Exposure Therapy for PTSD Benefits Patients With Comorbid Alcohol Use Disorder, Study Shows

People with co-occurring posttraumatic stress disorder (PTSD) and alcohol use disorder (AUD) can tolerate and benefit from prolonged exposure therapy, according to a study published online April 24 in JAMA Psychiatry. Among veterans with both disorders, prolonged exposure therapy more effectively reduced PTSD symptoms than a therapy focused on coping skills and did not increase alcohol problems.

“This information is critical because having an AUD continues to be a barrier to receiving exposure therapy because of therapist perceptions of patients’ fragility (i.e., beliefs that patients will not be able to handle trauma-related memories and may have an increase in alcohol use),” wrote Sonya Norman, Ph.D., of the Veterans Affairs San Diego Healthcare System, and colleagues.

Veterans with PTSD and AUD (N=119) were randomly divided to receive 12 sessions of either prolonged exposure therapy or coping skills therapy; both therapies were integrated to focus on both PTSD and substance use symptoms. The exposure program, known as COPE, combines live and image-based exposure to traumatic memories alongside cognitive-behavioral therapy (CBT) techniques to strengthen relapse prevention skills. The coping skills therapy combines CBT with case management to develop coping skills to manage trauma and substance use in a patient’s daily life. The participants were asked to attend at least one session a week but were allowed up to six months to finish therapy.

At the end of the study, participants in both treatment groups showed significant reductions in their PTSD severity (measured with the Clinician Administered PTSD Scale for DSM-5 [CAPS-5]) and total number of heavy drinking days. The prolonged exposure group did have greater CAPS-5 reductions on average, as well as a higher rate of remission for PTSD (22.2% vs. 6.8% in the coping skills group), despite attending fewer sessions on average (8.4 vs. 11.4 in the coping skills group).

“It is not clear whether some participants in the I-PE [integrated prolonged exposure] arm attended fewer sessions because they found I-PE treatment to be too difficult, if they completed treatment more quickly because they felt better, or for other reasons,” Norman and colleagues wrote. “Future research is needed to understand why participants had better PTSD outcomes with I-PE treatment even though they attended significantly fewer sessions, and who is most likely to benefit from each treatment under which conditions.”

To read more about PTSD therapy, see the Psychiatric Services article, “Factors Associated With Receipt of Cognitive-Behavioral Therapy or Prolonged Exposure Therapy Among Individuals With PTSD.”

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Senators Hear Testimony on MH Care and Suicide Prevention for Veterans

A bipartisan group of U.S. senators expressed concern at a hearing Wednesday about what they see as the slow pace of change in the Veterans Health Administration’s (VHA) mental health care system—a concern intensified after listening to two women whose sons, veterans of Iraq or Afghanistan, had died by suicide.

“When people are hurting, they don’t want to wait to get help,” stressed committee chair Sen. Bernie Sanders (I-Vt.), who then asked how the $5 billion authorized for hiring additional clinicians was being spent. Those funds were not specifically allocated for mental health care providers, replied psychiatrist Harold Kudler, M.D. (above, right), chief mental health services consultant for the VHA. However, the agency was nevertheless allocated a share of those funds to recruit more providers, increase points of access, and test new modes of outreach in rural areas.

Still other avenues could be explored in the effort to reduce the number of veterans who die by suicide, said psychiatrist Elspeth Cameron Ritchie, M.D., M.P.H., (above, left), a retired Army colonel who is now chief clinical officer of the Washington, D.C., Department of Behavioral Health and a member of an Institute of Medicine panel that studied the effectiveness of treatments for posttraumatic stress disorder.

The VHA should, for example, conduct more research to understand which of its patients are at increased risk for suicide, Ritchie said. Service members also should be screened with closer attention to specific tasks they performed while deployed, as well as for any toxic exposures—like Agent Orange or the antimalarial drug mefloquine—which might produce symptoms of psychiatric illness or increased suicide risk.

