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Using Peer Specialists to Reserve Dropout from Prolonged Exposure

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Using Peer Specialists to Reserve Dropout from Prolonged Exposure ADVERTIMENT. Lʼaccés als continguts dʼaquesta tesi queda condicionat a lʼacceptació de les condicions dʼús establertes per la següent llicència Creative Commons: http://cat.creativecommons.org/?page_id=184 ADVERTENCIA. El acceso a los contenidos de esta tesis queda condicionado a la aceptación de las condiciones de uso establecidas por la siguiente licencia Creative Commons: http://es.creativecommons.org/blog/licencias/ WARNING. The access to the contents of this doctoral thesis it is limited to the acceptance of the use conditions set by the following Creative Commons license: https://creativecommons.org/licenses/?lang=en Acknowledgements I would like to recognize the incredible support and professionalism of my mentor Dr. David Sánchez-Carracedo. Also, I will be endlessly grateful with the greatest and uninterested support of the Veterans Affairs Medical Center in Charleston, SC for believing strongly in finding better ways to innovate clinical mental research to better serve the Veterans. Many thanks to the hard-working professionals of the PTSD Clinical Research Team, particularly those working directly with me to achieve the goals of this project: Stephanie Hamski, Stephanie Ziegler, and Glenna Worsham. Of course, could not finish my recognition with the support of the Investigators of the original studies, Dr. Ron Acierno and Dr. Kenneth Ruggiero, for their generous access to the dropout study participants. I would like to thank to the administrative staff and faculty at the Department of Psychology of the Universitat Autònoma de Barcelona, from whom I will always be in debt for their support and flexibility towards my special conditions within the program. To my incredible and supportive family for their endless love and tolerance. And finally, my admiration and respect to the people who made this study possible: the Veterans. I do hope that my ideas could help to alleviate the burden of what you have been through and thank you always for your service. ii Table of Contents Acknowledgements .......................................................................................................... ii Table of Contents ............................................................................................................. iii General Introduction ........................................................................................................ iv Abstract .......................................................................................................................... vi Resumen ........................................................................................................................ vii I. INTRODUCTION ........................................................................................................... 1 1. POST-TRAUMATIC STRESS DISORDER (PTSD): DEFINITION, PREVALENCE AND RISK FACTORS ........................................................................................................................... 1 2. Prolonged Exposure: An Evidence-Based Treatment for PTSD .................................. 5 3. Dropout from PE and Other Evidence Based Treatment for PTSD .......................... 14 4. Social Support and Evidence Based PTSD Treatment Completion ........................... 19 5. Innovative Methods to Deliver Evidence-Based Treatments for PTSD and Address Dropout: Telehealth ........................................................................................................ 21 6. PROBLEM STATEMENT ................................................................................................... 26 II. METHODOLOGY ...................................................................................................... 29 1. Study Design .............................................................................................................. 29 2. Participants ................................................................................................................. 30 3. Measures ................................................................................................................... 31 4. Procedure .................................................................................................................. 33 5. Data Analyses ........................................................................................................... 40 III. RESULTS .................................................................................................................. 42 1. First Manuscript ...................................................................................................... 42 2. Second Manuscript ................................................................................................. 50 3. Third Manuscript ..................................................................................................... 75 IV. DISCUSSION .......................................................................................................... 102 V. REFERENCES ........................................................................................................ 110 VI. APPENDICES ......................................................................................................... 130 1. Informed Consent for Treatment .............................................................................. 130 2. PTSD Checklist – Military Version (PCL-M) ............................................................. 136 3. PHQ-9 ..................................................................................................................... 137 4. Barriers to Therapeutic Exposure Participation Scale (Subscale: Satisfaction in red) ..................................................................................................................................... 138 iii General Introduction The following study aimed to address the issue of Veteran dropout from Prolonged Exposure (PE) therapy, one of the most effective evidence-based treatments for PTSD. PE typically produces long lasting positive results if treatment is actually completed. As such, the Veterans Health Administration (VHA) has invested extensive resources into research and practices to make this treatment available to the Veterans under VHA care. Unfortunately, little research and attention has been paid to reversing dropout from PE, which is not insignificant at about 30%. This is of particular concern for Veterans in the United States, who are more likely to suffer from PTSD than civilians. A previous study by the author of the present thesis (Hernandez-Tejada, Zoller, Ruggiero, Kazley & Acierno, 2014) examined Veteran dropout from in person delivered and home-telehealth delivered PE. This study showed that, for in person delivered PE, logistics-related problems such as driving time to appointments, distance to the hospital, parking issues, and indirect cost (i.e., missed work) incurred through participation in therapy were related to dropout, whereas for those receiving PE via home telehealth, dropout related more specifically to treatment components themselves. In particular, participants in home telehealth delivered PE were more likely to report that in vivo exposure assignments were very uncomfortable, difficult, and almost intolerable, and noted that this was a factor leading to their attrition from treatment. The following work describes a program to address dropout from PE that uses ‘peer specialists” (as they are called within the VHA) in a novel way, that is, directly during in vivo exposure assignments. Peer specialists have not been used in this manner before, and in fact such use has been prohibited. Instead, peers are used iv primarily to encourage other Veterans to obtain treatment, and to help Veterans navigate the VHA hospital system. Thus, a major innovation of the present work is elevating the role of a trained peer to a central and key member of the treatment team. The idea of using peers comes from a wide evidence base in favor of leveraging social support to enhance mental and physical health recovery. Through the development of this proposal, concepts related to PTSD, PE and peer support are discussed in the Background. Methods are discussed in section II. The manuscripts published in peer-reviewed journals are presented, as is a summary of the results, in section III, and finally the discussion is presented in section IV. This manuscript also includes the Appendices within which informed consent and all study instruments are given. v Abstract Objective: the present study of United States military Veterans evaluated whether peers who had successfully completed Prolonged Exposure (PE) Therapy for combat- related Post-traumatic Stress Disorder (PTSD) could help other Veterans who had dropped out of treatment to both re-engage in, and complete PE by offering supportive encouragement directly during in vivo exposure homework exercises. Methods: The study sample was derived from two ongoing randomized controlled trials comparing PE delivered in person vs. PE delivered via home-based telehealth. All 82 PE dropouts from aforementioned trials were contacted and offered the opportunity to return to treatment, this time with the addition of a peer present during a limited number of in vivo exposure exercises. Measures included intent to re-engage in treatment, satisfaction with the program, and PTSD and depression outcomes. Results: of the 82 dropouts identified from the two trials, 29 (35,37%) agreed to re-engage in PE (delivered via the same treatment modality
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