Journal of Psychosocial Nursing and Mental Health Services

Original Article 

Engagement in Psychotherapy Improves Outcomes for Veterans

Jennifer W. Carpenter, MSN, CRNP, PMHNP-BC; W. Chance Nicholson, MSN, CRNP, PMHNP-BC; Mary J. Lee, MSN, CRNP, PMHNP-BC; Jessica W. Richardson, DNP, CRNP, PMHNP-BC; Teena M. McGuinness, PhD, CRNP, FAAN

Abstract

The longstanding partnership between the Birmingham Veterans Affairs Medical Center (BVAMC) and the University of Alabama at Birmingham School of Nursing inspired the establishment of one of the country's first psychiatric–mental health nurse practitioner (PMHNP) residencies and subsequent formation of a Resident Continuity Clinic (RCC). Within the RCC, PMHNP residents deliver evidence-based care that is informed by measurement-based care (MBC) to improve patient outcomes and reduce time to recovery. Determined by the BVAMC Institutional Review Board to be a quality improvement project, PMHNP residents administered the Patient Stress Questionnaire (PSQ), a MBC tool that uses four independently validated screening tools to measure the behavioral health symptoms of depression, anxiety, trauma, and alcohol use. Additional clinical variables of interest included patient use of illicit substances, participation in psychotherapy, and use of psychotropic medications. PSQ scores were reviewed retrospectively via descriptive statistics and nonparametric tests. Analysis demonstrated statistically significant improvements in depression and anxiety. Data also revealed that patients engaged in psychotherapy demonstrated greater improvements on all PSQ screening tools compared to patients not involved in psychotherapy. The results reinforce the value of MBC in psychiatric care and highlight the importance of engaging Veterans in psychotherapy to improve outcomes. [Journal of Psychosocial Nursing and Mental Health Services, xx(x), xx–xx.]

Abstract

The longstanding partnership between the Birmingham Veterans Affairs Medical Center (BVAMC) and the University of Alabama at Birmingham School of Nursing inspired the establishment of one of the country's first psychiatric–mental health nurse practitioner (PMHNP) residencies and subsequent formation of a Resident Continuity Clinic (RCC). Within the RCC, PMHNP residents deliver evidence-based care that is informed by measurement-based care (MBC) to improve patient outcomes and reduce time to recovery. Determined by the BVAMC Institutional Review Board to be a quality improvement project, PMHNP residents administered the Patient Stress Questionnaire (PSQ), a MBC tool that uses four independently validated screening tools to measure the behavioral health symptoms of depression, anxiety, trauma, and alcohol use. Additional clinical variables of interest included patient use of illicit substances, participation in psychotherapy, and use of psychotropic medications. PSQ scores were reviewed retrospectively via descriptive statistics and nonparametric tests. Analysis demonstrated statistically significant improvements in depression and anxiety. Data also revealed that patients engaged in psychotherapy demonstrated greater improvements on all PSQ screening tools compared to patients not involved in psychotherapy. The results reinforce the value of MBC in psychiatric care and highlight the importance of engaging Veterans in psychotherapy to improve outcomes. [Journal of Psychosocial Nursing and Mental Health Services, xx(x), xx–xx.]

The United States has been at war since 2001, the longest war in our nation's history. The signature wounds of the wars in Afghanistan and Iraq, which commenced in 2001 and 2003, respectively (Jaffee & Meyer, 2009), are posttraumatic stress disorder (PTSD) and traumatic brain injury. In 2014, a nursing partnership was formed between the Birmingham Veterans Affairs Medical Center (BVAMC) and the University of Alabama at Birmingham School of Nursing (UAB SON) to begin residency training for psychiatric–mental health nurse practitioners (PMHNPs). As part of this training, a quality improvement (QI) project was undertaken involving a clinic staffed by residents and partnership faculty, the Resident Continuity Clinic (RCC). Within the RCC, measurement-based care (MBC) was instituted to thoroughly assess the magnitude of Veterans' psychiatric symptoms and implement evidence-based guidelines to reduce time to recovery. The aim of the QI project was to explore associations between engagement in psychotherapy and reported psychiatric symptoms. The purpose of the current article is to share findings from the QI project, illustrating the importance of psychotherapy combined with psychopharmacology to reduce psychiatric symptoms.

