Available Reports

• Determining the Efficacy of Psychotherapy for Treatment Resistant Depression
• Determining the Responsiveness of Depression Questionnaires and Optimal Treatment Duration for Antidepressant Medications
• Assessment and Treatment of Individuals with History of TBI and PTSD
• Determining Key Features of Effective Depression Interventions
• Strategies for Suicide Prevention in Veterans
• Management of Inpatient Hyperglycemia
• Pain in Patients with Polytrauma
• Assessment and Management of Acute Pain in Adult Medical Inpatients
• Self-Monitoring of Blood Glucose in Patients with Type 2 Diabetes Mellitus: Meta Analysis of Effectiveness
• Racial and Ethnic Disparities in the VA Healthcare System
• Screening Men for Osteoporosis
• Benign Prostatic Hyperplasia Management

Determining the Efficacy of Psychotherapy for Treatment Resistant Depression  (October 2009)

Major depressive disorder (MDD) is a prevalent disorder impacting an estimated 13% of the general population, and a third of the veteran population. Antidepressant medications are the most commonly prescribed treatment modality for MDD and are often the first line of treatment in primary care settings. However, fewer than 50% of patients fully remit after adequate dosage of antidepressant treatment. Treatment options for these "treatment resistant" patients vary but typically involve using other psychoactive medications as augmentation (i.e., addition of another medication) or substitution treatment (i.e., switching medications). Less attention has been paid to using psychotherapy as an augmentation or substitution treatment for treatment resistant patients, despite psychotherapy being associated with clinical improvements in MDD comparable to those achieved with antidepressants. The current review will address the effectiveness of psychotherapeutic approaches as a second step treatment for MDD in patients who do not achieve remission after initial treatment with antidepressants.

The systematic literature review addressed the following key question:

In primary care patients with major depressive disorder who do not achieve remission with acute phase antidepressant treatment, is empirically based psychotherapy used as an augmentation or substitution treatment more effective than control for achieving remission?

Determining the Responsiveness of Depression Questionnaires and Optimal Treatment Duration for Antidepressant Medications  (October 2009)

According to projections from the World Health Organization, depression will be the second leading cause of disability in the developed world by 2020. Primary care clinicians care for approximately two thirds of depressed individuals. A variety of strategies have been tested to improve patient outcomes, with integrated care models having emerged as both clinically-and cost-effective. Patients randomized to integrated care are more likely to receive an adequate trial of antidepressants and/or empirically based psychotherapies and are approximately twice as likely to respond to treatment compared to usual care.

To inform recommendations for clinical guidelines and potential performance measures, this evidence synthesis evaluates the responsiveness of depression questionnaires feasible for primary care settings and data from randomized trials that examine the effects on continued antidepressant use to prevent relapse or recurrence.

The systematic literature review addressed the following key questions:

Assessment and Treatment of Individuals with History of TBI and PTSD  (August 2009)

VA and Department of Defense (DoD) healthcare facilities are increasingly serving a large population of OEF/OIF veterans who have sustained traumatic brain injury (TBI), suffer from post-traumatic stress disorder (PTSD), or have both a history of TBI and current PTSD. Mild TBI (mTBI) is considered the most common form of TBI. Uncertainty exists regarding the long-term health outcomes of mTBI as well as the validity of criteria used to assess for a history of this injury. Current evidence-based practices to screen, diagnose, prospectively evaluate, and treat mTBI symptoms or PTSD may be less accurate or effective when these conditions co-occur. Thus, there is a need to develop an evidence base to identify best practices to define, diagnose, evaluate, and manage patients with mTBI/PTSD, particularly in U.S. veterans of OEF/OIF.

The systematic literature review addressed the following key questions:

Determining Key Features of Effective Depression Interventions  (March 2009)

Current clinical guidelines for depression address depression treatment for patients detected in primary care and NICE guidelines. Research to date indicates that, under usual care conditions, less than half of primary care patients found to have major depression complete minimally adequate medications or psychotherapy. A variety of organizational changes aimed at improving care for depression in primary care have been tested. Yet evidence-based guidance for healthcare organizations and their primary care practices about which organizational changes are necessary for achieving improved depression outcomes is lacking. The purpose of this review is to establish a basis for organizational guidelines or best practices for achieving improved depression care.

The key questions addressed were:

Strategies for Suicide Prevention in Veterans  (January 2009)

Suicide is a devastating outcome of major public health importance. Suicide rates for patients abusing alcohol and other substances, or suffering from other mental health conditions may be elevated. Because suicide prevention is a priority of the Veterans Health Administration, the VA wishes to expand and enhance use of evidence-based prevention or reduction methods.

The key questions addressed were:

Management of Inpatient Hyperglycemia: A Systematic Review  (October 2008)

Hyperglycemia is a common finding in hospitalized patients and has been associated with worsened outcomes in a variety of inpatient subpopulations. The use of insulin to control blood glucose has been advocated as a way to improve health outcomes in hospitalized patients with hyperglycemia, but the evidence for the efficacy of this approach and the thresholds for initiating insulin management are unclear.

The key questions were:

Pain in Patients with Polytrauma: A Systematic Review  (September 2008)

Pain resulting from polytraumatic injuries poses numerous challenges during and after rehabilitation treatment. The objectives of this report are to systematically review the literature to address the assessment and management of pain in patients with polytraumatic injuries, to identify patient, clinician and systems factors associated with pain-related outcomes in these patients, and to describe current or planned research addressing the key questions in this report. The key questions were:

Assessment and Management of Acute Pain in Adult Medical Inpatients: A Systematic Review  (April 2008)

The prevalence of pain on the inpatient medical ward is lower than that of a surgical service, but is still substantial. A systematic review was conducted, including an integration of the existing literature on the delivery of effective pain care in the acute care setting, to inform the VA's National Pain Management Strategy and the VA's pain research agenda. The key questions addressed were:

Self-Monitoring of Blood Glucose in Patients with Type 2 Diabetes Mellitus: Meta Analysis of Effectiveness  (September 2007)

Diabetes is a prevalent and costly disease in Veterans. Control of blood glucose is an important VA objective. Self-monitoring of blood glucose (SMBG) is advocated as a method to better achieve control. The Key Questions investigated in this report were:

Racial and Ethnic Disparities in the VA Healthcare System  (June 2007)

Numerous studies have demonstrated racial and ethnic disparities in health care in the United States. These disparities have been demonstrated in the Veterans Affairs (VA) healthcare system, where financial barriers to receiving care are minimized. The VA is committed to delivering high-quality care in an equitable manner, and as such, to eliminating racial and ethnic disparities in health care. To inform this effort, the existing evidence on disparities within the VA was systematically reviewed, to address the following objectives:

Screening Men for Osteoporosis  (May 2007)

Although 25% of men over the age of 60 will sustain osteoporotic fractures during their lifetime, data suggest that male osteoporosis is underdiganosed and undertreated. In order to help inform decisions about whether the Veterans Health Administration should develop screening guidelines for male osteoporosis, the following Key Questions were analysed in this report:

Benign Prostatic Hyperplasia Management  (February 2007)

Benign prostatic hyperplasia (BPH) causes urinary hesitancy and intermittency, weak urine stream, nocturia, frequency, urgency, and the sensation of incomplete bladder emptying. These symptoms, collectively called "lower urinary tract symptoms," or LUTS, can significantly reduce quality of life. Depending upon the severity of sypmtoms, men may be managed without pharmacotherapy, or they may require medical treatments of drugs from two main classes. This Evidence Synthesis Report addresses the following questions about treatment for BPH: