; Maguen et al., 2012; Seal et al., 2010). Pietrzak, Johnson, Goldstein, Malley, and Southwick (2009) surveyed a sample of OEF/OIF veterans and found that 26% had reported having had a mental health counseling visit in the past six months, with 40% reporting a psychiatric medication visit. Pietrzak et al. found that positive screening for PTSD, depression, or alcohol problems, low levels of unit support, and negative beliefs about mental health care all predicted higher levels of perceived barriers to care and stigma, and negative beliefs about mental health care were also associated with lower likelihood of utilizing mental health care services. Evidence has indicated that VA is engaging OEF/OIF veterans with PTSD in mental health treatment at low rates. Thus far, studies conducted within the VA system have not examined specific types of care received (e.g., psychotherapy or pharmacotherapy), only mental health visits in general. Also, given the nature of data collection in these studies, individual records could not be reviewed to determine whether treatment progressed until provider and patient agreed goals had been met. The main purpose of the current chart-review study was to examine the outcome of referral to a specialized OEF/OIF PTSD psychotherapy provider among 200 veterans. In addition, this study sought to determine whether demographic and diagnostic variables were related to likelihood of engaging in and completing treatment.
Method Participants This study took place at a VA facility in southern New England with an outpatient mental hygiene clinic as well as other specialized mental health services but no outpatient PTSD treatment program, and was approved by the local VA Human Studies Subcommittee. Data for this study were gathered on 200 consecutive referrals for psychotherapy to a clinical psychologist hired to provide only psychotherapy for PTSD (in VA terms, a “PTSD Specialist”) to veterans of OEF, OIF, and Operation New Dawn (OND; given the period of time examined by this study, no veterans of OND were included in these data). Referrals to the PTSD Specialist were identified through review of provider records and specific clinic usage in the computerized patient record system. The PTSD Specialist was trained in cognitive– behavioral therapy for PTSD, with training in and experience providing both prolonged exposure therapy (e.g., Foa, Hembree, & Rothbaum, 2007) and cognitive processing therapy (e.g., Resick, Monson, & Chard, 2006). Attempts to engage referred veterans were consistent with VA policy. When a referral was received, several attempts were made to contact the veteran by telephone. If attempts to contact by telephone proved unsuccessful (either because the veteran did not
call back or the contact information in the record was not accurate), a letter was sent to the address in the medical record. If there was no response to that letter, the case was considered closed. The same process was used to attempt to reschedule after no-shows. Initial sessions with all referrals focused on collaboratively developing a treatment plan. The long-term goal for all referrals was the completion of evidence-based therapy for PTSD. If referrals were unwilling to engage in trauma-focused cognitive– behavioral therapies or if those therapies were contraindicated, referrals were offered symptom-focused interventions (e.g., anger management, cognitive– behavioral therapy for insomnia or anxiety). All referrals were also offered supportive group therapy specifically for veterans of OEF/OIF.
Data Collection and Analysis This study used a chart-review methodology. Each referral’s medical record was reviewed to gather basic demographic data, including gender, age, marital status, race, employment, school enrollment, branch of service, time since most recent deployment, number of deployments, service-connection rating, medication prescription, substance use and depressive disorder comorbidity, referral source, TBI screening results, and presence of pain problems and legal issues. Chart review indicated that numerous referrals had relocated and addresses clearly were not updated; therefore, distance to the VA facility was not examined in this study. Progress notes were reviewed to determine whether each referral was seen by the PTSD Specialist and, if so, whether and how treatment ended. If a referral was seen at least once and the medical record contained a progress note documenting that treatment ended when therapist and patient agreed that goals had been met, that referral was coded as a treatment completer. If treatment ended for any other reason, or if the referral stopped responding to attempts at contact, the referral was coded as having been seen without completing. Among referrals seen at least once, the number of days from referral and first contact to first scheduled visit and the number of psychotherapy sessions received from the PTSD Specialist were recorded. For noncompleting referrals, any other mental health services received after referral were recorded. For referrals that received nine or more therapy sessions, the dates of encounters were examined to determine whether a dose of nine or more sessions was administered within a 15-week period. For categorical data, chi-square analyses were performed to compare referrals never seen, noncompleters, and completers on frequency of the independent variables. For continuous independent variables, analyses of variance and t tests were used to compare groups.
Results Participants Other than cases excluded because they were referred specifically for evaluation, 200 consecutive psychotherapy referrals over a 31-month period from 04/08 to 11/10 were included in this chart review. The last referral occurred approximately 8 months before data collection began. The characteristics of the sample are displayed in Table 1. The majority of referrals (130, 65%) came from a walk-in Primary Care-Mental Health Integration clinic (Pomer-
OEF/OIF TREATMENT UTILIZATION
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Table 1 Dependent Variable Data for Entire Sample and Broken Down Among Inactive Cases by Treatment Engagement Variable Gender Male Female Age Marital status Single/divorced Married Race Caucasian Latino African-American Asian-American Employment Employed Unemployed School enrollment In school Not in school Branch of service Active-duty branches NG/Reserves Time since last deployment (mos.) Deployments Single Multiple Service connection (%) Total PTSD Medication usage No meds One med Two or more meds Comorbid SUD Present Not present Comorbid MD Present Not present Source of referral PMHC MH med provider Other VA program External source TBI screen Positive Negative Legal problems Yes No Comorbid pain Yes No ⴱ
p ⬍ .05.
ⴱⴱ
Total sample x/n (SD/%)
Never seen x/n (SD/%)
Seen, didn’t complete x/n (SD/%)
Completed x/n (SD/%)
171 (92%) 14 (8%) 30.2 (7.4)
67 (89%) 8 (11%) 28.8 (6.4)
83 (97%) 3 (4%) 30.2 (6.9)
21 (88%) 3 (13%) 35.1 (9.7)
121 (66%) 62 (34%)
57 (77%) 17 (23%)
53 (62%) 32 (38%)
11 (46%) 13 (54%)
120 (65%) 43 (23%) 19 (10%) 3 (2%)
51 (68%) 17 (23%) 6 (8%) 1 (1%)
54 (63%) 19 (22%) 11 (13%) 2 (2%)
15 (63%) 7 (29%) 2 (8%) 0 (0%)
74 (43%) 97 (57%)
26 (38%) 42 (62%)
31 (38%) 50 (62%)
17 (77%) 5 (23%)
45 (27%) 124 (73%)
20 (30%) 46 (70%)
20 (25%) 59 (75%)
5 (21%) 19 (79%)
86 (47%) 98 (53%) 31.3 (19.9)
34 (46%) 40 (54%) 28.3 (21.2)
153 (83%) 32 (17%)
61 (81%) 14 (19%)
45.5 (27.3) 43.5 (24.1)
43.5 (27.7) 40.4 (23.1)
68 (37%) 44 (24%) 73 (40%)
27 (36%) 17 (23%) 31 (41%)
29 (34%) 22 (26%) 35 (41%)
12 (50%) 5 (21%) 7 (29%)
61 (35%) 124 (65%)
26 (35%) 49 (65%)
28 (33%) 58 (67%)
7 (29%) 17 (71%)
56 (43%) 129 (57%)
30 (40%) 45 (60%)
16 (19%) 70 (81%)
10 (42%) 14 (58%)
117 (63%) 58 (31%) 9 (5%) 1 (1%)
49 (65%) 22 (29%) 3 (4%) 1 (1%)
49 (57%) 32 (37%) 5 (6%) 0 (0%)
19 (79%) 4 (17%) 1 (4%) 0 (0%)
106 (58%) 76 (42%)
45 (61%) 29 (39%)
47 (55%) 38 (45%)
14 (61%) 9 (39%)
11 (6%) 163 (94%)
1 (2%) 66 (98%)
9 (11%) 74 (89%)
1 (4%) 23 (96%)
85 (48%) 92 (52%)
33 (48%) 36 (52%)
42 (50%) 42 (50%)
10 (42%) 14 (58%)
df, 2/F 2, 3.91 2, 7.28ⴱⴱ 2, 8.88ⴱ 6, 2.30
2, 11.89ⴱⴱ 2, 0.63 2, 0.24
37 (43%) 49 (57%) 33.7 (18.7) 75 (87%) 11 (13%) 46.9 (27.9) 45.8 (26.6)
15 (63%) 9 (38%) 32.6 (19.8)
2, 144, 1.21 2, 3.63
17 (71%) 7 (29%) 45.8 (24.6) 41.4 (10.7)
2, 133, 0.23 2, 66, 0.39 4, 2.36
2, .26 2, 10.39ⴱⴱ 6, 6.00
2, 0.57 2, 5.69 2, 0.52
p ⬍ .01.
antz, 2005) that served as the main point of entry for veterans with any mental health needs. The sample was 92% male, with a racial breakdown similar to that of the local region. Roughly half of the sample was single and about a third was married. The sample had a mean age of about 30 years, and was referred to the PTSD Specialist an average of about 31 months after returning from deployment.
Outcome of Referral Of the 200 referrals for specialized PTSD treatment, 75 (38%) were never seen by the PTSD Specialist (either never responded to multiple attempts to contact or never presented for a scheduled session). Of the remaining 125 referrals, 24 (12% of the total sample) were rated as having completed treatment. An additional
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86 cases (43% of the total sample) had been closed as a result of having discontinued treatment and not responded to numerous phone calls and letters attempting to reengage them. The remaining 15 referrals had not been closed either because of completion or discontinuation. These individuals were classified as currently active in treatment, and were not included in analysis. Among active patients, the average time from referral to the point data collection began was 15 months. Of the 161 referrals who did not complete psychotherapy for PTSD (referrals never seen and referrals seen without completing), 76 (47%) had no other encounters with any mental health provider in the local VA medical record after referral to the PTSD Specialist. An additional 61 (38%) met at least once with a medication provider but received no psychotherapy, and the remaining 24 (15%) engaged in other VA mental health programs. Of those 24 referrals who engaged in other VA mental health programs, only 2 (1% of the 161 noncompleters) went on to receive PTSD-focused psychotherapy from some other source within the local VA system.
Engagement in and Completion of Therapy Among the 185 closed cases, chi-square analysis indicated that outcome of referral was not randomly associated with marital status; a higher proportion of treatment completers were married, 54%, than referrals never seen, 23%, or seen but noncompleting referrals, 38%, 2(2) ⫽ 8.88, p ⬍ .05. In addition, a higher proportion of treatment completers were employed, 77%, than referrals never seen, 38%, or seen but noncompleting referrals, 38%, 2(2) ⫽ 11.89, p ⬍ .01. A lower proportion of seen but noncompleting referrals had a comorbid depressive disorder diagnosis, 22%, than referrals never seen, 40%, or treatment completers, 42%, 2(2) ⫽ 6.35, p ⬍ .05. The three groups also differed in age, F(2, 182) ⫽ 7.28, p ⬍ .01, with post hoc comparisons indicating that completers, x ⫽ 35.1 year SD ⫽ 9.7, were older than both referrals never seen, x ⫽ 28.8 years, SD ⫽ 6.4, and seen but noncompleting referrals, x ⫽ 30.2 years, SD ⫽ 6.9. No other variables were related to outcome of referral (see Table 1).