Background

The relationship between patient outcomes and combination treatment with medication and therapy has been established in the literature. The Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study demonstrated MBC to assess symptoms of depression and response to treatment. When a 12-week trial of citalopram alone failed (at least 20 mg per day), some participants were augmented with psychotherapy or an additional medication; augmentation with psychotherapy was found to be as effective as augmentation with medication (Thase et al., 2007; Trivedi et al., 2006). A more recent meta-analysis found evidence to suggest that medication combined with psychotherapy was more effective at reducing psychiatric symptoms compared to medication alone in major depressive disorder (MDD), panic disorder, and obsessive-compulsive disorder (Cuijpers et al., 2014). Cuijpers et al. (2014) also found that improvement in psychiatric symptoms of depression and anxiety was sustained for up to 2 years following combined treatment (Cuijpers et al., 2014). Thus, the combination of pharmacological treatment and psychotherapy has been associated with improved quality of life and sustained symptom reduction in patients with depression (Cuijpers et al., 2014; Ishak et al., 2011).

Although many psychotherapies are offered by the U.S. Department of Veterans Affairs (VA) (see Table A for details), it is unfortunate that most Veterans do not engage in these programs. Mott, Hundt, Sansgiry, Mignogna, and Cully (2014) estimated that only approximately 27% of Veterans receiving mental health care received at least one visit to psychotherapy and even fewer received an adequate number of sessions.

Therapy Resources for Veterans

Table A:

Therapy Resources for Veterans

Clinical and Regulatory Importance of Measurement-Based Care

The goal of patient-reported information to create an individualized treatment plan and guide decision making has moved into the forefront of mental health care. The Joint Commission has announced it will soon require the use of standardized assessment tools to measure outcomes in the behavioral health setting (Lavin, Berry, & Williams, 2017). In addition, the American Psychiatric Association (2016) recommends MBC as an evidence-based approach for the treatment of depression.

The VA (2016) has also implemented a pilot program to administer rating scales to Veterans in mental health clinics around the country with the intention of MBC becoming part of routine psychiatric assessment. The benefit to using rating scales and patient reports is to gain an understanding of how symptoms affect patients' daily lives and quantitatively track treatment progress.

MBC can also enhance patients' engagement in their care and treatment planning. According to Fortney et al. (2016), MBC fosters therapeutic rapport and relationship, and encourages patients to be active participants in treatment planning and decision making. Furthermore, MBC can help patients and providers identify residual symptoms and tailor the treatment plan to target these symptoms, which could reduce relapse (Fortney et al., 2016).

Using MBC can also help identify symptoms that may have been missed in the standard psychiatric assessment (VA, 2016). For example, the Patient Health Questionnaire-9 (Kroenke, Spitzer, & Williams, 2001) assesses for difficulty concentrating and energy level. Although those symptom categories can inform providers of patients' depression, they can also launch a discussion into patients' performance at work or involvement in family functions or relationships. Rating scales offer a way for providers not only to quickly assess for diagnostic criteria, but also to further assess symptoms based on the frequency or intensity of patients' reports and describe patients' level of impairment (Fortney et al., 2016; The Kennedy Forum, 2015). Another potential benefit of MBC is that it helps align the encounter with patients' most pressing concerns or their most severe symptoms. In this regard, MBC can help make appointment time more efficient while still addressing patient needs and potential safety concerns (Fortney et al., 2016). By accurately assessing levels of psychiatric symptoms, evidence-based psychopharmacology guidelines can be accurately undertaken. Multiple clinical practice guidelines developed by the VA and the U.S. Department of Defense (DoD) that offer evidence-based approaches for the treatment of MDD (VA & DoD, 2017), PTSD (VA & DoD, 2016), and substance use disorders (VA & DoD, 2015) can be found at https://www.healthquality.va.gov.

Method

Resident Continuity Clinic

The BVAMC has partnered with the UAB SON to sponsor a 1-year, post Master's of Science in Nursing PMHNP residency. The program began in 2014 and has continued into its fifth cohort (2017–2018). The current quality improvement (QI) project took place in 2016–2017 in the RCC. This clinic was implemented to give PMHNP residents the opportunity to follow patients during the entire year of the residency and is supervised by a residency faculty member.