The testimony was presented as the Senate considered the Clay Hunt SAV [Suicide Prevention for American Veterans] Act, which includes measures for suicide prevention and medical school loan forgiveness for psychiatrists and certain other practitioners who join the VHA.

For more about mental health issues that affect veterans and the findings of the Institute of Medicine report, see the Psychiatric News article “Pentagon, VA Lack Data to Assess PTSD Care Systems.”

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Counseling Veterans on Benefits Can Increase Their Working Rate and Mental Health Service Use

Veterans applying for psychiatric disability benefits are likely to work more days and to use more mental health services if they receive counseling about the value of working, said Department of Veterans Affairs (VA) researchers based on data they published in Psychiatric Services in Advance.

The researchers randomized 84 veterans who had applied for disability benefits based on psychiatric illness to either a four-session intervention program of benefits counseling or a general introduction to the VA’s health system (control subjects). The counseling used motivational interviewing and other techniques to “increase the veterans’ desire to engage in work and related activities,” said Marc Rosen, M.D., an associate professor of psychiatry at Yale University School of Medicine, and colleagues. Rosen is also affiliated with the VA Connecticut Healthcare System in West Haven.

The control group showed no change in the average number of days worked at six months from baseline, but the group that received counseling significantly increased their working time from 6.6 days to 10.5 days per month.

The increase came not from a few veterans working more hours but from more veterans going back to work, Rosen and colleagues pointed out. The counseling intervention also increased these veterans' use of mental health services.

“Benefits counseling might help veterans who have applied for disability because of a service connection to obtain other evidence-based services that help them successfully find and maintain employment,” the researchers concluded.

“This study summarizes the dilemma that both veteran/patients and providers face in trying to encourage veterans to get back into the workforce without losing their disability benefits,” said former U.S. Army psychiatrist Elspeth Cameron Ritchie, M.D., M.P.H., chief medical officer of the District of Columbia Department of Behavioral Health. “Providing briefings is a good idea, but the effect size is relatively mild, and more work is needed to determine just how we can get veterans back to the work.”

To read about programs that help people with psychiatric disabilities remain employed, see the Psychiatric News article, “Study Finds Evidence Showing Supported Employment Works.”

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Legislation Would Improve Veterans’ Access to Mental Health Care

In an 11th hour move last night, the Senate approved a compromise bill that includes a number of provisions to increase veterans’ access to mental health care as part of broader plan to enhance the VA's medical workforce and allow access to care outside the VA system. The legislation, known as the Veterans' Access to Care Through Choice, Accountability, and Transparency Act, was passed by the House earlier this week and is now awaiting signature by President Obama.

The legislation calls for several actions that would lead to improved health care of veterans. Among them:

• Annual studies of workforce shortages: The VA would identify annually the five occupations of health care providers with the largest staffing shortages and be able to utilize direct-appointment authority to fill these openings in an expedited manner.
  
• Increased medical residency positions at the VA: The VA would establish or ensure sufficient numbers of medical residency positions at facilities in areas with health professional shortages. The number of graduate medical education residency positions will increase by up to 1,500 over five years with a priority for primary care, mental health, and other specialties.
  
• Increased medical education debt repayment: The VA' s authority to operate the Health Professionals Educational Assistance Program (HPEAP) would extend through 2019, and the cap on debt reduction payments to participants would be increased from $60,000 to $120,000.

“We have a deep obligation to care for all the wounds of war,” said APA President Paul Summergrad, M.D. “In 2012, the VA Office of the Inspector General identified recruiting and retaining psychiatrists as the VA’s greatest mental health challenge. This legislation puts in place several actions to directly address that shortage and will result in many more veterans having timely access to needed psychiatric services.”

APA CEO and Medical Director Saul Levin, M.D., said, “With the enactment of this legislation, the VA will have the authority to provide appropriate incentives to attract psychiatrists and other health care professionals in line with other similar federal programs and be better able to grow and maintain the workforce needed to serve all veterans.”

