Self-Help Intervention for Post 9/11 Veterans With Depression or PTSD Symptoms

An 80-item self-report measure of mental-health related psychosocial functional impairment over the past 30 days. The IPF yields domain scores for up to 7 domains (e.g., work, family, self care), with only those domains relevant for the individual being scored, and an overall score. The overall IPF score is an unweighted average of all calculated domain scores, scaled to a range of 0-100. Higher scores indicate greater psychosocial functional impairment (i.e., lower scores = better functioning).

An 18-item self-report measure of general psychological distress over the past 7 days serves as a cross-cutting mental health outcome not specific to any one mental health diagnosis. The Global Severity Index (GSI) uses all three 6-item subscales (depression, anxiety, somatization), with a total raw score range of 0-72. Raw scores can be converted to T-scores using normative data. Higher scores indicate greater distress.

A 9-item self-report measure of depression symptom severity over the past 2 weeks. The total PHQ-9 score is the sum of all 9 items and can range from 0-27. Higher scores indicate greater depression symptom severity.

A 20-item self-report measure of PTSD symptom severity over the past month. The total PCL-5 score is the sum of all 20 items and can range from 0-80. Higher scores indicate greater PTSD symptom severity.

This self-report item assesses suicidal ideation over the past month with yes or no response options. The full C-SSRS used in VHA will be administered, but this outcome focuses specifically on active suicidal ideation.

An 12-item self-report measure of frequency of cognitive-behavioral therapy (CBT) skill utilization over the past week. This measure is sensitive to change from CBT self-help. The total FATS score is the sum of all 12 items (from 4 subscales) and can range from 0 to 48. Higher scores indicate greater frequency of CBT skill utilization.

The investigators will use cumulative measures of utilization of 3 components across the 40-week study: (1) outpatient mental health treatment (a) within VHA and (b) outside VHA, (2) other relevant VHA whole-person health care, and (3) informal resources. See the other pre-specified outcomes with prefix RSSU below for details on measurement of each component.

Outpatient mental health treatment within the Veterans Health Administration (VHA) will be assessed using electronic health record (EHR) data. The cumulative total count of three care components occurring across the 40-week study period will be used: (1) encounters of outpatient psychotherapy in primary care (Primary Care Mental Health Integration) or specialty mental health care (outpatient behavioral health, PTSD clinic, substance treatment clinic, or OEF/OIF/OND mental health clinic), (2) encounters of medication management visits with psychiatric prescribers, and (3) psychotropic medication fill or refill not tied to a specific medication management visit (e.g., through primary care). Medication fills/refills identified from the EHR will only be counted if the participant also self-reports taking the medication for at least 4 weeks (assessed every 8 weeks).

Mental health treatment outside VHA will be assessed using self-report occurring every 8 weeks. The cumulative total count of three care components occurring across the 40-week study period will be used: (1) encounters of outpatient psychotherapy (e.g., in community clinic or with therapist in the community), (2) encounters of medication management visits with non-VHA psychiatric prescribers, and (3) psychotropic medication fill or refill not tied to a specific medication management visit (e.g., through non-VHA primary care). Medication fills/refills will only be counted if the participant also self-reports taking the medication for at least 4 weeks (assessed every 8 weeks).

Other relevant VHA whole-person health care will be assessed using EHR data. The cumulative total count of encounters with the following outpatient services/programs will be used: Whole Health (e.g., Whole Health Coaching, Whole Health classes), Complementary and Integrative Health (acupuncture, biofeedback, clinical hypnosis, massage therapy, meditation, guided imagery, tai chi / qigong, yoga), Social work, Case management (e.g., Military 2 VA, Healthcare for Homeless Veterans), Peer support, Vocational rehabilitation, and Veterans Justice Outreach.

Informal resource use or use of self-directed resources or approaches to support mental health and wellness will be measured via self-report every 8 weeks. To reduce recall bias and assessment reactivity while balancing participant burden, a two-pronged approach will be used. First, open-ended prompts will elicit behaviors over the past 8 weeks related to 5 categories (categorized per codebook): Socialization, VA Resources & Benefits, Health & Wellbeing, Self-Help for Mental Health, and Preparation for Mental Health Treatment. Then, participants will report how often they engaged in each behavior over the past week only using the FATS Likert-scale from 0 (not at all) to 4 (every day). Scores across the 5 categories will be summed for a total score for each time period. An average score will be created using the total scores from weeks 8, 16, 24, 32, and 40. For the exploratory mediation analysis, an average score using the total scores from weeks 8, 16, and 24 only will be created.

An 8-item self-report measure of treatment satisfaction will be administered to participants in the intervention condition. The total CSQ-8 score is the sum of all 8 items (4 of which are reverse-scored) and can range from 8 to 32. Higher scores indicate greater treatment satisfaction.