Timing of Treatment Among the 107 referrals for whom time of first contact and first scheduled appointment were available, the average time from first contact to first scheduled session was 7.3 calendar days, SD ⫽ 4.4, with a range of 1 to 22 days. More than 60% of referrals received an appointment within 7 days of the day they were scheduled, and all but 4 of the 107 referrals, or 96%, received an appointment within two weeks. Among referrals seen at least once, the total time from initial referral until the first scheduled session was obtainable for 107 of 110 cases. The mean time from referral to first scheduled appointment was 33.6 days, SD ⫽ 75. There were no differences between any groups on time from first contact to first session or time from initial referral to first scheduled session. Of referrals seen but not completing, 22 of 86 (26%) received more than nine sessions with the PTSD Specialist, with 11 receiving those nine sessions within a 15-week period. Of the 24 completers, 18 (75%) received nine or more sessions of therapy, with the remaining six completing treatment in fewer than nine ses-
sions, and 13 of the completers (54%) received nine sessions of therapy within a 15-week period.
Treatment Received The overall sample received a mean of 4.1 sessions of therapy with the PTSD Specialist, SD ⫽ 6.4. Considering only those who were seen at least once, the average number of sessions was 7.0, SD ⫽ 7.0. Treatment completers were seen significantly more times, x ⫽ 12.0 sessions, SD ⫽ 6.7, than referrals seen at least once without completing, x ⫽ 5.6 sessions, SD ⫽ 6.4, t(108) ⫽ 4.27, p ⬍ .001. As noted earlier, all referrals who presented for treatment initially participated in collaborative treatment planning and when appropriate were offered trauma-focused CBT, general CBT for anxiety, symptom-focused therapies, or supportive group therapy. Overall, 30% of referrals seen at least once engaged in traumafocused CBT, whereas an additional 25% received CBT for anxiety and 13% received symptom-focused intervention. Of those seen at least once who did not complete, 24% discontinued treatment during the treatment planning phase; these 21 cases were not included in analysis of treatment received. Chi-square analysis indicated that treatment completers did not differ from cases seen without completing in the types of treatment received (see Table 2).
Discussion This chart review yielded data on treatment engagement and completion rates in a sample of OEF/OIF veterans consecutively referred for psychotherapy for PTSD in a VA facility over a 31-month period, including the eight months after that referral period. The data are useful for their description of referral outcome and also for the relationships found between treatment engagement and completion and the other variables measured. Of 200 cases referred for specialized PTSD psychotherapy, most of whom had already been screened and diagnosed with PTSD and who had accepted referral at the time of screening, 24 (12%) had completed psychotherapy by the time of data analysis. More than a third (75, 38%) were never seen during the study time period by the PTSD specialist to whom they were referred, despite efforts to contact and schedule them, and an additional 86 cases (43%) were seen at least once but did not complete treatment. Fifteen patients (8%) were still in treatment at the time of data collection. The average time from return from deployment to referral was more than 31 months, and active cases had been referred to therapy an average of 15 months before data collection began. These results are likely
Table 2 Types of Treatments Received by Referrals Seen at Least Once Engagement/ Completion
Traumafocused CBT
CBT for anxiety
Symptomfocused therapies
Group therapy
Total
Seen, didn’t complete Completers Total
26 (40%) 7 (29%) 33 (37%)
18 (28%) 9 (38%) 27 (30%)
8 (12%) 6 (25%) 14 (16%)
13 (20%) 2 (8%) 15 (17%)
65 24 89
Note.
2(3) ⫽ 4.68, p ⫽ .19.
OEF/OIF TREATMENT UTILIZATION
not attributable to clinic availability, as referrals averaged about seven days from first contact to first scheduled appointment. These results are comparable with those reported by Harpaz-Rotem and Rosenheck (2011), Maguen et al. (2012), and Seal et al. (2010) in that a minority of referrals engaged in treatment to an apparently meaningful degree. The current study expands on those findings by specifically examining psychotherapy engagement and by providing data on treatment completion. Overall, evidence appears to suggest that OEF/OIF veterans with PTSD tend not to engage in or complete psychotherapy. Treatment completers were more likely to be older, married, and employed at the time of referral than referrals who were never seen and referrals who were seen at least once but did not complete. It is possible that being in a marital relationship or having a job provided additional incentive to initiate and complete the treatment process, or additional potential negative consequences for not completing. It is also possible that individuals who could sustain a marriage and hold a job were functioning at a higher level overall and therefore were better able to engage in and complete therapy. Harpaz-Rotem and Rosenheck (2011) also found that older age and higher income levels were associated with lower likelihood of discontinuing treatment, and Seal et al. (2010) found similar results in terms of age. Referrals who were seen at least once but did not complete treatment were less likely to have a comorbid depressive disorder than both referrals who were never seen and referrals who completed treatment. It is possible that depression interacted with other unmeasured variables to produce apparently opposite effects in these two sets of referrals. Harpaz-Rotem and Rosenheck (2011) found that comorbid mood disorder diagnosis was associated with lower likelihood of discontinuing treatment and higher number of mental health visits. The 185 closed cases received an average of about 4 sessions of therapy with the PTSD Specialist. The 110 referrals who met at least once with the PTSD Specialist received an average of about 7 sessions of therapy, with completers receiving 12 sessions and noncompleters more than 5, which is consistent with data reported by Harpaz-Rotem and Rosenheck (2011), Lu et al. (2011), and Erbes et al. (2009). The results of the current study indicate that the construct of receiving 9 sessions of therapy over a 15-week period that was used in other studies to indicate a meaningful dose of treatment may not be useful for this purpose. About a quarter of treatment completers received fewer than 9 sessions of therapy, and about a quarter of those who were seen but did not complete received more than 9 sessions of therapy. Just over half of treatment completers received 9 sessions of therapy in a 15-week period. The heterogeneity of treatment utilization among completers and referrals seen without completing suggests that it may not be feasible to operationalize the construct of “a meaningful dose of therapy.” The accumulating body of treatment utilization research among OEF/OIF veterans yields a somewhat consistent picture thus far. These veterans tend to present for care well over a year after returning from deployment, and VA has been able to engage this population in treatment for about seven sessions of mental health care before they discontinue, apparently often without completing therapy. Younger age, unemployment, single marital status, and diagnostic comorbidity are all associated with lower likelihood of remaining in treatment. To a degree, it may be useful to focus extra treatment engagement efforts on veterans with these demographic
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characteristics; however, VA has not been able to engage this cohort as a whole, so it is likely that all veterans of OEF/OIF would benefit from extra efforts to engage them in treatment. Though treatment completion was not related to time since deployment or time from referral to first session in the present study, it would still likely be beneficial to engage this population in treatment sooner, to provide relief as soon as possible. There is some evidence that interventions designed to increase motivation can lead to greater levels of treatment utilization and self-reported readiness for change in veterans with PTSD (Murphy, Thompson, Murray, Rainey, & Uddo, 2009) and lead to better treatment compliance and greater treatment efficacy for anxiety disorders other than PTSD (Antony, 2011). Further research on the application of motivation-enhancement interventions to OEF/OIF veterans with PTSD may yield effective methods for increasing the likelihood that these veterans will engage in and complete treatment. Given that more than a third of the current sample was never seen by the PTSD Specialist despite having accepted referral, it may be beneficial to develop motivation-enhancing interventions that can be administered in primary or secondary health care settings. The current results indicate that the process of engaging OEF/OIF veterans in PTSD treatment is best conceptualized as a longer-term undertaking, in relation to both when they return from deployment and when they are initially referred. The majority of treatment completers in the present study did not receive an evidence-based therapy, whereas 30% of noncompleters did. Though VA’s efforts to make evidence-based therapies widely available are undoubtedly positive, these results may indicate that a more useful strategy than broad-based application of traumafocused therapy might be to allow veterans to select the treatments that they believe suit them best. The most significant shortcoming of this study is that only one provider was responsible for scheduling, engaging, and treating referrals. It is very likely that provider factors affected these results, even though institutional procedures were followed in attempting to contact and engage referrals, 37% of the sample was never seen by the provider, and the large majority of noncompleting referrals did not go on to receive care specifically for PTSD from other VA providers. A second significant limitation of this study is the classification of referrals as having engaged with or completed treatment. Engagement in treatment by this population appears to be a dynamic variable, so the proportions of referrals engaging in and completing treatment will likely change over time, limiting the generalizability of these data. In addition, a somewhat conservative definition of treatment completion was used. It is possible that some of the referrals classified as seen at least once but not completing actually did benefit from treatment to a degree that was satisfactory to them and that they then simply stopped coming. These results are correlational in nature, which prevents strong conclusions about causality. Also, data examined were limited to those accessible through the VA medical record. It is possible that unmeasured factors account for the relationships found in this study. Lastly, chart review did not allow investigation of psychotherapy received outside of the VA. There was no way to access records from three nearby Vet Centers or local providers to determine whether referrals in the current study were receiving services from them.
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Received May 18, 2012 Revision received July 19, 2013 Accepted September 26, 2013 䡲
In the public domain DOI: 10.1037/a0035077
Treatment Utilization Among OEF/OIF Veterans Referred for Psychotherapy for PTSD Jason C. DeViva Veterans Affairs Connecticut Health Care System, Yale School of Medicine Despite high levels of positive screening for mental health complaints, research indicates that veterans of Operations Enduring Freedom and Iraqi Freedom (OEF/OIF) seek mental health care at low rates. The purpose of this study was to examine treatment utilization in 200 consecutive OEF/OIF referrals to a PTSD specialist for psychotherapy. This study also examined the relationships between treatment engagement/completion and numerous demographic and clinical variables. This chart-review study identified whether referrals were seen at all and whether they completed psychotherapy (as defined by documented mutual agreement between therapist and referral). Chi-square analyses and t tests were performed to determine whether engagement and completion were related to gender, age, marital status, race, employment, school enrollment, branch of service, time since most recent deployment, number of deployments, service-connection rating, medication prescription, substance use and depressive disorder comorbidity, referral source, TBI screening results, and presence of pain problems and legal issues. Of 200 consecutively referred OEF/OIF veterans, 75 were never seen, 86 were seen at least once without completing, and 24 completed psychotherapy. Being married and employed and older age were associated with higher likelihood of completing therapy. Completers received significantly more sessions of psychotherapy than those who were seen without completing, but the 2 groups did not differ in the types of therapy received. Keywords: military, psychotherapy, retention, veteran