Intervention

At each visit, Veterans seen in the RCC were asked to complete the Patient Stress Questionnaire (PSQ). The PSQ is a tool used in primary care settings to screen for behavioral health symptoms and includes four subscales to rate depression, anxiety, trauma, and alcohol use. There is also a one-question pain assessment asking whether pain is present (no rating of pain is requested). The Substance Abuse and Mental Health Services Administration (SAMHSA) supports the use of screening tools, such as the PSQ (SAMHSA–HRSA Center for Integrative Health Solutions, n.d.).

Patients were given the rationale for using the PSQ, which was that the use of rating scales helps increase patients' awareness of symptoms and patterns of illness and measures progress toward recovery. Furthermore, incorporating rating scales into patient encounters validates patients' feelings and may foster hope and improve adherence to the treatment plan (Fortney et al., 2016). Rating scales can also inform PMHNPs of the efficacy of prescribed medication. Although the PSQ includes five assessment tools, no literature addresses the effectiveness of the combined tool. However, there is evidence for validity of its individual tools, as discussed below.

PSQ Subscales. Patient Health Questionnaire (PHQ-9). The PHQ-9 is widely used across many health care settings as a single instrument to screen for depression. Its psychometric properties were tested on structured interviews of 580 patients. Sensitivity and specificity were established at 88%, respectively; higher scores are reflective of higher rates of depressive symptoms, with scores <5 associated with a lower likelihood of depression (range = 0 to 27) (Kroenke et al., 2001).

Generalized Anxiety Disorder-7 (GAD-7). The GAD-7 was also established as a valid instrument with a large sample (N = 985); sensitivity of 89% and specificity of 82% were reported by Spitzer, Kroenke, Williams, and Löwe (2006); a score >10 indicates GAD. A score >15 indicates severe anxiety (range = 0 to 21) (Spitzer et al., 2006).

Primary Care Screen for PTSD (PC-PTSD). A 2008 study of 352 combat Veterans was conducted to validate the PC-PTSD, which has four questions indicating the presence or absence of cardinal PTSD symptoms. Scores range from 0 to 4, with higher scores indicative of the presence of more PTSD symptoms; three positive responses produced a sensitivity of 78% and specificity of 87% (Bliese et al., 2008).

Alcohol Use Disorder Identification Test (AUDIT). The AUDIT is a tool scored from 0 to 40, with higher scores indicating increased alcohol use and problems related to alcohol use. The first three questions of the AUDIT comprise the AUDIT-Consumption, which is an instrument shown to be valid, sensitive, and specific to a variety of populations (Frank et al., 2008). Use in African American, White, and Latino women yielded sensitivities of 67%, 70%, and 85%, respectively. Specificities of 92%, 91%, and 88%, respectively, were reported in the same group of women. In a population of African American, White, and Hispanic men, sensitivities were 76%, 95%, and 85%, respectively, and specificities were 93%, 89%, and 88%, respectively (Frank et al., 2008).

Pain. The final component of the PSQ is the one-question screen for pain, asking if pain is present and requiring only a yes or no answer.

Approach

The BVAMC Institutional Review Board determined this intervention to be a QI project. Each administrator of the MBC measures was given instructions on how to administer, score, and interpret the scores. Likewise, all patients were given instructions on how to complete the MBC measures. Scores were recorded in patients' charts as part of the documentation at each visit. Deidentified patient data from the previous years were used and data points were added. De-identified patient data included date of visit, PSQ scores, and demographic information. Additional data points added were number and class of medications prescribed and engagement in and frequency of psychotherapy services. Data were maintained in a Microsoft® Excel spreadsheet and analysis was conducted in R Studio version 3.5.0.

Participation in psychotherapy and a single-item drug use screen were added to the data collection for the 2016–2017 residency. For the purposes of this QI project, psychotherapy was defined as cognitive-behavioral therapy (CBT); CBT for insomnia (CBT-I); CBT for chronic pain; individual psychotherapy; and PTSD group psychotherapies, which target topics such as stress management, sleep promotion, and spirituality. Involvement in psychotherapy was found through record review and identification of documentation of patient encounter completed by a therapist or social worker for the purpose of therapy. The number of sessions of psychotherapy in between RCC appointments was also recorded. Given the breadth of record reviews involved in the current study, patient engagement (e.g., completing homework) in treatment was difficult to determine due to the necessary reliance on various therapists to document this consistently. As such, a binary variable was created for medication and psychotherapy participation. To be included in the analysis as participating in both medication and psychotherapy treatment, patients had to demonstrate ongoing participation in these treatment modalities upon initiation as measured by attending appointments and filling/re-filling medications consistently.

Forty-seven patients were identified as having at least two encounters with PSQ data in the chart. Only these patients were included in the comparison of scores and involvement in psychotherapy. Patients' first and last scores were compared across MBC tools. For the purposes of this project, the “first” score describes the first documented PSQ scores. These scores could be from an initial assessment of the patient upon first mental health appointment in the RCC or performed on an existing patient who had been referred to the RCC. The “last” score describes the most recent scores available for a patient. These scores, for example, could be the patient's second or fifth appointment in the RCC. The highest number of appointments for individual patients in the RCC with scored PSQs was eight across the course of 14 months.

Data Analysis

Descriptive statistics provided percentages for categorical variables; means, standard deviations, medians, and ranges were calculated for continuous data. As expected, PSQ measures were highly correlated. Shapiro-Wilks and Levene's Test were used to test assumptions of normality and homogeneity (distributions were visualized using q-q plots and histograms). Normality and homogeneity were violated for all measures. As such, the non-parametric Wilcoxon signed-ranked test (with continuity correction) was used to assess differences or shifts between first and last scores for each of the paired components of the PSQ. Effect sizes were used to assess the size of any significant differences found. Effect sizes were calculated by dividing the standardized test statistic by the square root of the number of observations in each grouping (denoted by r) (Rosenthal, 1991).

Given the limitations of participant access in the RCC and non-parametric nature of this sample, a priori power analysis was performed to estimate sample size needed to examine associations within the entire sample. With a two-tailed hypothesis (assuming population distribution normality), an alpha = 0.05, and moderately strict power (1 – β) set at 0.90, the projected sample size suggested to detect a large effect size (defined at 0.5) was N = 47 (G*Power version 3.1.9.2; Erdfelder, Faul, & Buchner, 1996).

Results

Patient Demographics

Patients' demographic information and data were collected from March 2016 to June 2017, including patients established in the RCC as well as new referrals obtained during the 2016–2017 residency. Of RCC patients, 73% were male. Patients' ages ranged from 21 to 75 years (mean age = 50.29 years). The majority of RCC patients were African American (59%) and Caucasian (40%); approximately 1% were Latino.

The most common diagnoses in order of frequency were PTSD, anxiety disorders, and depressive disorders. Substance use disorders were among common comorbid diagnoses, with alcohol, cannabis, and cocaine being the most common substances of abuse. Commonly prescribed medications included selective serotonin reuptake inhibitors (SSRI); serotonin-norepinephrine reuptake inhibitors (SNRI); and non-controlled sleep medications, such as trazodone, low-dose mirtazapine (7.5 mg or 15 mg), and melatonin.

First to Last Treatment Comparisons for Entire Sample

Non-parametric analysis of PHQ-9 and GAD-7 scores revealed significant differences (Table 1). A significant change in scores was observed from PHQ-9 first (median score = 12) to last (median score = 10; p = 0.002, r = 0.46) treatment. Likewise, scores were significantly lower in the GAD-7 from first (median score = 10) to last (median score = 7; p = 0.002, r = 0.45) treatment. Using Cohen's (1988) convention of 0.3 and 0.5, the changes in PHQ-9 and GAD-7 scores were found to have a moderate to large effect size. The downward trend suggests improvement in these scores from first to last visit. No significant differences were found between the PTSD or AUDIT tools.

