The Impact of Modifiable Psychosocial Factors on Veterans' Long-term Trajectories of Functioning and Quality of Life: Promoting Recovery by Targeting Mindfulness and Psychological Flexibility
| Status: | Enrolling by invitation |
|---|---|
| Conditions: | Chronic Pain, Chronic Pain, Depression, Neurology, Psychiatric |
| Therapuetic Areas: | Musculoskeletal, Neurology, Psychiatry / Psychology |
| Healthy: | No |
| Age Range: | 18 - Any |
| Updated: | 12/23/2018 |
| Start Date: | October 1, 2018 |
| End Date: | September 30, 2022 |
Research by the investigators' team and others demonstrates that posttraumatic stress
disorder (PTSD), depression, alcohol use disorders (AUD), traumatic brain injury (TBI), and
chronic pain frequently co-occur among post-9/11 war Veterans and are associated with
functional impairment and suicide risk; however, no treatment currently exists that has been
specifically designed to promote functional recovery among Veterans experiencing any
combination of these most common mental and physical wounds of war. The investigative team
has: (A) identified multiple modifiable psychosocial factors (emotion regulation,
psychological flexibility, self-compassion) that prospectively predict impairment and
suicidal ideation in Veterans; (B) characterized long-term trajectories of resilience and
functional disability in Veterans; (C) determined that high utilization of VA mental health
services appears to have little, if any, impact on the functional recovery of Veterans on the
moderate and severely impaired trajectories; (D) identified psychological flexibility (i.e.,
the ability to remain present in the moment despite emotional distress and to persist in
changing behavior in the pursuit of one's values and goals) as a unique, prospective
predictor of membership in the severely impaired functional trajectory and of suicidal
ideation, even after accounting for the effects of co-morbidity; and (E) demonstrated that
Acceptance and Commitment Therapy (ACT)-a trans-diagnostic, mindfulness-based behavior
therapy that seeks to improve functioning by targeting psychological flexibility -can lead to
recovery, including sustained improvements in functional disability, quality of life (QoL),
suicidal ideation, PTSD, and AUD symptoms among severely impaired Veterans with co-occurring
PTSD-AUD.
This study is Phase 3 of Project SERVE (Study Evaluating Returning Veterans' Experiences).
Through two prior RR&D MERIT awards, SERVE has followed a cohort of post-9/11 Veterans since
2010 and has identified numerous risk and protective factors. SERVE's overall objective is to
understand and improve the long-term functional outcomes of post-9/11 Veterans. Consistent
with the investigators' conceptual model, the central hypothesis is that psychological
flexibility and other trans-diagnostic treatment targets mediate the effects of the most
common mental and physical wounds of war on long-term functioning and self-directed violence
(i.e., suicide risk). Thus, integrated interventions specifically designed to improve
functioning associated with these conditions are most likely to promote long-term recovery
among the most impaired Veterans. The investigators will test the central hypothesis and
accomplish the overall objective by pursuing the following specific aims:
Aim 1: Identify treatment targets that prospectively predict functional disability and
self-directed violence (SDV) in post-9/11 Veterans with PTSD, depression, chronic pain, TBI,
and/or AUD.
To achieve this aim, the investigators will follow 500 Veterans for 2 years in order to
prospectively evaluate the impact of several novel, treatment-relevant factors on functional
disability and SDV over time.
H1: Novel factors (mindfulness, perceived burdensomeness, thwarted belongingness, and moral
injury) along with established treatment targets (psychological flexibility, self-compassion,
and emotion regulation) will prospectively predict functional disability and SDV after
accounting for covariates.
Aim 2: Develop, refine, and evaluate the feasibility and acceptability of a transdiagnostic,
personalized ACT-based behavioral therapy (ACT-FX) specifically designed to improve
functioning in Veterans.
The investigators will use the Successive Cohort Design method to refine ACT-FX. The
investigators will then evaluate the feasibility and acceptability of ACT-FX in 60 Veterans
randomly assigned to ACT-FX or treatment as usual (TAU) and who will remain in the
longitudinal assessment study (Aim 1) for long-term follow-ups.
H2: ACT-FX will be feasible and acceptable to Veterans with complex mental and physical
wounds of war.
Aim 3: (Exploratory) Evaluate if participation in ACT-FX leads to the emergence of a new
trajectory class among Veterans in Project SERVE that is characterized by long-term
functional recovery.