the national VA system between 2002 and 2008 and were diagnosed with PTSD, 80% had at least one follow-up visit specifically for PTSD. Seal et al. determined that nine sessions of treatment would allow for delivery of a minimum adequate dosage of an evidence-based psychotherapy for PTSD; they reported that 27% of their sample had nine or more visits targeting PTSD within the year after diagnosis, and only 9% of the sample received those nine sessions within a 15-week time period. Maguen, Madden, Cohen, Bertenthal, and Seal (2012) examined the records of more than 290,000 OEF/OIF veterans with at least one of several mental health diagnoses common to that population and found that the median time from end of deployment to the first primary care visit was about a year and a half, with more than two years to the first mental health visit. Maguen et al. also defined receiving eight or more mental health visits in a 12-month period as “minimally adequate mental health care” (p. 1206), and found that by three years postdeployment only about a quarter of the population examined had received minimally adequate mental health care. On a smaller scale, Lu, Duckert, O’Malley, and Dobscha (2011) found that among more than 800 veterans who screened positive for PTSD in VA primary care visits over an approximately 2-year period from 2006 –2008 across four VA facilities in the Pacific Northwest, OEF/OIF veterans received an average of 8 visits to specialty PTSD clinics in the year after screening, with only 29% of OEF/OIF veterans receiving 9 or more sessions in the year after screening, which constituted “minimally adequate specialty treatment” (p. 944). Both statistics were significantly lower than those of non-OEF/OIF veterans diagnosed with PTSD. Erbes, Curry, and Leskela (2009) reported that 106 OEF/OIF veterans referred to an outpatient VA PTSD program were scheduled for an average of 11
Research indicates that substantial proportions of service members returning from deployment to Iraq or Afghanistan screen positive for anxiety, depression, or posttraumatic stress disorder (PTSD; Hoge, Auchterlonie, & Milliken, 2006; Hoge et al., 2004; Hoge, Terhakopian, Castro, Messer, & Engel, 2007). Exposure to combat and PTSD among veterans of Operations Enduring Freedom (OEF) and Iraqi Freedom (OIF) have been associated with increased functional impairment, including greater levels of alcohol use (Jacobson et al., 2008), health problems (Hoge et al., 2007), and relationship problems (Renshaw, Rodrigues, & Jones, 2009). Research on treatment utilization among OEF/OIF veterans suggests that health care providers in the Department of Veterans Affairs (VA) engage these veterans in mental health care at low rates. Three studies have examined engagement in treatment within the VA system at the national level. Harpaz-Rotem and Rosenheck (2011) found that, among a national sample of over 29,000 OEF/OIF veterans, VA clinicians provided an average of about 7 encounters with PTSD listed as a primary or secondary diagnosis over the year after initial diagnosis, with an average of 221 days between the first and last visits. Seal et al. (2010) reported that of more than 84,000 OEF/OIF veterans who entered
This article was published Online First December 23, 2013. Jason C. DeViva, Veterans Affairs Connecticut Health Care System, Yale School of Medicine. Correspondence concerning this article should be addressed to Jason C. DeViva, VA Connecticut Health Care System, 950 Campbell Avenue, West Haven, CT 06516. E-mail: [email protected] 179
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mental health appointments but kept an average of 6, which was a significantly lower proportion than Vietnam veterans referred to the same program. Numerous factors appear to correlate with measures of treatment utilization. Studies have found that variables such as older age, female gender, service connection benefits from the VA, higher income, receiving services in a specialty mental health clinic, comorbid depression, and urban residence were associated with greater treatment utilization (Harpaz-Rotem & Rosenheck, 2011; Lu et al., 2011; Maguen et al., 2012; Seal et al., 2010). Pietrzak, Johnson, Goldstein, Malley, and Southwick (2009) surveyed a sample of OEF/OIF veterans and found that 26% had reported having had a mental health counseling visit in the past six months, with 40% reporting a psychiatric medication visit. Pietrzak et al. found that positive screening for PTSD, depression, or alcohol problems, low levels of unit support, and negative beliefs about mental health care all predicted higher levels of perceived barriers to care and stigma, and negative beliefs about mental health care were also associated with lower likelihood of utilizing mental health care services. Evidence has indicated that VA is engaging OEF/OIF veterans with PTSD in mental health treatment at low rates. Thus far, studies conducted within the VA system have not examined specific types of care received (e.g., psychotherapy or pharmacotherapy), only mental health visits in general. Also, given the nature of data collection in these studies, individual records could not be reviewed to determine whether treatment progressed until provider and patient agreed goals had been met. The main purpose of the current chart-review study was to examine the outcome of referral to a specialized OEF/OIF PTSD psychotherapy provider among 200 veterans. In addition, this study sought to determine whether demographic and diagnostic variables were related to likelihood of engaging in and completing treatment.
Method Participants This study took place at a VA facility in southern New England with an outpatient mental hygiene clinic as well as other specialized mental health services but no outpatient PTSD treatment program, and was approved by the local VA Human Studies Subcommittee. Data for this study were gathered on 200 consecutive referrals for psychotherapy to a clinical psychologist hired to provide only psychotherapy for PTSD (in VA terms, a “PTSD Specialist”) to veterans of OEF, OIF, and Operation New Dawn (OND; given the period of time examined by this study, no veterans of OND were included in these data). Referrals to the PTSD Specialist were identified through review of provider records and specific clinic usage in the computerized patient record system. The PTSD Specialist was trained in cognitive– behavioral therapy for PTSD, with training in and experience providing both prolonged exposure therapy (e.g., Foa, Hembree, & Rothbaum, 2007) and cognitive processing therapy (e.g., Resick, Monson, & Chard, 2006). Attempts to engage referred veterans were consistent with VA policy. When a referral was received, several attempts were made to contact the veteran by telephone. If attempts to contact by telephone proved unsuccessful (either because the veteran did not
call back or the contact information in the record was not accurate), a letter was sent to the address in the medical record. If there was no response to that letter, the case was considered closed. The same process was used to attempt to reschedule after no-shows. Initial sessions with all referrals focused on collaboratively developing a treatment plan. The long-term goal for all referrals was the completion of evidence-based therapy for PTSD. If referrals were unwilling to engage in trauma-focused cognitive– behavioral therapies or if those therapies were contraindicated, referrals were offered symptom-focused interventions (e.g., anger management, cognitive– behavioral therapy for insomnia or anxiety). All referrals were also offered supportive group therapy specifically for veterans of OEF/OIF.
