PTSD Treatment for Veterans with Serious Mental Illness to Improve Functional Outcomes

Principal Investigator: Mary Katherine Howell, Ph.D.
Funding: VA Rehabilitation Research & Development (VA RR&D), Career Development Award (CDA)

PTSD is a critical obstacle to the recovery of Veterans with serious mental illness (SMI; psychotic spectrum and bipolar disorders). The Veterans Health Administration (VHA) has made treatment of PTSD a high priority and has initiated dissemination of evidence-based practices (EBPs) for PTSD across the national VHA system. However, EBPs for PTSD have not been tested among, and are largely not provided to, Veterans living with both PTSD and SMI, despite high co-occurrence rates and profound associated negative functional impact. This RR&D CDA-2 study will: Aim 1) administer the Cultural Formulation Interview (CFI) during a pre-pilot study of Written Exposure Therapy (WET) with 10 Veterans with SMI and PTSD to inform how best to incorporate aspects of cultural identity into the WET intervention pilot-testing in Aim 2; Aim 2) conduct a pilot randomized controlled trial (RCT) with 48 Veterans with SMI and PTSD to examine the feasibility and acceptability of WET, monitor fidelity, and preliminarily evaluate clinical and functional outcomes; Aim 3) complete a well-specified process evaluation to determine what, if any, considerations are needed to optimize WET for Veterans with SMI and regarding culturally responsive methods. Overall impact will be to move WET towards full evaluation as a potential EBP for Veterans with PTSD and SMI.

PTSD is prevalent among Veterans and others with SMI,^3-8 contributing to substantial mental and physical health impairments.^1-10 Written Exposure Therapy (WET) is a new EBP for PTSD that may have special clinical utility for Veterans with SMI and PTSD.^11-14  However, such Veterans have been largely excluded from PTSD clinical trials, and no WET trials to date have focused on an SMI population.^13-16 Further, there are significant race and ethnicity disparities in PTSD and SMI prevalence and treatment, even in VHA.^17-18 For instance, persistence and chronicity of SMI and PTSD are higher for Black, Indigenous, and other people of color (BIPOC),^19-20 underlining the need for PTSD EBPs to be delivered in culturally responsive ways.

Our research study will address research and clinical gaps by integrating culturally responsive assessment methods and testing the feasibility and acceptability of WET among Veterans with SMI and PTSD. The first step of this research will focus on administering culturally responsive assessments and WET to Veterans with PTSD and SMI in a training trial (n = 10), including qualitative interviews exploring participants’ experiences with and views of these instruments and WET. The second step will involve completing a small randomized controlled trial of WET to examine feasibility, acceptability, and fidelity of WET, and to preliminarily explore changes to clinical outcomes and functioning among 48 Veterans randomized to WET (n = 32) vs. a PTSD psychoeducation control intervention (n = 16). We will assess rates of recruitment, initial intervention engagement, and session attendance (feasibility); Veteran satisfaction with WET (acceptability); and preliminarily explore response to WET. The final step of this research will involve conducting a process evaluation to consider ways to optimize WET for future clinical trials to improve functional recovery for Veterans with SMI. This evaluation will synthesize information from: 1) WET interventionist notes and 2) qualitative interviews with a subset of Veterans in the WET condition (n = 15).

This project will include: 1) delivering WET with the CFI during a training trial followed by qualitative interviews with Veterans with PTSD and SMI; 2) completing a randomized control trial (RCT) with 48 Veteran participants, monitoring fidelity, feasibility, and acceptability; and 3) studying Veterans’ experiences of WET and culturally responsive assessment methods through qualitative interviews. We will measure functional outcomes during the RCT at baseline, post-treatment and 3-month follow-up using clinician-rated and self-report questionnaires for preliminary exploratory analysis, preparatory to a future full RCT if WET proves promising.