Comparison of Participants’ First and Last Scores on the Patient Stress Questionnaire Subscales (N = 47)

Table 1:

Comparison of Participants’ First and Last Scores on the Patient Stress Questionnaire Subscales (N = 47)

Comparison of Patients With PTSD

After initial data were assessed, a sub-sample (n = 13) was created for patients with a diagnosis of PTSD to determine if a difference in scores emerged from all four components of the PSQ. Patients with a diagnosis of PTSD were identified via diagnostic codes (F43.10 or F43.12) included in the dataset. Assumptions of normality were violated for all variables. A minimal improvement in GAD-7 scores was observed. Likewise, a minimal mean decrease in PHQ-9 scores was observed; however, the median demonstrated an increase. GAD-7 and PHQ-9 scores failed to reach significance in the non-parametric analysis. On the contrary, scores for the PC-PTSD and AUDIT demonstrated an increase; however, these differences were not significant (Table 2).

Comparison of Patient Stress Questionnaire Subscale Scores in Patients with PTSD (n = 13)

Table 2:

Comparison of Patient Stress Questionnaire Subscale Scores in Patients with PTSD (n = 13)

Comparison of Patients Reporting Alcohol Use

A substantial number of participants (n = 18) endorsed no alcohol use at all. Patients who reported any alcohol use (AUDIT score ≥1) were isolated and assessed to compare AUDIT scores (n = 29). Non-parametric analysis failed to demonstrate any differences between first and last AUDIT scores (p = 0.34). Likewise, when this group was divided into medication versus dual treatment, no differences were found in AUDIT scores (p = 0.25). Medication (n = 15) versus dual-treatment analysis (n = 14) was also conducted on other PSQ measures to determine if there were differences in scores in the context of those using alcohol. Interestingly, in the medication only group, GAD-7 (p = 0.01; r = 0.47) and PHQ-9 (p = 0.03; r = 0.40) scores improved. On the contrary, in the dual-treatment group, only GAD-7 scores improved (p = 0.02; r = 0.33).

Comparison of Patients Participating in Medication Plus Therapy

Differences in patients receiving medication plus psychotherapy services and those receiving medication only were assessed (Table 3). These patients had at least one encounter in the above mentioned psychotherapy services. Scores of the PHQ-9, GAD-7, and PC-PTSD were examined (n = 34). For the medication plus psychotherapy group, a significant change in scores was observed from PHQ-9 first (median score = 12) to last (median score = 10; p < 0.001, r = 0.43) treatment. Likewise, scores were significantly lower in the GAD-7 from first (median score = 12) to last (median score = 8; p < 0.001, r = 0.40) treatment. Similar to the effect sizes observed in the entire sample, the changes in scores for the PHQ-9 and GAD-7 were moderate (Cohen, 1988). Scores of the PHQ-9, GAD-7, and PC-PTSD were examined for the medication only group (n = 13) for comparison. No significant differences were found from first to last treatment in this group. However, the sample size for this group was small.

Comparison of Patient Stress Questionnaire Subscales in Veterans Participating in Therapy Versus Using Medication Only (N = 47)

Table 3:

Comparison of Patient Stress Questionnaire Subscales in Veterans Participating in Therapy Versus Using Medication Only (N = 47)

Discussion

Despite the limited sample size, the results of the current QI project agree with larger previous studies that suggest that combining medication and psychotherapy services results in better outcomes of depression than either treatment modality alone (Cuijpers et al., 2014). The outcomes of this project suggest that Veterans who receive pharmacological intervention and psychotherapy services have greater reduction in depression and anxiety symptoms based on PHQ-9 and GAD-7 scores. Compared with national averages, Veterans served in the RCC were more likely to be involved in psychotherapy (72%) than other Veterans around the country (27%) (Mott et al., 2014). This involvement in psychotherapy coupled with the outcomes of the current project suggest that RCC patients are more likely to use the evidence-based combination of medication and psychotherapy services.

Veterans seen in the RCC who were enrolled in psychotherapy had higher initial PHQ-9 and GAD-7 scores, which could account for their increased involvement in psychotherapy. Veterans with severe symptoms may be more likely to be referred to psychotherapy by their provider and/or be more willing to engage in other modalities of treatment to relieve their symptoms. Educating patients about the types of therapies available to them and briefing them on what they can expect may help decrease hesitancy to starting therapy. In addition, offering referrals at each visit and assisting Veterans who have an established therapy provider get back into treatment are ways to increase therapy utilization and improve patient outcomes. Providing patients with knowledge of the services available to them, as well as brief education on the differences between types of therapies, could increase patient engagement in these services.