In addition, the legislation would allow veterans to obtain health care at non-VA facilities if they live more than 40 miles from a VA clinic or can't get an appointment at a VA clinic within 30 days, provide for improvements in VA health care facilities and the opening of 27 additional VA health facilities across the nation, require the VA to post online the wait times for scheduling appointments at VA medical facilities, and require an independent assessment of hospital care and medical services furnished in VA medical facilities.

A full report on the legislation will appear in an upcoming issue of Psychiatric News. For information on the VA’s failure to provide adequate and timely health care to veterans, see the Psychiatric News article Veterans Affairs Scheduling Scandal Leads to Turmoil at the Top. 

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IOM Faults Pentagon, VA for Lack of Data to Assess Effectiveness of PTSD Care

In a just-published two-year study, the Institute of Medicine (IOM) has concluded that despite enormous investments of time, money, and effort in programs to treat posttraumatic stress disorder (PTSD), neither the Department of Defense (DoD) nor the Department of Veterans Affairs (VA) "knows with certainty whether those programs and services are actually successful in reducing the prevalence of PTSD in service members or veterans and in improving their lives."

The 300-page report points out that between 7% and 20% of U.S. service members and veterans of the Iraq and Afghanistan wars may have PTSD and that it can "pervade all aspects of a service member's or veteran's life...," yet neither department collects much treatment outcome data, and what few data exist "suggest that there are only modest improvements in PTSD symptoms after treatment in these programs." To remedy this situation, the IOM committee urges the agencies to develop "an integrated, coordinated, and comprehensive PTSD management strategy that plans for the growing burden of PTSD for service members, veterans, and their families, including female veterans and minority group members."

Committee members emphasized as well that the number of mental health care providers "has not kept pace with the growing demand for PTSD services," and the two agencies have "no formal procedures for evaluating those providers" who have been hired in the last few years or for tracking the care they deliver.

APA President Paul Summergrad, M.D., said, "The IOM's report and recommendations are helpful as our nation contemplates comprehensive reforms to the VA. The IOM Committee found that DoD and VA "should have available an adequate workforce of mental health care providers," especially to meet the demand for PTSD treatment, which is why APA is strongly advocating for the passage of the Ensuring Veterans' Resiliency Act. We also agree that it's crucial to have accurate data and mechanisms in place to evaluate which programs are most effective in relieving PTSD symptoms."

To read about the IOM committee's initial report on PTSD programs in the DoD and VA, see the Psychiatric News article, "Military, VA Can Do Better in PTSD Response, Experts Say."

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Vets Still Not Getting Enough Psychotherapy, Study Finds

More U.S. military veterans seen at Department of Veterans Affairs Health Administration (VHA) facilities are receiving psychotherapy for posttraumatic stress disorder (PTSD) than ever before, but still not enough veterans who need care are entering or remaining in treatment, according to Juliette Mott, Ph.D., an assistant professor in the Menninger Department of Psychiatry and Behavioral Sciences at Baylor College of Medicine and a researcher at the VA’s South Central Mental Illness Research, Education, and Clinical Center in Houston.

The researchers assessed the use of psychotherapy in the VHA system during the 12 months after a veteran's new-onset diagnosis of depression, anxiety, or PTSD during fiscal years 2004 (N=424,428), 2007 (N=494,318), and 2010 (N=583,733) in the study "Changes in Psychotherapy Utilization Among Veterans With Depression, Anxiety, and PTSD" published yesterday in Psychiatric Services in Advance.

The good news was that the percentage of patients receiving psychotherapy increased from 21 percent in 2004 to 27 percent in 2010, and the median time between diagnosis and start of treatment dropped from 56 days to 47 days. However, the proportion of vets receiving at least eight sessions of psychotherapy remained about the same for PTSD patients, even in 2010, after an expansion of the VHA’s mental health workforce to address a soaring demand for mental health care.

“Additional efforts to engage veterans in psychotherapy are needed,” concluded Mott and colleagues.

