Implementing Computer-Based Psychotherapy among Veterans in Outpatient Treatment for Substance Use Disorders

OBJECTIVE:

Computer-based psychotherapy interventions (CBPIs) are increasingly offered as first-level access to evidence-based mental health treatment. However, their implementation has not been evaluated in public-sector outpatient settings.

METHODS:

An evidence-based CBPI for insomnia was implemented with provider and patient education sessions, on-site Internet access, and clinician telephone support. Persons receiving care at a Veterans Health Administration substance abuse treatment clinic were screened for chronic insomnia and offered CBPI access. The feasibility of this strategy was evaluated in a pre-post design, which assessed engagement and completion rates, participant-reported acceptability, and clinical outcomes.

RESULTS:

Of 100 veterans referred, 51 enrolled in the program, of whom 22 (43%) completed all sessions, 13 (26%) partially completed the program, and 16 (31%) did not engage. There were no statistically significant differences between these three groups in baseline characteristics. In the total sample, Insomnia Severity Index (ISI) scores decreased (improved) by 32% (mean±SD of 6.3±6.2 points, t=6.82, df=44, p<.001). Veterans who completed all six sessions displayed clinically and statistically significant improvements on the ISI compared with those who did not engage, as shown in a regression analysis that controlled for baseline insomnia severity, time between assessments, and sedative-hypnotic medication use (F=3.87, df=4 and 40, p≤.004). Among all participants, 67% agreed that they would engage in another CBPI in the future. When questioned about potential barriers, 36% of the full sample endorsed a preference for face-to-face therapy.

CONCLUSIONS:

A strategy of brief provider and patient education, on-site Internet access, and telephone support was feasible and effective for implementing CBPIs in outpatient substance abuse treatment settings for veterans.

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By:  Hermes ED1, Rosenheck RA1.

• 1Dr. Hermes and Dr. Rosenheck are with the New England Mental Illness Research, Education and Clinical Center (MIRECC), Veterans Affairs (VA) Connecticut Healthcare System, West Haven, Connecticut, and with the Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut (e-mail: eric.hermes@yale.edu ).

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Insomnia in Alcohol Dependent Subjects Is Associated with Greater Psychosocial Problem Severity

Although psychosocial problems are commonly associated with both alcohol misuse and insomnia, very little is known about the combined effects of insomnia and current alcohol dependence on the severity of psychosocial problems. The present study evaluates whether the co-occurrence of insomnia and alcohol dependence is associated with greater psychosocial problem severity.

Alcohol dependent individuals (N = 123) were evaluated prior to participation in a placebo-controlled medication trial. The Short Index of Problems (SIP), Addiction Severity Index (ASI), Insomnia Severity Index (ISI), and Time Line Follow Back (TLFB), were used to assess psychosocial, employment, and legal problems; insomnia symptoms; and alcohol consumption, respectively. Bivariate and multivariate analyses were used to evaluate the relations between insomnia and psychosocial problems.

Subjects' mean age was 44 years (SD = 10.3), 83% were male, and their SIP sub-scale scores approximated the median for normative data. A quarter of subjects reported no insomnia; 29% reported mild insomnia; and 45% reported moderate-severe insomnia. The insomnia groups did not differ on alcohol consumption measures. The ISI total score was associated with the SIP total scale score (β = 0.23, p = 0.008). Subjects with moderate-severe insomnia had significantly higher scores on the SIP total score, and on the social and impulse control sub-scales, and more ASI employment problems and conflicts with their spouses than others on the ASI.

In treatment-seeking alcohol dependent subjects, insomnia may increase alcohol-related adverse psychosocial consequences. Longitudinal studies are needed to clarify the relations between insomnia and psychosocial problems in these subjects.

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By: Chaudhary NS1, Kampman KM2, Kranzler HR2, Grandner MA2, Debbarma S3, Chakravorty S4.

• 1Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA 19104, United States; Washington University in St. Louis, St. Louis, MO 63110, United States.
• 2Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA 19104, United States; Philadelphia Veterans Affairs Medical Center, Philadelphia, PA 19104, United States.
• 3Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA 19104, United States; Thomas Jefferson University, Philadelphia, PA 19107, United States.
• 4Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA 19104, United States; Philadelphia Veterans Affairs Medical Center, Philadelphia, PA 19104, United States. Electronic address: Subhajit.Chakravorty@uphs.upenn.edu.  

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Prevalence and Trends of Concurrent Opioid Analgesic and Benzodiazepine Use among Veterans Affairs Patients with PTSD, 2003-2011

Patients with PTSD have complex and multiple symptoms, including anxiety, insomnia, and co-occurring pain, often treated with opioids and benzodiazepines.,.

The trend in age-adjusted long-term concurrent opioid and benzodiazepine use over 9-years increased 52.7%, 

• from 3.6%, in men 
• and 79.5%, from 3.9% to 7.0%, in women. 
• In 2011, 17.1% of long-term concurrent users were prescribed morphine-equivalent daily doses of opioids ≥100 mg and 49.4% had a documented high-risk condition.

Despite known risks associated with prescribing opioids and benzodiazepines concurrently, the adjusted prevalence of long-term concurrent use rose significantly among men and women with PTSD over a 9-year period. 

Common use of these medications among patients with high-risk conditions suggests comprehensive strategies are needed to identify and monitor patients at increased risk for adverse outcomes.

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By: Hawkins EJ1,2,3,4, Malte CA1,2,3, Grossbard JR2, Saxon AJ1,2,3,4.

• 1Health Services Research & Development (HSR&D) Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, USA.
• 2Center of Excellence in Substance Abuse Treatment and Education, Seattle, USA.
• 3VA Puget Sound Health Care System, Seattle, Washington, USA.
• 4Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington, USA.

Prevalence & Mental Health Correlates of Insomnia in First-Encounter Veterans With & Without Military Sexual Trauma

There is limited information about prevalence of insomnia in general populations of veterans of recent wars in Iraq and Afghanistan...

53.1% of veterans without military sexual trauma (MST) and 60.8% of veterans with MST had clinically significant insomnia symptoms, with the MST subsample reporting more severe symptoms. Insomnia was more prevalent than depression, hypomania, PTSD, and substance misuse. Veterans with insomnia were more likely to seek care for physical health problems and primary care versus mental health concerns. For the veteran sample without MST, age, combat service, traumatic brain injury, pain, and depression were associated with worse insomnia. For the MST subsample, employment status, pain, and depression were associated with worse insomnia.

Study findings indicate a considerably higher rate of insomnia in veterans compared to what has been found in the general population. Insomnia is more prevalent, and more severe, in veterans with MST. Routine insomnia assessments and referrals to providers who can provide evidence-based treatment are crucial.

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By: Jenkins MM, Colvonen PJ, Norman SB, Afari N, Allard CB, Drummond SP.