1. Seow, L. S. E., Ong, C., Mahesh, M. V., et al. (2016). A systematic review on comorbid post-traumatic stress disorder in schizophrenia. Schizophrenia Research, 176(2-3), 441-451.
2. Calhoun, P. S., Bosworth, H. B., Stechuchak, K. A., et al. (2006). The impact of posttraumatic stress disorder on quality of life and health service utilization among veterans who have schizophrenia. Journal of Traumatic Stress, 19(3), 393-397.
3. Fan, X., Henderson, D. C., Nguyen, D. D., et al. (2008). Posttraumatic stress disorder, cognitive function and quality of life in patients with schizophrenia. Psychiatry Res,159, 140–146.
4. Quarantini, L. C., Miranda-Scippa, Â., Nery-Fernandes, F., et al. (2010). The impact of comorbid posttraumatic stress disorder on bipolar disorder patients. Journal of affective disorders, 123(1-3), 71-76.
5. Sautter, F. J., Brailey, K., Uddo, M. M., et al. (1999). PTSD and comorbid psychotic disorder: comparison with veterans diagnosed with PTSD or psychotic disorder. Journal of Traumatic Stress: Official Publication of The International Society for Traumatic Stress Studies, 12(1), 73-88.
6. Goldberg, R. W., Rollins, A. L., & Lehman, A. F. (2003). Social network correlates among people with psychiatric disabilities. Psychiatric Rehabilitation Journal, 26(4), 393.
7. Blanchard, J. J., Park, S. G., Catalano, L. T., et al. (2015). Social affiliation and negative symptoms in schizophrenia: Examining the role of behavioral skills and subjective responding. Schizophrenia research, 168(1-2), 491-497.
8. McCarthy, J. M., Bradshaw, K. R., Catalano, L. T., et al. (2018). Negative symptoms and the formation of social affiliative bonds in schizophrenia. Schizophrenia research, 193, 225-231.
9. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). American Psychiatric Pub.
10. Tsai, J., Harpaz-Rotem, I., Pietrzak, R. H., et al. (2012). The role of coping, resilience, and social support in mediating the relation between PTSD and social functioning in veterans returning from Iraq and Afghanistan. Psychiatry: Interpersonal & Biological Processes, 75(2), 135-149.
11. Sloan, D. M., & Marx, B. P. (2019). Written exposure therapy for PTSD: A brief treatment approach for mental health professionals. Washington, DC: American Psychological Association.
12. Sloan, D. M., Marx, B. P., Bovin, M. J., et al. (2012). Written exposure as an intervention for PTSD: A randomized clinical trial with motor vehicle accident survivors. Behavior research & therapy, 50(10),627-35.
13. Sloan, D. M., Marx, B. P., Lee, D. J., et al. (2018). A brief exposure-based treatment vs cognitive processing therapy for PTSD: A randomized noninferiority clinical trial. Jama Psychiatry, 75(3), 233-239.
14. Marx, B. P., Thompson-Hollands, J., Lee, D. J., et al. (2021). Estimated intelligence moderates cognitive processing therapy outcome for posttraumatic stress symptoms. Behavior Therapy, 52(1), 162-169.
15. Weathers, F. W., Blake, D. D., Schnurr, P. P., et al. (2013). The Clinician-Administered PTSD Scale for DSM-5 (CAPS-5). Available online from the National Center for PTSD.
16. Bernard, M., Jackson, C., & Jones, C. (2006). Written emotional disclosure following first-episode psychosis: effects on symptoms of post-traumatic stress disorder.  J. Clin. Psychol,45, 403–415.
17. McClendon, J., Dean, K.E. & Galovski, T. (2020). Addressing Diversity in PTSD Treatment: Disparities in Treatment Engagement and Outcome Among Patients of Color. Curr Treat Options Psych7, 275–290.
18. Gross, G. M., Smith, N., Holliday, R., et al. (2021). Racial disparities in clinical outcomes of Veterans Affairs residential PTSD treatment between Black and White veterans. Psychiatric services.
19. Schwartz, R. C., & Blankenship, D. M. (2014). Racial disparities in psychotic disorder diagnosis: A review of empirical literature. World journal of psychiatry, 4(4), 133.
20. Maura, J., & de Mamani, A. W. (2017). Mental health disparities, treatment engagement, and attrition among racial/ethnic minorities with severe mental illness: A review. Journal of Clinical Psychology in Medical Settings, 24(3), 187-210.