The mental health impact of COVID-19-related stressors among treatment-seeking trauma-exposed veterans

Mission Alliance Community Engagement Project: Exploring the Impact of COVID-19 on Social Isolation, Loneliness, Mental Health and Wellbeing in Veterans

During the Coronavirus disease pandemic, many U.S. veterans with posttraumatic stress disorder (PTSD) experienced increased symptomology and worsened mental health and well-being due in part to social isolation and loneliness. The Mission Alliance project explored these ramifications and prioritized critical issues expressed by U.S. veterans and stakeholders (N = 182) during virtual regional meetings (N = 32). Field notes created specifically for this project were recorded and thematically analyzed. Emerging themes included: (1) social isolation: missed opportunities, collapsed social circles, work-life balance, fostering relationships, and evolving health care delivery; (2) loneliness: deteriorated mental health, suffered with PTSD together but alone, looked out for each other, ambivalence toward technology, and strained and broken systems; (3) mental health: sense of chaos, increased demand and decreased access, aggravation, implementation of tools, innovative solutions, fear and loss, and availability of resources; (4) wellbeing: sense of purpose, holistic perspective on well-being, recognition of balance, persisting stigma, redefined pressures, freedom to direct treatment, and reconnection and disconnection. A PTSD-related patient centered outcomes research (PCOR)/comparative effectiveness research (CER) agenda was developed from these themes. Establishment of a veteran and stakeholder network is suggested to support, facilitate, and promote the PTSD-related PCOR/CER agenda. Furthermore, enhancement of opportunities for veterans with PTSD and stakeholders to partner in PCOR/CER is required to develop and conduct projects that lead to PTSD-related comprehensive care of veterans affected by traumatic events with the potential to translate findings to other populations.

Preliminary Investigation Into the Effectiveness of Group webSTAIR for Trauma-exposed Veterans in Primary Care

INTRODUCTION

A substantial number of trauma-exposed veterans seen in primary care report significant symptoms of PTSD and depression. While primary care mental health integration (PCMHI) providers have been successful in delivering brief mental health treatments in primary care, few studies have evaluated interventions that combine mobile health resources with PCMHI groups. This pilot study assessed the potential benefits of webSTAIR, a 10-module transdiagnostic treatment for trauma-exposed individuals, supported by 5 biweekly group sessions delivered via telehealth. The transdiagnostic and mobile health nature of the treatment, as well as the therapist and peer support provided through group sessions, may offer an innovative approach to increasing access to patient-centered and trauma-informed treatment in primary care settings.

MATERIALS AND METHODS

Thirty-nine male and female veterans with trauma-related symptoms (i.e., PTSD and/or depression) participated in group webSTAIR. Mixed effects analyses were conducted to assess changes in PTSD and depression at pre-, mid-, and post-treatment. Baseline symptom severity was assessed as a predictor of module completion and group attendance. The project was part of a VHA quality improvement project, and IRB approval was waived by the affiliated university.

RESULTS

Analyses revealed significant pre-to-post improvement in both PTSD and depression outcomes with a large effect size for PTSD (Hedges' gav = 0.88) and medium to large for depression (Hedges' gav = 0.73). Of participants who completed the baseline assessment, 90% began webSTAIR; of those, 71% completed the program. Baseline symptoms of PTSD and depression did not predict group attendance or module completion.

CONCLUSIONS

Good outcomes and a satisfactory retention rate suggest that group webSTAIR may provide easily accessible, high-quality, and effective treatment for patients presenting with trauma-related problems without increasing therapist or system burdens. The results suggest the value of conducting a randomized controlled trial to test the effectiveness of group webSTAIR relative to PCMHI usual care or other evidence-based, disorder-specific (e.g., PTSD) treatments for trauma-exposed individuals in PCMHI.

Factors associated with a lack of health care utilization among Veterans after a positive suicide screen in the emergency department

OBJECTIVES

Many Veterans at high risk for suicide are identified in Veterans Health Administration (VHA) emergency departments (ED). Little is known about what may predict care utilization in this population. To address this knowledge gap, we explored factors associated with Veterans' lack of VHA care utilization following a positive suicide risk screen in the ED.

METHODS

In a retrospective observational study, we identified all patients who were seen in a VHA ED from October 1, 2019, to September 30, 2020. We examined factors associated with not utilizing VHA mental health (MH) and all VHA care in the 6 months following a positive suicide ED screen. Predictors included comorbidity, homelessness, and MH visit and diagnosis history.

RESULTS

We identified 23,446 Veterans with a positive suicide risk screen in the ED in fiscal year 2020. Overall, 4.1% had no VHA MH visits 6 months postscreen. The probability of not utilizing MH care was significantly higher for Veterans with no comorbidity (4.7% vs. 3.4% for mild comorbidity), no MH diagnosis (10.5% vs 2.8%), no past-year MH visits (13.6% vs 2.3%), and no past-year homelessness (5.4% vs. 1.1%). A smaller proportion of the population did not receive any VHA care 6 months postscreen (0.5%). Veterans who did not experience homelessness (0.6% vs 0.2%), had no MH diagnosis (1.6% vs. 0.3%), and had no previous MH visits (1.9% vs 0.2%) were significantly more likely to not utilize VHA care.

CONCLUSIONS

Veterans who do not utilize VHA care after a positive suicide risk screen appear to have fewer documented health and housing concerns than those who do receive care. Yet, Veterans with a positive suicide risk screen who are otherwise healthy may remain at elevated risk for suicide following their ED visit. ED providers may consider enhanced follow-up care to mitigate suicide risk for these Veterans.

The Effects of an Exposure-Based Mobile App on Symptoms of Posttraumatic Stress Disorder in Veterans: Pilot Randomized Controlled Trial

BACKGROUND

Barriers to accessing in-person care can prevent veterans with posttraumatic stress disorder (PTSD) from receiving trauma-focused treatments such as exposure therapy. Mobile apps may help to address unmet need for services by offering tools for users to self-manage PTSD symptoms. Renew is a mobile mental health app that focuses on exposure therapy and incorporates a social support function designed to promote user engagement.

OBJECTIVE

We examined the preliminary efficacy of Renew with and without support from a research staff member compared with waitlist among 93 veterans with clinically significant PTSD symptoms. We also examined the impact of study staff support on participant engagement with the app.

METHODS

In a pilot randomized controlled trial, we compared Renew with and without support from a research staff member (active use condition) with waitlist (delayed use condition) over 6 weeks. Participants were recruited through online advertisements. The Posttraumatic Stress Disorder Checklist for Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) was used to measure PTSD symptoms at pre, post, and 6-week follow-up. Usage data were collected to assess engagement with Renew.

RESULTS

Results indicated a small effect size (d=-0.39) favoring those in the active use conditions relative to the delayed use condition, but the between-group difference was not significant (P=.29). There were no differences on indices of app engagement between the 2 active use conditions. Exploratory analyses found that the number of support persons users added to the app, but not the number of support messages received, was positively correlated with app engagement.

CONCLUSIONS

Findings suggest Renew may hold promise as a self-management tool to reduce PTSD symptoms in veterans. Involving friends and family in mobile mental health apps may help bolster engagement with no additional cost to public health systems.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04155736; https://clinicaltrials.gov/ct2/show/NCT04155736.