For more in Psychiatric News about veterans mental health, see "Expectations Deter Vets From Mental Health Care." Also see Clinical Manual for Management of PTSD from American Psychiatric Publishing.

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VA Researchers Question FDA Antidepressant Warning

The U.S. Food and Drug Administration (FDA)
in 2011 and 2012 issued warnings that higher doses of the antidepressant citalopram hydrobromide increased the risk of two adverse cardiac outcomes—prolonged QT interval and torsade de pointes. Now, after studying records of nearly 1 million patients with depression, a group of Department of Veterans Affairs (VA) researchers “question[s] the continued merit of the warning.”

They compared low, medium, and high doses of citalopram with those another antidepressant, sertraline, that does not have an FDA cardiac-related warning. Adjusted results revealed that higher doses (40 mg/day) of citalopram were actually associated with lower risks of ventricular arrhythmia, all-cause mortality, and noncardiac mortality, compared with doses of 1 mg/day to 20 mg/day, they wrote in the June American Journal of Psychiatry. There was no increase in risk of cardiac mortality with the higher dose.

Patients prescribed sertraline recorded similar results, although without any associations with all-cause or noncardiac mortality.

“These findings raise questions regarding the continued merit of the FDA warning and provide support for the questions of whether the warning itself will cause more harm than good,” said Kara Zivin, Ph.D., of the VA’s National Serious Mental Illness Treatment and Evaluation Center and an assistant professor of psychiatry at the University of Michigan Medical School and colleagues.

For more in Psychiatric News about the FDA’s warning on citalopram, click here.

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Some Veterans Not Getting Best Drug for PTSD

Mental health clinicians in the Veterans Health Administration too often prescribe medications for posttraumatic stress disorder (PTSD) that are not supported by guidelines, report researchers from the U.S. Department of Veterans Affairs (VA). The guidelines jointly used by the VA and the Department of Defense recommend use of selective serotonin–norepinephrine reuptake inhibitors (SSRI/SNRIs) for veterans with PTSD. They also recommend against routine use of benzodiazepines or second-generation antipsychotics.

After examining 2009 data on 356,958 veterans with PTSD, the researchers found that 66 percent were prescribed SSRI/SNRIs. However, 26 percent were prescribed second-generation antipsychotics, and 37 percent were prescribed benzodiazepines. Between 70% and 80% of these prescriptions were written by mental health clinicians, wrote Thad Abrams, M.D., M.S., and colleagues in the February Psychiatric Services.

Many factors contribute to the misalignment between guidelines and actual practice, said the authors. These might include “service providers’ attitudes, lack of organizational leadership, and insufficient resources dedicated to practitioner education and clinical staff development.”

To read more about guidelines for treating PTSD, see Psychiatric News here. Also see Clinical Manual for Management of PTSD from American Psychiatric Publishing.
 

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Defense Bill Could Help Troops' Mental Health

The National Defense Authorization Act just passed by the U.S. Senate includes several new provisions affecting mental health care. The bill will allow family members to access some Department of Veterans Affairs (VA) mental health services, for example, and will increase oversight of the Integrated Disability Evaluation System jointly established by the Department of Defense and the VA.

In addition, the act includes an amendment proposed by Senate Veterans Affairs Committee Chair Patty Murray (D-Wash.) requiring the Pentagon “to implement a standardized and comprehensive suicide prevention program.”

The number of suicides by active-duty troops had risen to 166 by October 31, 2012, more than the total number for all of 2011. “[T]his amendment seeks to reduce wait times and improve access to mental health care; ensure proper diagnosis; and achieve true coordination of care and information between the U.S. Departments of Defense and Veterans Affairs,” said Murray in a statement. The House of Representative must now vote on the bill.

To read more about military-related mental health issues, see Psychiatric News  here and here.

