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Principal Investigator: Nicholas Holder
Organization: VETERANS AFFAIRS MED CTR SAN FRANCISCO
Fiscal Year: 2024
Funding agency: Veterans Affairs
Background: Posttraumatic stress disorder (PTSD) is one of the most common mental health diagnoses
among Veterans. Cognitive processing therapy (CPT) and prolonged exposure therapy (PE) were widely
disseminated in the Veterans Health Administration (VHA) as recommended PTSD treatments. Despite these
efforts, few post-9/11 Veterans diagnosed with PTSD initiate CPT or PE. In the small percentage of Veterans
who receive these therapies, CPT and PE are rarely the first treatment a Veteran receives. A common
treatment sequence identified in implementation research, begins with “stabilization treatment,” combinations
of psychosocial and medication treatments that prepare Veterans for CPT or PE. A gap in existing research is
how treatment sequences, particularly stabilization treatment, influence initiation of CPT or PE.
Significance/Impact: PTSD is an HSR&D priority condition due to its substantial negative biopsychosocial
impact on Veterans lives. Novel strategies are needed to increase engagement, retention, and improve
outcomes from recommended PTSD treatments, and to reduce disparities in access to this care.
Understanding how to most effectively combine and sequence PTSD treatment is an HSR&D identified area of
interest, and a research gap identified in the VHA PTSD clinical practice guideline.
Innovation: Despite consistently identifying stabilization treatment as a common VHA practice, little research
has investigated this treatment sequence. A novel approach to solving existing limitations in PTSD treatment
delivery involves developing an intervention that both acknowledges the ubiquitous presence and benefits of
stabilization treatment, while facilitating timely transition from stabilization treatment to CPT or PE.
Specific Aims: This CDA-2 aims to improve delivery of PTSD services in the VHA, while simultaneously
providing me with training in health services research methods to support my development into an independent
VHA researcher. The proposed research aims are: (1) To qualitatively understand Veterans’ and clinicians’
perspectives on selecting stabilization treatments and how stabilization treatment serves as a barrier or
facilitator of transition to CPT or PE; (2) To develop and conduct a randomized, pragmatic pilot trial of a brief,
Veteran-centered intervention to support transition from stabilization treatment to CPT or PE; and (3) To
identify sociodemographic disparities in treatment sequences and to determine how treatment sequences
influence time to CPT or PE initiation across the VHA.
Methodology: I will then conduct qualitative interviews with a national sample of Veterans (n=30) and
clinicians (n=20; Aim 1). Using rapid qualitative analysis procedures, I will evaluate how treatment sequences,
particularly stabilization treatment, are chosen and how they serve as a barrier or facilitator of transition to CPT
and PE. I will then use knowledge gained from Aim 1 to develop a health services intervention that facilitates
timely transition to CPT or PE. I will test this intervention in a randomized, pragmatic, pilot trial comparing the
intervention (n=20) to treatment as usual (n=20; Aim 2). I will assess the proportion of Veterans who initiate
CPT or PE within a year after beginning the intervention as a primary outcome and feasibility as a secondary
outcome. Using electronic health record data from a national, longitudinal cohort of post-9/11 Veterans who
received VHA PTSD treatment (anticipated n=400,000) from 10/05-12/23, I will identify treatment sequences;
understand how treatment sequence impacts time to CPT or PE initiation using Cox proportional hazard
regression; and identify disparities in treatment sequences based on sociodemographic characteristics (Aim 3).
Implementation/Next Steps: I will apply the knowledge and training gained through this proposal to an
HSR&D Merit application to test the benefits of the developed intervention on a large scale through a multisite
hybrid type-II pragmatic trial. I will collaborate with organizational partners at the Office of Mental Health and
Suicide Prevention to ensure that work supports efforts to promote clinical practice guideline-consistent care.
Terms: <Access to Care><Advocate><Affect><Area><Base Sequence><Caring><Characteristics><Clinical Practice Guideline><Cognitive><Collaborations><Combination Medication><Coping Skills><Data><Decision Making><Decrease disparity><Development><Diagnosis><Disparities><Disparity><Drugs><Effectiveness><Electronic Health Record><Emotional><Ensure><Evaluation><Future><Goals><Group Psychotherapy><Health Services><Health Services Accessibility><Health Services Evaluation><Health Services Research><Hybrids><Intervention><Intervention Strategies><Interview><Investigators><Knowledge><Long-term cohort><Longitudinal cohort><Longterm cohort><Lower disparity><Medical Care Research><Medication><Mental Health><Mental Hygiene><Methodology><Methods><Nucleotide Sequence><Outcome><PTSD><Patient Preferences><Pharmaceutical Preparations><Post-Traumatic Neuroses><Post-Traumatic Stress Disorders><Posttraumatic Neuroses><Procedures><Psychological Health><Psychotherapy><Qualitative Methods><Randomized><Recommendation><Recovery><Research><Research Methodology><Research Methods><Research Personnel><Researchers><Risk><Sampling><Services><Site><Suicide precaution><Suicide prevention><Testing><Time><Training><Translating><Veterans><Veterans Health Administration><Veterans Health Affairs><Woman><Work><acceptability and feasibility><access disparities><access to health services><access to services><access to treatment><accessibility disparities><accessibility to health services><availability of services><biopsychosocial><care access><care as usual><career><clinical practice and guidelines><common treatment><compare intervention><comparison intervention><coping strategy><design><designing><develop therapy><developmental><disparities in access><disparities in treatment><disparity reduction><drug/agent><electronic health care record><electronic health medical record><electronic health plan record><electronic health registry><electronic medical health record><ethnic minority><experience><group intervention><hazard><health service access><health services availability><implementation research><implementation science><improved><improved outcome><inequality in access><inequality in treatment><inequity in access><inequity in accessibility><innovate><innovation><innovative><interest><intervention development><interventional strategy><men><mitigate disparity><new approaches><novel approaches><novel strategies><novel strategy><nucleic acid sequence><pilot trial><post 9/11><post-trauma stress disorder><posttrauma stress disorder><pragmatic effectiveness trial><pragmatic trial><prevent suicidality><prevent suicide><primary outcome><psychosocial><qualitative reasoning><racial minority><randomisation><randomization><randomly assigned><reduce disparity><reduction in disparity><research and methods><secondary outcome><service availability><service intervention><services research><shared decision making><socio-demographic disparity><socio-demographic inequality><socio-demographic inequity><socio-demographics><sociodemographic disparity><sociodemographic inequality><sociodemographic inequity><sociodemographics><success><suicidality prevention><suicide intervention><therapy development><traumatic neurosis><treatment access><treatment as usual><treatment development><treatment disparity><treatment inequality><treatment inequity><treatment research><usual care>