MBC often relies on self-report, as is the case in the current study. It is likely that symptoms are underreported during the initial appointment, before the clinician and patient have established therapeutic rapport. This underreporting could account for the increase in symptoms from first to last appointment seen in one sub-set analysis, and for the high rate of Veterans denying any alcohol use (>30% in the current study). Although MBC offers ways to quickly and easily assess for many different symptoms, it should not replace providers' clinical judgment. Engagement in psychotherapy may help patients feel comfortable talking about their symptoms and has been associated with improved patient outcomes in mental health care via MBC when compared to Veterans only receiving psychopharmacological treatment. The underutilization of psychotherapy warrants investigation in clinical practice and future studies.

PC-PTSD scores for Veterans with PTSD appeared to increase from first to last scores, although this difference was not significant. One possible influence for this finding is that the PC-PTSD has the potential of scores ranging from 0 to 4; therefore, changes in symptoms may not be captured in such a limited range of scores. Unlike the PHQ-9 and GAD-7, the PC-PTSD is a brief screening tool with only four questions. Providers can use the PHQ-9 and GAD-7 not only to make an informed assessment, but also to assess for treatment efficacy and symptom reduction over time. Given the inability of the PC-PTSD to assess the frequency, intensity, and severity of PTSD symptoms, implementing a valid PTSD tool, such as the PTSD Checklist (PCL-5) (Blevins, Weathers, Davis, Witte, & Domino, 2015), for Veterans with a previous diagnosis of PTSD in their record or a positive score on the PC-PTSD would allow for further assessment of symptoms and response to treatment.

Limitations and Future Study

One limitation to the strength of the presented results is the small sample size. Although some of the data suggest statistical significance, the study included only 47 participants, which could limit the significance of findings. The limitation of sample size is particularly germane for analyses where subsets were created, as they lack adequate power to minimize or adequately control for potential errors in testing. The small sample size relative to the current study's design could overestimate significant findings from interventions or fail to detect smaller effects. Interpretability and comparisons to other clinical studies are further restricted given that participants were not divided into specific treatment groups (e.g., SSRI vs SNRI, specific type of psychotherapy). Although the aims of the current study were to examine associations or shifts in the data, it is important to emphasize caution if trying to extrapolate and apply these findings in a clinical context. From a direct clinical application position, the results lack generalizability and should be interpreted carefully within the frame of similar findings from larger clinical studies. One goal of the RCC is to continue growing and adding more available appointment times to meet Veterans' needs and improve access to mental health care. More work should be done in the future to assess Veterans' PTSD symptoms and substance use.

Another limitation is the broad nature in which therapy was defined and the different time frames that constituted “first” and “last” scores. For example, one Veteran may have had two encounters with the RCC whereas another had five encounters. Those nuances in data are lost in the current sample. With more patients, it would be prudent to establish a “frequency of therapy” cut-off score and compare patients who attend, for example, one therapy appointment every 8 weeks with other patients who attend weekly. A follow-up study using a larger sample size from this clinic should be performed to better explicate these findings and account for these limitations.

In addition, the nature of specific therapies used by individual patients was not collected as part of this project; thus, the variable was whether Veterans were engaged in any kind of psychotherapy. Although this limitation prevents the current project from drawing associations between improvement in psychiatric symptoms and specific types of psychotherapy, it points to the possibility that engagement in any mode of psychotherapy could be associated with greater psychiatric symptom reduction. Further studies should explore the differences between modalities of psychotherapy and symptom reduction.

Another topic future studies should address is the large percentage of Veterans seeking mental health services who are not involved in psychotherapy services. Investigating barriers to psychotherapy services on the patient level and institutional level would be prudent. Patients' attitudes toward psychotherapy, knowledge deficit on indications, and manner of psychotherapy likely play a role; in addition, time until first available appointment or available dates and locations of psychotherapy services could also inhibit engagement. Another opportunity for future studies is assessing the utility of a PTSD assessment tool that would allow clinicians to screen and assess for benefit from treatment.