H3: ACT-FX treatment will predict membership in a new trajectory class characterized by
functional recovery compared to Veterans receiving TAU who will continue to exhibit flat or
worsening trajectories.
Impact: The proposed research will help identify novel modifiable factors for functional
recovery and provide proof-of-concept, within the context of the longitudinal study, that
ACT-FX promotes recovery. This innovative project has potential to advance VA healthcare by
promoting long-term functional recovery in Veterans.
disorder (PTSD), depression, alcohol use disorders (AUD), traumatic brain injury (TBI), and
chronic pain frequently co-occur among post-9/11 war Veterans and are associated with
functional impairment and suicide risk; however, no treatment currently exists that has been
specifically designed to promote functional recovery among Veterans experiencing any
combination of these most common mental and physical wounds of war. The investigative team
has: (A) identified multiple modifiable psychosocial factors (emotion regulation,
psychological flexibility, self-compassion) that prospectively predict impairment and
suicidal ideation in Veterans; (B) characterized long-term trajectories of resilience and
functional disability in Veterans; (C) determined that high utilization of VA mental health
services appears to have little, if any, impact on the functional recovery of Veterans on the
moderate and severely impaired trajectories; (D) identified psychological flexibility (i.e.,
the ability to remain present in the moment despite emotional distress and to persist in
changing behavior in the pursuit of one's values and goals) as a unique, prospective
predictor of membership in the severely impaired functional trajectory and of suicidal
ideation, even after accounting for the effects of co-morbidity; and (E) demonstrated that
Acceptance and Commitment Therapy (ACT)-a trans-diagnostic, mindfulness-based behavior
therapy that seeks to improve functioning by targeting psychological flexibility -can lead to
recovery, including sustained improvements in functional disability, quality of life (QoL),
suicidal ideation, PTSD, and AUD symptoms among severely impaired Veterans with co-occurring
PTSD-AUD.
This study is Phase 3 of Project SERVE (Study Evaluating Returning Veterans' Experiences).
Through two prior RR&D MERIT awards, SERVE has followed a cohort of post-9/11 Veterans since
2010 and has identified numerous risk and protective factors. SERVE's overall objective is to
understand and improve the long-term functional outcomes of post-9/11 Veterans. Consistent
with the investigators' conceptual model, the central hypothesis is that psychological
flexibility and other trans-diagnostic treatment targets mediate the effects of the most
common mental and physical wounds of war on long-term functioning and self-directed violence
(i.e., suicide risk). Thus, integrated interventions specifically designed to improve
functioning associated with these conditions are most likely to promote long-term recovery
among the most impaired Veterans. The investigators will test the central hypothesis and
accomplish the overall objective by pursuing the following specific aims:
Aim 1: Identify treatment targets that prospectively predict functional disability and
self-directed violence (SDV) in post-9/11 Veterans with PTSD, depression, chronic pain, TBI,
and/or AUD.
To achieve this aim, the investigators will follow 500 Veterans for 2 years in order to
prospectively evaluate the impact of several novel, treatment-relevant factors on functional
disability and SDV over time.
H1: Novel factors (mindfulness, perceived burdensomeness, thwarted belongingness, and moral
injury) along with established treatment targets (psychological flexibility, self-compassion,
and emotion regulation) will prospectively predict functional disability and SDV after
accounting for covariates.
Aim 2: Develop, refine, and evaluate the feasibility and acceptability of a transdiagnostic,
personalized ACT-based behavioral therapy (ACT-FX) specifically designed to improve
functioning in Veterans.
The investigators will use the Successive Cohort Design method to refine ACT-FX. The
investigators will then evaluate the feasibility and acceptability of ACT-FX in 60 Veterans
randomly assigned to ACT-FX or treatment as usual (TAU) and who will remain in the
longitudinal assessment study (Aim 1) for long-term follow-ups.
H2: ACT-FX will be feasible and acceptable to Veterans with complex mental and physical
wounds of war.
Aim 3: (Exploratory) Evaluate if participation in ACT-FX leads to the emergence of a new
trajectory class among Veterans in Project SERVE that is characterized by long-term
functional recovery.
H3: ACT-FX treatment will predict membership in a new trajectory class characterized by
functional recovery compared to Veterans receiving TAU who will continue to exhibit flat or
worsening trajectories.
Impact: The proposed research will help identify novel modifiable factors for functional
recovery and provide proof-of-concept, within the context of the longitudinal study, that
ACT-FX promotes recovery. This innovative project has potential to advance VA healthcare by
promoting long-term functional recovery in Veterans.