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CAM Not Ready for Prime Time

Although complementary and alternative medicine (CAM) is considered outside the usual canon of western medical practice, it is often desired by patients for any number of somatic or psychiatric complaints, including posttraumatic stress disorder (PTSD). CAM techniques for PTSD include meditation, acupuncture, and relaxation. However, the evidence base for such approaches is slim, according to an article in the fall PTSD Research Quarterly. A systematic review found just seven randomized controlled trials, and they were small and poorly designed.

“[T]he most basic question ‘Can it work?’ for PTSD has not yet been answered,” wrote Jennifer Strauss, Ph.D., of Duke University and the Department of Veterans Affairs in Washington D.C.; and Ariel Lang, Ph.D., M.P.H., of the VA San Diego Healthcare System and the University of California, San Diego.

These approaches “merit consideration” but require more research before they can be used as alternatives to current, validated treatments for PTSD, concluded the authors. However, they added, “[CAM] may be best applied as an adjunct to other PTSD treatments or as a gateway."

For more in Psychiatric News about CAM treatments in psychiatry, click here. See also the American Journal of Psychiatry here.

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APA Urges Senate Committee on Veterans Affairs to Take Further Steps

APA Medical Director James H. Scully Jr., M.D., addressed the Senate Committee on Veterans’ Affairs (VA) earlier this week, citing concerns that veterans and their families continue to experience delays in accessing quality mental health and substance abuse care in the VA system. Scully, himself a Navy veteran and former head of the Denver VA, said that APA applauds the recent announcement by the VA to hire an additional 1,900 psychiatrists, psychologists, and social workers to better serve veterans.

In his letter, Scully emphasized that addressing workload issues and VA payscale inequities affecting psychiatrists would help alleviate the department's psychiatrist shortage. Scully also urged the VA to focus its human resources efforts on hiring psychiatrists, as well as engaging community-based psychiatrists, and said that strategies such as engaging rural psychiatrists and using telepsychiatry are crucial to meeting the mental health needs of rural veterans.

The VA is already working on a number of important initiatives to engage community psychiatrists, including training them on military culture. Scully said that APA would welcome a more robust training partnership with the VA.

Read about community-level programs that provide support for returning veterans in Psychiatric News, here.

VA to Beef Up Mental Health Staffing at VA Medical Centers

The Department of Veterans Affairs announced yesterday that it plans to hire an additional 1,900 psychiatrists, psychologists, social workers, and other mental health care staff in order to reduce long wait times for services at many veterans medical centers. The New York Times reported today that the hiring would increase the department’s mental health staff by nearly 10 percent at a time when the veterans health system is being overwhelmed not just by veterans returning from Iraq and Afghanistan, but also by aging veterans from the Vietnam era.

Commenting on the need for the new positions, Senate Veterans Affairs Committee Chair Patty Murray (D-Wash.) said, "Too often we have seen staff vacancies, scheduling delays, and red tape leave those veterans who have been brave enough to seek help in the first place left with nowhere to turn."

For extensive reporting about veterans’ mental health issues see Psychiatric News here and here.

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Staff Say VA's Mental Health Care Lacks Adequate Resources

Physicians, social workers, and nurses working for the Department of Veterans Affairs (VA) are expressing concern that the agency has inadequate staff to address the surge in demand for mental health care from troops who have experienced combat, according a Washington Post story on October 4 based on results of a survey obtained by the paper. More than a third of respondents, for example, said it takes more than the VA-mandated time frame of 14 days for them to schedule an appointment for a new patient, a delay that could raise the risk of suicide among these former troops, many of whom suffer from posttraumatic stress disorder or depression. The VA responded that its data show such delays are not common, but that it "is working to better understand where service gaps exist." The VA has hired mroe than 3,500 mental health professionals in recent years.

"It is not acceptable to have veterans, who have stepped up and shown the courage to ask for help, be denied that care," Sen. Patty Murray, chair of the Senate Committee on Veterans Affairs, told the Post.

To read more about mental health issues of current and former U.S. troops, see Psychiatric News at http://pn.psychiatryonline.org/content/46/14/20.2full and http://pn.psychiatryonline.org/content/46/7/4.1.full.

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