Data Collection and Analysis This study used a chart-review methodology. Each referral’s medical record was reviewed to gather basic demographic data, including gender, age, marital status, race, employment, school enrollment, branch of service, time since most recent deployment, number of deployments, service-connection rating, medication prescription, substance use and depressive disorder comorbidity, referral source, TBI screening results, and presence of pain problems and legal issues. Chart review indicated that numerous referrals had relocated and addresses clearly were not updated; therefore, distance to the VA facility was not examined in this study. Progress notes were reviewed to determine whether each referral was seen by the PTSD Specialist and, if so, whether and how treatment ended. If a referral was seen at least once and the medical record contained a progress note documenting that treatment ended when therapist and patient agreed that goals had been met, that referral was coded as a treatment completer. If treatment ended for any other reason, or if the referral stopped responding to attempts at contact, the referral was coded as having been seen without completing. Among referrals seen at least once, the number of days from referral and first contact to first scheduled visit and the number of psychotherapy sessions received from the PTSD Specialist were recorded. For noncompleting referrals, any other mental health services received after referral were recorded. For referrals that received nine or more therapy sessions, the dates of encounters were examined to determine whether a dose of nine or more sessions was administered within a 15-week period. For categorical data, chi-square analyses were performed to compare referrals never seen, noncompleters, and completers on frequency of the independent variables. For continuous independent variables, analyses of variance and t tests were used to compare groups.
Results Participants Other than cases excluded because they were referred specifically for evaluation, 200 consecutive psychotherapy referrals over a 31-month period from 04/08 to 11/10 were included in this chart review. The last referral occurred approximately 8 months before data collection began. The characteristics of the sample are displayed in Table 1. The majority of referrals (130, 65%) came from a walk-in Primary Care-Mental Health Integration clinic (Pomer-
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Table 1 Dependent Variable Data for Entire Sample and Broken Down Among Inactive Cases by Treatment Engagement Variable Gender Male Female Age Marital status Single/divorced Married Race Caucasian Latino African-American Asian-American Employment Employed Unemployed School enrollment In school Not in school Branch of service Active-duty branches NG/Reserves Time since last deployment (mos.) Deployments Single Multiple Service connection (%) Total PTSD Medication usage No meds One med Two or more meds Comorbid SUD Present Not present Comorbid MD Present Not present Source of referral PMHC MH med provider Other VA program External source TBI screen Positive Negative Legal problems Yes No Comorbid pain Yes No ⴱ
p ⬍ .05.
ⴱⴱ
Total sample x/n (SD/%)
Never seen x/n (SD/%)
Seen, didn’t complete x/n (SD/%)
Completed x/n (SD/%)
171 (92%) 14 (8%) 30.2 (7.4)
67 (89%) 8 (11%) 28.8 (6.4)
83 (97%) 3 (4%) 30.2 (6.9)
21 (88%) 3 (13%) 35.1 (9.7)
121 (66%) 62 (34%)
57 (77%) 17 (23%)
53 (62%) 32 (38%)
11 (46%) 13 (54%)
120 (65%) 43 (23%) 19 (10%) 3 (2%)
51 (68%) 17 (23%) 6 (8%) 1 (1%)
54 (63%) 19 (22%) 11 (13%) 2 (2%)
15 (63%) 7 (29%) 2 (8%) 0 (0%)
74 (43%) 97 (57%)
26 (38%) 42 (62%)
31 (38%) 50 (62%)
17 (77%) 5 (23%)
45 (27%) 124 (73%)
20 (30%) 46 (70%)
20 (25%) 59 (75%)
5 (21%) 19 (79%)
86 (47%) 98 (53%) 31.3 (19.9)
34 (46%) 40 (54%) 28.3 (21.2)
153 (83%) 32 (17%)
61 (81%) 14 (19%)
45.5 (27.3) 43.5 (24.1)
43.5 (27.7) 40.4 (23.1)
68 (37%) 44 (24%) 73 (40%)
27 (36%) 17 (23%) 31 (41%)
29 (34%) 22 (26%) 35 (41%)
12 (50%) 5 (21%) 7 (29%)
61 (35%) 124 (65%)
26 (35%) 49 (65%)
28 (33%) 58 (67%)
7 (29%) 17 (71%)
56 (43%) 129 (57%)
30 (40%) 45 (60%)
16 (19%) 70 (81%)
10 (42%) 14 (58%)
117 (63%) 58 (31%) 9 (5%) 1 (1%)
49 (65%) 22 (29%) 3 (4%) 1 (1%)
49 (57%) 32 (37%) 5 (6%) 0 (0%)
19 (79%) 4 (17%) 1 (4%) 0 (0%)
106 (58%) 76 (42%)
45 (61%) 29 (39%)
47 (55%) 38 (45%)
14 (61%) 9 (39%)
11 (6%) 163 (94%)
1 (2%) 66 (98%)
9 (11%) 74 (89%)
1 (4%) 23 (96%)
85 (48%) 92 (52%)
33 (48%) 36 (52%)
42 (50%) 42 (50%)
10 (42%) 14 (58%)
df, 2/F 2, 3.91 2, 7.28ⴱⴱ 2, 8.88ⴱ 6, 2.30
2, 11.89ⴱⴱ 2, 0.63 2, 0.24
37 (43%) 49 (57%) 33.7 (18.7) 75 (87%) 11 (13%) 46.9 (27.9) 45.8 (26.6)
15 (63%) 9 (38%) 32.6 (19.8)
2, 144, 1.21 2, 3.63
17 (71%) 7 (29%) 45.8 (24.6) 41.4 (10.7)
2, 133, 0.23 2, 66, 0.39 4, 2.36
2, .26 2, 10.39ⴱⴱ 6, 6.00
2, 0.57 2, 5.69 2, 0.52
p ⬍ .01.
antz, 2005) that served as the main point of entry for veterans with any mental health needs. The sample was 92% male, with a racial breakdown similar to that of the local region. Roughly half of the sample was single and about a third was married. The sample had a mean age of about 30 years, and was referred to the PTSD Specialist an average of about 31 months after returning from deployment.