Conclusion

The current QI project builds on a foundation of work that suggests that the addition of psychotherapy to the treatment of depression is associated with improved patient outcomes. This QI project addressed multiple diagnoses common to the Veteran population. In addition, comorbidities, such as substance use disorders, were also assessed. Although the limitations of this project inhibit the generalizability of the findings, the results are suggestive of reduction of psychiatric symptoms with the combined treatments of medication and psychotherapy. The small sample size is a limitation; however, the breadth of assessment and inclusion in this QI project provides a sample that is more representative of the average patient engaged in mental health services than most research, which tends to have many exclusion criteria. Psychiatric–mental health nurses are equipped to assess the symptoms of depression, anxiety, and PTSD and highlight the utility of MBC in the field of psychiatric–mental health nursing. Quantitative assessments of psychiatric symptoms are key to ensuring that Veterans experience symptom reduction. Use of MBC should be standard in the treatment of psychiatric illness for all Veterans.

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  • U.S. Department of Veterans Affairs & U.S. Department of Defense. (2015). VA/DoD clinical practice guideline for the management of substance use disorders. Retrieved from https://www.healthquality.va.gov/guidelines/MH/sud/VADoDSUDCPGRevised22216.pdf
  • U.S. Department of Veterans Affairs & U.S. Department of Defense. (2016). VA/DoD clinical practice guideline for the management of major depressive disorder. Retrieved from https://www.healthquality.va.gov/guidelines/MH/mdd/VADoDMDDCPGFINAL82916.pdf
  • U.S. Department of Veterans Affairs & U.S. Department of Defense. (2017). VA/DoD clinical practice guideline for the management of posttraumatic stress disorder and acute stress disorder. Retrieved from https://www.healthquality.va.gov/guidelines/MH/ptsd/VADoDPTSDCPGClinicianSummaryFinal.pdf

Comparison of Participants' First and Last Scores on the Patient Stress Questionnaire Subscales (N = 47)

Measure/Score Mean (SD) Median Range SE Significance (ES)
PHQ-9a 0.002 (0.46)*
  First 2.60 (6.37) 12.0 0 to 27 0.93
  Last 9.81 (6.01) 10.0 1 to 25 0.88
GAD-7b 0.002 (0.45)*
  First 10.9 (6.21) 10.0 0 to 21 0.91
  Last 7.98 (4.68) 7.00 0 to 21 0.68
PC-PTSDc 0.194
  First 2.38 (1.68) 3.00 0 to 4 0.24
  Last 2.15 (1.56) 2.00 0 to 4 0.23
AUDITd 0.370
  First 2.34 (2.93) 1.00 0 to 13 0.43
  Last 2.13 (2.79) 1.00 0 to 11 0.41

Comparison of Patient Stress Questionnaire Subscale Scores in Patients with PTSD (N = 13)

Measure Mean (SD) Median Range SE Significance (ES)
PHQ-9a 0.99
  First 12.08 (4.50) 10 7 to 23 1.25
  Last 11.77 (6.58) 11 1 to 25 1.83
GAD-7b 0.93
  First 10.46 (5.41) 10 2 to 21 1.50
  Last 10.00 (4.71) 9 5 to 19 1.31
PC-PTSDc 0.39
  First 3.00 (1.53) 2 0 to 4 0.42
  Last 3.23 (1.09) 4 1 to 4 0.30
AUDITd 0.83
  First 2.69 (2.78) 3 0 to 10 0.30
  Last 3.15 (3.51) 2 0 to 11 0.26

Comparison of Patient Stress Questionnaire Subscales in Veterans Participating in Therapy Versus Using Medication Only (N = 47)

