MILITARY MEDICINE, 179, 11:1368, 2014
Veterans’ Service Utilization and Associated Costs Following Participation in Dialectical Behavior Therapy: A Preliminary Investigation Laura L. Meyers, PhD*; Sara J. Landes, PhDf; Paul Thuras, PhD*
A BSTR A C T Context: Dialectical Behavior Therapy (DBT) is an evidence-based therapy developed for the treatment of suicidal behaviors and disorders characterized by emotional and behavioral dyscontrol that is effective in veteran populations. The impact of DBT on veterans’ Veterans Affairs (VA) service utilization and cost is unknown. Evidence Acquisition: This study evaluated the impact of DBT in a VA outpatient mental health setting on VA service utilization and cost of services. Veterans treated for symptoms of Borderline Personality Disorder, who had completed at least 6 months of the DBT program were sampled (N = 41). Use o f physical and mental health services during the years prior and following DBT was assessed using medical record information. Results: There was a significant decrease in mental health service utilization. Psychiatric hospitalization dropped in half, and for those with a hospitalization, length of stay decreased significantly. Direct costs associated with all health care were significantly reduced. Conclusion: Changes in service utilization resulted in a significant reduction in direct costs o f providing care to veterans with symptoms of Borderline Personality Disorder. Additional research is needed to compare the reduction in overall costs to the cost of im plementing DBT and to compare these changes to a control group.
INTRODUCTION In the last decade, more than 2.2 million troops have been deployed to Iraq and Afghanistan and many have experienced multiple deployments. As these conflicts come to an end and troop size diminishes, the number of veterans will increase and health care settings, including the Department of Veterans Affairs (VA), will see an increase in the number of veterans seeking health and mental health services.1 A number of veterans struggle with emotional and behav ioral dysregulation and/or chronic issues, such as ongoing suicidal behavior. Suicide is a serious problem for veterans. According to the VA/Department of Defense (DoD) Clinical Practice Guidelines for the Assessment and Management of Suicidality,2 veterans account for approximately 20% of deaths from suicide in the United States and veterans using VA services account for about 5 suicides per day. For those veterans using VA services with a recorded mental health diagnosis within the past year, the rate of suicide is 70 per 100.000 (as compared to rates of approximately 38 per 100.000 among men and 15 per 100,000 among women in civilian populations). Evidence-based psychotherapies exist for treating suicide, such as cognitive therapy3 and Collaborative Assessment and
*Minneapolis VA Health Care System, University of Minnesota Medical School, One Veterans Drive (116A), Minneapolis, MN 55417. fNational Center for PTSD, VA Palo Alto Health Care System, 795 Willow Road, Menlo Park, CA 94025. This article was presented at the annual VA Psychology Leadership Conference, San Antonio, TX, April 11-14, 2012. The views expressed reflect those of the authors and not necessarily those of the U.S. Department of Veterans Affairs, the U.S. Government, or the University of Minnesota Medical School, doi: 10.7205/MILMED-D-14-00248
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Management of Suicidality.4'5 However, in addition to suicidal behavior, some veterans also struggle with concomitant emo tional and behavioral dysregulation and/or chronic issues that place them at risk for chronic coping deficits or increased risk of suicidal behaviors. For veterans with additional difficulties beyond acute suicidality, longer term or more comprehensive treatments are necessary. One such treatment is Dialectical Behavior Therapy (DBT).6 The VA/DoD Clinical Practice Guidelines recom mend DBT for treating an underlying disorder (i.e., Border line Personality Disorder or other personality disorders characterized by emotional dysregulation and a history of suicide attempts and/or self-harm) in patients who are suicidal. “With its emphasis on skills training and mindful ness-based emotion regulation, DBT is the most thoroughly studied treatment of the existing psychotherapies for suicidal behavior.”2
Veterans’ Service Utilization and Associated Costs Following Participation in Dialectical Behavior Therapy: A Preliminary Investigation Laura L. Meyers, PhD*; Sara J. Landes, PhDf; Paul Thuras, PhD*
A BSTR A C T Context: Dialectical Behavior Therapy (DBT) is an evidence-based therapy developed for the treatment of suicidal behaviors and disorders characterized by emotional and behavioral dyscontrol that is effective in veteran populations. The impact of DBT on veterans’ Veterans Affairs (VA) service utilization and cost is unknown. Evidence Acquisition: This study evaluated the impact of DBT in a VA outpatient mental health setting on VA service utilization and cost of services. Veterans treated for symptoms of Borderline Personality Disorder, who had completed at least 6 months of the DBT program were sampled (N = 41). Use o f physical and mental health services during the years prior and following DBT was assessed using medical record information. Results: There was a significant decrease in mental health service utilization. Psychiatric hospitalization dropped in half, and for those with a hospitalization, length of stay decreased significantly. Direct costs associated with all health care were significantly reduced. Conclusion: Changes in service utilization resulted in a significant reduction in direct costs o f providing care to veterans with symptoms of Borderline Personality Disorder. Additional research is needed to compare the reduction in overall costs to the cost of im plementing DBT and to compare these changes to a control group.
INTRODUCTION In the last decade, more than 2.2 million troops have been deployed to Iraq and Afghanistan and many have experienced multiple deployments. As these conflicts come to an end and troop size diminishes, the number of veterans will increase and health care settings, including the Department of Veterans Affairs (VA), will see an increase in the number of veterans seeking health and mental health services.1 A number of veterans struggle with emotional and behav ioral dysregulation and/or chronic issues, such as ongoing suicidal behavior. Suicide is a serious problem for veterans. According to the VA/Department of Defense (DoD) Clinical Practice Guidelines for the Assessment and Management of Suicidality,2 veterans account for approximately 20% of deaths from suicide in the United States and veterans using VA services account for about 5 suicides per day. For those veterans using VA services with a recorded mental health diagnosis within the past year, the rate of suicide is 70 per 100.000 (as compared to rates of approximately 38 per 100.000 among men and 15 per 100,000 among women in civilian populations). Evidence-based psychotherapies exist for treating suicide, such as cognitive therapy3 and Collaborative Assessment and
*Minneapolis VA Health Care System, University of Minnesota Medical School, One Veterans Drive (116A), Minneapolis, MN 55417. fNational Center for PTSD, VA Palo Alto Health Care System, 795 Willow Road, Menlo Park, CA 94025. This article was presented at the annual VA Psychology Leadership Conference, San Antonio, TX, April 11-14, 2012. The views expressed reflect those of the authors and not necessarily those of the U.S. Department of Veterans Affairs, the U.S. Government, or the University of Minnesota Medical School, doi: 10.7205/MILMED-D-14-00248
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Management of Suicidality.4'5 However, in addition to suicidal behavior, some veterans also struggle with concomitant emo tional and behavioral dysregulation and/or chronic issues that place them at risk for chronic coping deficits or increased risk of suicidal behaviors. For veterans with additional difficulties beyond acute suicidality, longer term or more comprehensive treatments are necessary. One such treatment is Dialectical Behavior Therapy (DBT).6 The VA/DoD Clinical Practice Guidelines recom mend DBT for treating an underlying disorder (i.e., Border line Personality Disorder or other personality disorders characterized by emotional dysregulation and a history of suicide attempts and/or self-harm) in patients who are suicidal. “With its emphasis on skills training and mindful ness-based emotion regulation, DBT is the most thoroughly studied treatment of the existing psychotherapies for suicidal behavior.”2