Outcome of Referral Of the 200 referrals for specialized PTSD treatment, 75 (38%) were never seen by the PTSD Specialist (either never responded to multiple attempts to contact or never presented for a scheduled session). Of the remaining 125 referrals, 24 (12% of the total sample) were rated as having completed treatment. An additional
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86 cases (43% of the total sample) had been closed as a result of having discontinued treatment and not responded to numerous phone calls and letters attempting to reengage them. The remaining 15 referrals had not been closed either because of completion or discontinuation. These individuals were classified as currently active in treatment, and were not included in analysis. Among active patients, the average time from referral to the point data collection began was 15 months. Of the 161 referrals who did not complete psychotherapy for PTSD (referrals never seen and referrals seen without completing), 76 (47%) had no other encounters with any mental health provider in the local VA medical record after referral to the PTSD Specialist. An additional 61 (38%) met at least once with a medication provider but received no psychotherapy, and the remaining 24 (15%) engaged in other VA mental health programs. Of those 24 referrals who engaged in other VA mental health programs, only 2 (1% of the 161 noncompleters) went on to receive PTSD-focused psychotherapy from some other source within the local VA system.
Engagement in and Completion of Therapy Among the 185 closed cases, chi-square analysis indicated that outcome of referral was not randomly associated with marital status; a higher proportion of treatment completers were married, 54%, than referrals never seen, 23%, or seen but noncompleting referrals, 38%, 2(2) ⫽ 8.88, p ⬍ .05. In addition, a higher proportion of treatment completers were employed, 77%, than referrals never seen, 38%, or seen but noncompleting referrals, 38%, 2(2) ⫽ 11.89, p ⬍ .01. A lower proportion of seen but noncompleting referrals had a comorbid depressive disorder diagnosis, 22%, than referrals never seen, 40%, or treatment completers, 42%, 2(2) ⫽ 6.35, p ⬍ .05. The three groups also differed in age, F(2, 182) ⫽ 7.28, p ⬍ .01, with post hoc comparisons indicating that completers, x ⫽ 35.1 year SD ⫽ 9.7, were older than both referrals never seen, x ⫽ 28.8 years, SD ⫽ 6.4, and seen but noncompleting referrals, x ⫽ 30.2 years, SD ⫽ 6.9. No other variables were related to outcome of referral (see Table 1).
Timing of Treatment Among the 107 referrals for whom time of first contact and first scheduled appointment were available, the average time from first contact to first scheduled session was 7.3 calendar days, SD ⫽ 4.4, with a range of 1 to 22 days. More than 60% of referrals received an appointment within 7 days of the day they were scheduled, and all but 4 of the 107 referrals, or 96%, received an appointment within two weeks. Among referrals seen at least once, the total time from initial referral until the first scheduled session was obtainable for 107 of 110 cases. The mean time from referral to first scheduled appointment was 33.6 days, SD ⫽ 75. There were no differences between any groups on time from first contact to first session or time from initial referral to first scheduled session. Of referrals seen but not completing, 22 of 86 (26%) received more than nine sessions with the PTSD Specialist, with 11 receiving those nine sessions within a 15-week period. Of the 24 completers, 18 (75%) received nine or more sessions of therapy, with the remaining six completing treatment in fewer than nine ses-
sions, and 13 of the completers (54%) received nine sessions of therapy within a 15-week period.
Treatment Received The overall sample received a mean of 4.1 sessions of therapy with the PTSD Specialist, SD ⫽ 6.4. Considering only those who were seen at least once, the average number of sessions was 7.0, SD ⫽ 7.0. Treatment completers were seen significantly more times, x ⫽ 12.0 sessions, SD ⫽ 6.7, than referrals seen at least once without completing, x ⫽ 5.6 sessions, SD ⫽ 6.4, t(108) ⫽ 4.27, p ⬍ .001. As noted earlier, all referrals who presented for treatment initially participated in collaborative treatment planning and when appropriate were offered trauma-focused CBT, general CBT for anxiety, symptom-focused therapies, or supportive group therapy. Overall, 30% of referrals seen at least once engaged in traumafocused CBT, whereas an additional 25% received CBT for anxiety and 13% received symptom-focused intervention. Of those seen at least once who did not complete, 24% discontinued treatment during the treatment planning phase; these 21 cases were not included in analysis of treatment received. Chi-square analysis indicated that treatment completers did not differ from cases seen without completing in the types of treatment received (see Table 2).
Discussion This chart review yielded data on treatment engagement and completion rates in a sample of OEF/OIF veterans consecutively referred for psychotherapy for PTSD in a VA facility over a 31-month period, including the eight months after that referral period. The data are useful for their description of referral outcome and also for the relationships found between treatment engagement and completion and the other variables measured. Of 200 cases referred for specialized PTSD psychotherapy, most of whom had already been screened and diagnosed with PTSD and who had accepted referral at the time of screening, 24 (12%) had completed psychotherapy by the time of data analysis. More than a third (75, 38%) were never seen during the study time period by the PTSD specialist to whom they were referred, despite efforts to contact and schedule them, and an additional 86 cases (43%) were seen at least once but did not complete treatment. Fifteen patients (8%) were still in treatment at the time of data collection. The average time from return from deployment to referral was more than 31 months, and active cases had been referred to therapy an average of 15 months before data collection began. These results are likely
Table 2 Types of Treatments Received by Referrals Seen at Least Once Engagement/ Completion
Traumafocused CBT
CBT for anxiety
Symptomfocused therapies
Group therapy
Total
Seen, didn’t complete Completers Total
26 (40%) 7 (29%) 33 (37%)
18 (28%) 9 (38%) 27 (30%)
8 (12%) 6 (25%) 14 (16%)
13 (20%) 2 (8%) 15 (17%)
65 24 89
Note.