Inclusion Criteria:
Veterans will be recruited for the SCD treatment study (total n = 100 across 3 stages) from
the ongoing longitudinal assessment study. The inclusion criteria for the longitudinal
assessment study are as follows:
- Potential participants include male and female
- English-speaking OEF/OIF/OND Veterans
- Enrolled at CTVHCS or willing to be enrolled for the purpose of participation in this
study.
To be eligible, participants must be
- able to comprehend and sign the informed consent form
- able to complete the structured interviews and self-report assessments
- willing to be contacted for follow-up assessments
For newly enrolled participants:
- given that the investigators have already recruited a large sample of veterans who are
reporting relatively little functional impairment, the investigators will require
newly enrolled participants to self-report global functional impairment on the WHODAS
2.0 12-item self-report version equivalent to a mean item score of 1.0.
- Although the investigators anticipate being able to meet the recruitment goals,
should recruitment prove more challenging than expected, the investigators will
remove this inclusion criterion
- deemed stable on psychotropic medications (defined as 3 months on a selective
serotonin reuptake inhibitor or monoamine oxidase inhibitor; >1 month on an anxiolytic
or beta-blocker; >1 month medication discontinuation or "wash out" for all
medications) at the time of the BL assessment
- deemed stable in psychotherapy (3 months stabilization for psychotherapy and 1-month
psychotherapy wash-out) at the time of the BL assessment
- These latter two criteria are instated to ensure that symptoms assessed during
the baseline assessment are due to any underlying psychiatric condition and not
due to the effects of starting or stopping medications and/or psychotherapy.
- Changes in treatment will be permissible during the current study, as this reflects
real-world practice
- All changes in medications will be monitored over time, and appropriately covaried, as
treatment can have important effects on functioning over time
- Individuals will be eligible to participate with current and lifetime psychiatric
diagnoses, with the exception of:
- schizophrenia
- schizophreniform disorder
- schizoaffective disorder
- delusional disorder
- unspecified schizophrenia spectrum/other psychotic disorder, and bipolar disorder
Additional inclusion criteria specific to the SCD treatment study are:
- Veterans will have a global disability (mean item) score on the WHODAS 2.0 of 1.0,
which is 1 SD above the mean of the large non-psychiatric sample of Veterans from
SERVE and VA Boston during both of their last 2 assessments
- Those enrolling in the pilot RCT must be willing to be randomized
Exclusion Criteria:
Exclusion criteria for the longitudinal assessment study are as follows:
- plan to relocate out of the CTVHCS system within four months of protocol initiation
- meet criteria for a diagnosis of:
- schizophrenia
- schizophreniform disorder
- schizoaffective disorder
- delusional disorder
- a manic/hypomanic episode
- report current suicidal or homicidal risk warranting crisis intervention
- report symptoms consistent with severe traumatic brain injury (TBI) that interfere
with their ability to complete the consent process or assessment
- i.e., due to ethical concerns about obtaining informed consent and difficulties
with completing the structured assessment
- report current non-military related hallucinations or delusions that cause significant
distress and/or impairment
Additional exclusion criteria for the SCD treatment study are:
- recent (1 month) or anticipated change in psycho-pharmacological treatment. Veterans
may stay on current medications but will be asked to refrain from changes to the
extent possible based on safety
- for those randomized to ACT-FX, current participation in another form of individual or
group psychotherapy
- logistical circumstances that would interfere with study completion
- Presence of a non-alcohol substance use disorder (SUD) deemed to be the primary focus
of treatment
- Those with a principal AUD will be eligible.
- Additional diagnoses of non-alcohol SUD are allowed, unless they are deemed the
principal focus of treatment.
- Potentially eligible Veterans who score above the clinical cutoff on the DAST will be
asked additional questions during the eligibility screening to determine whether they
meet criteria for a principal non-alcohol SUD (see phone screen)
- AUD/SUD of sufficient severity that residential, rather than outpatient, treatment is
indicated based on potential safety concerns associated with withdrawal.
- This determination will be made by the PI, with consultation from the Veteran's
existing treatment providers, as appropriate.
- The investigators will begin the treatment adaptation (Stage 1) and refinement
(Stage 2) by recruiting transfer participants who have already been assessed over
time immediately following their baseline assessment.
- The pilot RCT will include both transfer and newly enrolled Veterans.
We found this trial at
1
site
Waco, Texas 76711
Principal Investigator: Eric C Meyer, PhD
Phone: 254-297-5166
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