Advancing Health Equity by Understanding the Impact of Race on PTSD Symptom Improvement Following Evidence-Based Psychotherapy

Background: In several studies, including our national VHA study examining nearly 15 years of VHA utilization in over 300,000 Iraq and Afghanistan War Veterans who had a post-deployment PTSD diagnosis, Black Veterans receiving evidence-based psychotherapy (EBP) demonstrated decreased odds of PTSD symptom improvement, relative to their White counterparts. Significance: We propose a mixed-methods study to understand these disparities, improve health service delivery, and promote equity in PTSD EBPs, goals aligned with VHA priorities. Innovation & Impact: Despite documented disparities in PTSD EBPs for Black Veterans, there have been no national mixed-methods studies across the VHA to better understand these disparities with the goal of impacting delivery of care. Given that MPIs are researchers and trained clinicians, as are several of our co- investigators, we have the skills required to acquire information that will impact how these treatments are delivered. Specific Aims: Our aims are: (1) To determine factors associated with less PTSD symptom improvement for Black Veterans receiving PTSD EBPs in the VA through analysis of electronic health records (EHRs); (2) To determine needs, perceptions, and experiences of Black Veterans engaging in PTSD EBPs through qualitative interviews, including the processing of race-based trauma during EBPs; and (3) To determine the perceived efficacy of current trauma-focused treatments in supporting experiences of racial trauma though interviews with Black Veterans. Methodology: We will utilize a mixed methods approach to identify how to improve PTSD EBPs for Black Veterans. The quantitative study is designed to better understand factors associated with EBP disparities in Black Veterans by examining demographic, clinical, service utilization, and EBP factors in an all-era, national, clinical sample (Aim 1). We will include all Veterans enrolled in the VA who have a PTSD diagnosis, have initiated or completed an evidence-based psychotherapy, and have at least two PTSD symptom measures during treatment. For the primary outcome of the quantitative aim, we will examine change in PTSD symptom score from before to after PTSD EBPs. We will then determine factors, including race, that are differentially associated with symptom improvement. The qualitative study (Aims 2 and 3) will overlap with the quantitative study. Participant stakeholders (N=60) will include Black Veterans who have participated in VHA PTSD EBPs from the four US regions. We will recruit Veterans to capture adequate diversity in service era, gender, and other intersecting identities (e.g., LGBTQ+ and Veterans with disabilities), and will interview Veterans until thematic saturation is reached for each qualitative aim. For our qualitative analysis, we will identify themes that arise from our semi-structured interview guide using Rapid Analysis Procedures. We will use these themes to understand potential disparities as well as how to improve PTSD EBPs for Black Veterans. Next Steps/Implementation: We will disseminate results through publications, conferences, and our VHA operational partners, who we will work closely with throughout the grant. Next steps, depending on our mixed methods findings, include submitting a grant focused on applying findings from the current study to improve administration of PTSD EBPs for race-based trauma and to train PTSD EBP providers on assessment and treatment of race-based trauma within PTSD EBPs. We will work closely with our partners to leverage information learned from our research to ensure health equity in PTSD EBP treatment. Project Number: 1I01HX003806-01A1 | Fiscal Year: 2025 | NIH Institute/Center: Veterans Affairs (VA) | Principal Investigator: Shira Maguen (+1 co-PI) | Institution: VETERANS AFFAIRS MED CTR SAN FRANCISCO, SAN FRANCISCO, CA | Activity Code: I01 | Study Section: HSR-2 Behavioral, Social, and Cultural Drivers of Health and Care[HSR2] View on NIH RePORTER: https://reporter.nih.gov/project-details/10854253