Subscale/Treatment/Score N Mean (SD) Median Range SE Significance (ES)
PHQ-9a
  Medication only 0.79
    First 13 9.15 (4.34) 10 2 to 6 1.2
    Last 9.69 (6.17) 9 2 to 25 1.71
  Medication plus therapy <0.001 (0.43)*
    First 34 13.91 (6.58) 12 0 to 27 1.13
    Last 9.85 (6.05) 10 1 to 25 1.04
GAD-7b
  Medication only 0.58
    First 13 7.46 (4.39) 8 1 to 16 0.22
    Last 7.08 (4.21) 7 2 to 19 1.17
  Medication plus therapy <0.001 (0.40)*
    First 34 12.21 (6.35) 12 0 to 21 1.09
    Last 8.32 (4.86) 8 0 to 21 0.83
PC-PTSDc
  Medication only 0.20
    First 13 2.15 (1.77) 2 0 to 4 0.49
    Last 1.85 (1.63) 1 0 to 4 0.45
  Medication plus therapy 0.45
    First 34 2.47 (1.66) 3 0 to 4 0.28
    Last 2.26 (1.54) 2 0 to 4 0.26

Therapy Resources for Veterans

Consistent with the U.S. Department of Veterans Affairs (VA; 2017), the Birmingham VA Medical Center offers several different types of evidence-based psychotherapies. Veterans may be referred to individual therapies or various small group therapies. Individual psychotherapies or group therapies are led by either a licensed clinical social worker (LCSW) or a psychologist. Veterans with posttraumatic stress disorder (PTSD) may also participate in PTSD Clinic Teams (PCT), which offer specific therapies through a team-based approach aimed at improving PTSD symptoms. Below is an overview of the various modalities. Interpersonal therapy (IPT) is commonly used to help Veterans with PTSD, anxiety, and depression develop healthy relationships. Veterans learn how to process and resolve relationship issues, as well as how to promote healthy relationships with others. A study by Markowitz et al. (2015) found that 63% of participants with PTSD showed more than 30% improvement in Clinician-Administered PTSD Scale scores after participating in a 14-week randomized controlled trial (RCT) which compared IPT, prolonged exposure therapy (PET), and relaxation therap y. One half of participants had a comorbid diagnosis of major depression (Markowitz et al., 2015). Cognitive-behavioral therapy (CBT) is an example of individual psychotherapy used to treat anxiety and depression (VA, 2017). This therapy helps Veterans understand the relationship between their emotions, behaviors, and thoughts. Through this understanding, Veterans can adopt new ways of thinking and implement new, more positive behaviors and coping skills. Some learned behaviors may be relaxation techniques, exercising, socialization, and using calming music or applications to improve sleep. A meta-analysis of five RCTs showed significant effectiveness of trauma-focused CBT when compared to supportive therapy (Kar, 2011). This meta-analysis also showed that CBT is most effective when initiated within 3 months of the traumatic event (Kar, 2011). Many participants also had comorbid conditions such as anxiety, depression, and mood disorders (Kar, 2011). Additional offerings for the treatment of PTSD are cognitive processing therapy (CPT) and PET. CPT is a structured therapy that incorporates exposure through writing exercises to help Veterans identify negative thought patterns that interfere with daily life. Veterans learn to correct these patterns so that traumatic memories do not interfere with daily life. A 2008 RCT examined the individual parts of CPT and concluded that the combined components of CPT are more effective than standard written exposure techniques (Sharpless & Barber, 2011). The goal of CPT is to reduce Veterans' fears and anxieties elicited by reminders of traumatic events. This reduction is achieved by exposing Veterans to situations that trigger traumatic memories while in a safe, controlled environment. Over time, Veterans find these events to be less troubling, with the goal of learning to be more present, with reminders causing much less distress (VA, 2017).
Authors

Ms. Carpenter is Instructor, Mr. Nicholson is Instructor and PhD Candidate, and Dr. McGuinness is Professor, The University of Alabama at Birmingham School of Nursing; Dr. McGuinness is also Co-Director, and Dr. Richardson is Co-Director, Joint Mental Health Nurse Practitioner Residency, Birmingham Veterans Affairs Medical Center, Birmingham; and Ms. Lee is Psychiatric–Mental Health Nurse Practitioner and Captain, United States Army Reserve, Mobile, Alabama.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Jennifer W. Carpenter, MSN, CRNP, PMHNP-BC, Instructor, The University of Alabama at Birmingham School of Nursing, NB 2M019B, 1720 2nd Avenue South, Birmingham, AL 35294-1210; e-mail: jenlw@uab.edu.

Received: August 02, 2018
Accepted: September 28, 2018
Posted Online: December 26, 2018

10.3928/02793695-20181220-01

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