A Self-Help Intervention to Improve Functioning, Symptoms, and Treatment Utilization among Non-Treatment Engaged Post 9/11 Veterans withDepression or PTSD Symptoms

About This Grant

Significance to VA: Many Veterans who served on or after September 11, 2001 (post 9/11) experience impaired psychosocial functioning, due in part to high rates of posttraumatic stress disorder (PTSD) and major depressive disorder (MDD). Less than half of post 9/11 Veterans with these conditions seek mental health (MH) treatment, with key barriers being a preference to self-manage and lack of time. Veterans also report difficulty navigating the overwhelming array of resources available. To address a gap for post 9/11 Veterans with unmet MH needs, we propose a self-help intervention to provide skills for healthy self-management as well as curated guidance on recovery support services that address MH and broader whole-person functional challenges. There is ample evidence that self-help interventions improve MH symptoms, possibly with greater impact if clinicians provide support, but their impact on psychosocial functioning is understudied. Resilience Training for Veterans (REST-V) is a self-help intervention tailored for post 9/11 Veterans with MDD and/or PTSD symptoms who are not in psychotherapy. REST-V comprises 2 handouts per week for 6 weeks delivering (a) instruction and cues to use evidence-based self-management coping skills (to promote use of adaptive coping) and (b) information to educate, normalize, and navigate recovery support services (to promote use of MH treatment, Other relevant VHA care such as Whole Health, and Informal resources such as MH apps). Veterans may elect to receive optional support via brief calls or text reminders. Using a stepped care approach with low-cost self-help as the first step, REST-V aims to increase access to evidence-based coping skills and easy-to-understand guidance on recovery support services for Veterans who choose not to access MH treatment. Given high rates of untreated MDD and PTSD among post 9/11 Veterans, this proposal addresses a known gap to support VHA priorities, suicide prevention efforts, and Brain, Behavioral and Mental Health (BBMH) Portfolio priorities for clinical studies to improve functioning and reintegration in Veterans with MH conditions. Innovation & Impact: REST-V is innovative for its dual focus on psychosocial functioning/MH and recovery support services, examining whether self-help improves functioning and resource utilization, and accommodating patient preferences for format of delivery (mail, secure message, text) and support (telephone, text). REST-V aims to increase Veterans’ tools for recovery to reduce functional impairment impacting family, social, work, and other life roles. REST-V is being delivered through Primary Care Mental Health Integration (PCMHI) in this study but could be used in a variety of VHA care settings. Specific Aims: The specific aims of this clinical trial are to: Evaluate the efficacy of REST-V (vs. Control) at improving 1) psychosocial functional impairment, 2) MH outcomes, and utilization of 3a1) cognitive-behavioral coping skills and 3a2) recovery support services, with use of skills and services being 3b) explored as potential mediators. We hypothesize that REST-V will be more efficacious than Control. Methodology: This randomized controlled trial (RCT) will take place at 2 VHA healthcare systems (Syracuse and Durham). VHA-enrolled post 9/11 Veterans (N=200) who screen positive for MDD and/or PTSD symptoms and functional impairment but are not in psychotherapy will be randomized to the intervention (REST-V) or control (standard printed resource/ treatment information) condition and assessed at baseline, 8, 16, 24, 32, and 40 weeks using validated self-report scales and electronic health record (EHR) data (for VHA care utilization). The primary outcome is psychosocial functional impairment. Secondary MH outcomes are psychological distress, MDD and PTSD symptom severity, and suicidal ideation. Aims 1, 2, and 3a will be tested using generalized linear mixed models with an intent-to-treat analysis. Aim 3b will use exploratory mediation models with non-parametric bootstrapping procedures. Path to Translation/Implementation: If efficacy is confirmed, we will work with our national operations partners and use data collected in this trial to plan a hybrid II or III trial to facilitate implementation into VHA clinical practice.