2(3) ⫽ 4.68, p ⫽ .19.
OEF/OIF TREATMENT UTILIZATION
not attributable to clinic availability, as referrals averaged about seven days from first contact to first scheduled appointment. These results are comparable with those reported by Harpaz-Rotem and Rosenheck (2011), Maguen et al. (2012), and Seal et al. (2010) in that a minority of referrals engaged in treatment to an apparently meaningful degree. The current study expands on those findings by specifically examining psychotherapy engagement and by providing data on treatment completion. Overall, evidence appears to suggest that OEF/OIF veterans with PTSD tend not to engage in or complete psychotherapy. Treatment completers were more likely to be older, married, and employed at the time of referral than referrals who were never seen and referrals who were seen at least once but did not complete. It is possible that being in a marital relationship or having a job provided additional incentive to initiate and complete the treatment process, or additional potential negative consequences for not completing. It is also possible that individuals who could sustain a marriage and hold a job were functioning at a higher level overall and therefore were better able to engage in and complete therapy. Harpaz-Rotem and Rosenheck (2011) also found that older age and higher income levels were associated with lower likelihood of discontinuing treatment, and Seal et al. (2010) found similar results in terms of age. Referrals who were seen at least once but did not complete treatment were less likely to have a comorbid depressive disorder than both referrals who were never seen and referrals who completed treatment. It is possible that depression interacted with other unmeasured variables to produce apparently opposite effects in these two sets of referrals. Harpaz-Rotem and Rosenheck (2011) found that comorbid mood disorder diagnosis was associated with lower likelihood of discontinuing treatment and higher number of mental health visits. The 185 closed cases received an average of about 4 sessions of therapy with the PTSD Specialist. The 110 referrals who met at least once with the PTSD Specialist received an average of about 7 sessions of therapy, with completers receiving 12 sessions and noncompleters more than 5, which is consistent with data reported by Harpaz-Rotem and Rosenheck (2011), Lu et al. (2011), and Erbes et al. (2009). The results of the current study indicate that the construct of receiving 9 sessions of therapy over a 15-week period that was used in other studies to indicate a meaningful dose of treatment may not be useful for this purpose. About a quarter of treatment completers received fewer than 9 sessions of therapy, and about a quarter of those who were seen but did not complete received more than 9 sessions of therapy. Just over half of treatment completers received 9 sessions of therapy in a 15-week period. The heterogeneity of treatment utilization among completers and referrals seen without completing suggests that it may not be feasible to operationalize the construct of “a meaningful dose of therapy.” The accumulating body of treatment utilization research among OEF/OIF veterans yields a somewhat consistent picture thus far. These veterans tend to present for care well over a year after returning from deployment, and VA has been able to engage this population in treatment for about seven sessions of mental health care before they discontinue, apparently often without completing therapy. Younger age, unemployment, single marital status, and diagnostic comorbidity are all associated with lower likelihood of remaining in treatment. To a degree, it may be useful to focus extra treatment engagement efforts on veterans with these demographic
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characteristics; however, VA has not been able to engage this cohort as a whole, so it is likely that all veterans of OEF/OIF would benefit from extra efforts to engage them in treatment. Though treatment completion was not related to time since deployment or time from referral to first session in the present study, it would still likely be beneficial to engage this population in treatment sooner, to provide relief as soon as possible. There is some evidence that interventions designed to increase motivation can lead to greater levels of treatment utilization and self-reported readiness for change in veterans with PTSD (Murphy, Thompson, Murray, Rainey, & Uddo, 2009) and lead to better treatment compliance and greater treatment efficacy for anxiety disorders other than PTSD (Antony, 2011). Further research on the application of motivation-enhancement interventions to OEF/OIF veterans with PTSD may yield effective methods for increasing the likelihood that these veterans will engage in and complete treatment. Given that more than a third of the current sample was never seen by the PTSD Specialist despite having accepted referral, it may be beneficial to develop motivation-enhancing interventions that can be administered in primary or secondary health care settings. The current results indicate that the process of engaging OEF/OIF veterans in PTSD treatment is best conceptualized as a longer-term undertaking, in relation to both when they return from deployment and when they are initially referred. The majority of treatment completers in the present study did not receive an evidence-based therapy, whereas 30% of noncompleters did. Though VA’s efforts to make evidence-based therapies widely available are undoubtedly positive, these results may indicate that a more useful strategy than broad-based application of traumafocused therapy might be to allow veterans to select the treatments that they believe suit them best. The most significant shortcoming of this study is that only one provider was responsible for scheduling, engaging, and treating referrals. It is very likely that provider factors affected these results, even though institutional procedures were followed in attempting to contact and engage referrals, 37% of the sample was never seen by the provider, and the large majority of noncompleting referrals did not go on to receive care specifically for PTSD from other VA providers. A second significant limitation of this study is the classification of referrals as having engaged with or completed treatment. Engagement in treatment by this population appears to be a dynamic variable, so the proportions of referrals engaging in and completing treatment will likely change over time, limiting the generalizability of these data. In addition, a somewhat conservative definition of treatment completion was used. It is possible that some of the referrals classified as seen at least once but not completing actually did benefit from treatment to a degree that was satisfactory to them and that they then simply stopped coming. These results are correlational in nature, which prevents strong conclusions about causality. Also, data examined were limited to those accessible through the VA medical record. It is possible that unmeasured factors account for the relationships found in this study. Lastly, chart review did not allow investigation of psychotherapy received outside of the VA. There was no way to access records from three nearby Vet Centers or local providers to determine whether referrals in the current study were receiving services from them.
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Received May 18, 2012 Revision received July 19, 2013 Accepted September 26, 2013 䡲
