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Publication Briefs

321 results for topic, "Mental Health"

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  • Caring Letters Not Associated with Suicide Attempts Following Veterans Crisis Line Contact, But Are Associated with Higher Probability of VA Mental Healthcare Use
    This study examined the effectiveness of the Veterans Crisis Line (VCL) Caring Letters intervention and determined whether there were differences in outcomes by signatory. Findings showed that Caring Letters were not associated with suicide attempts following VCL contact, but were associated with higher probability of VHA outpatient and inpatient mental healthcare use. There was no association among clinician vs. peer Veteran signatory and suicide attempts; VHA inpatient, outpatient, and emergency healthcare use; or all-cause mortality. Caring Letters may support access to care for high-risk Veterans who contact the VCL.
    Date: April 29, 2024
  • COVID-19 Infection Associated with More Depression Symptoms among Veterans at 18 months Post-Infection
    This study robustly matched COVID-19 infected patients with contemporaneous, uninfected controls to assess the effects of COVID-19 on depression symptoms. Findings showed that COVID-19 infection was associated with more depression symptoms among Veterans at 18 months post-infection, with a significantly higher prevalence of positive depression screening among Veterans with COVID compared to those without (49% vs 12%). COVID-19 infection was associated with significantly elevated psychological depression symptoms, but not physical depression symptoms. History of depression diagnosis did not appear to affect the risk of depression symptoms after COVID-19 infection. Primary care and Primary Care-Mental Health Integration providers may consider monitoring depression symptoms among Veterans after being infected with COVID-19 and should be aware that such symptoms may be present long after infection (up to 18 months post-infection).
    Date: April 16, 2024
  • Veterans with a Racial/Ethnic Minority Background, Rural Residence, or Mental Health Disability History Were Less Likely to Complete Preoperative Goals of Care Documentation
    This study assessed factors – including race, ethnicity, rurality, history of mental health disability, and VA facility type – that are known or hypothesized to be linked with disparities in preoperative life-sustaining treatment (LST) documentation. The study also described the COVID-19 pandemic’s effect on completion of preoperative LST. Findings showed that Veterans with a racial or ethnic minority background, rural residence, mental health disability history, or who were seen at low-complexity, low-volume facilities were significantly less likely to complete preoperative LST compared to Veterans who were white or non-Hispanic, urban residents, without a mental health disability history, or who had access to a high-complexity, high-volume facility. Of the 229,737 Veterans in the cohort, 13,408 (6%) completed preoperative LST documentation within 30 days prior to surgery. With each passing year, Veterans undergoing surgical procedures had greater likelihoods of completing LST before surgery, including during the COVID-19 pandemic. Findings suggest there is continued need for interventions that target Veteran groups at risk of not engaging in serious illness communication.
    Date: December 19, 2023
  • Despite Equal Access and Use of VA Care, Black Veterans are More Likely to Experience Postpartum Rehospitalization and Low-Birthweight Infants
    This study sought to determine whether Black/white racial disparities in access, use, and outcomes are present among pregnant and postpartum Veterans and their infants using VA maternity care. Findings showed no statistically significant racial disparities in access or use of care during the perinatal period; nevertheless, Black Veterans were more likely than white Veterans to experience postpartum rehospitalization and to have a low-birthweight infant. After adjusting for age, rurality, and parity, Black Veterans were 67% more likely than white Veterans to have a postpartum rehospitalization and 67% more likely to have a low-birthweight infant. No other racial disparities in outcomes for birthing Veterans or their infants were detected. Approximately one-third of both Black and white Veterans reported needing mental healthcare during pregnancy. However, one in five Veterans were unable to access needed mental healthcare indicating there may be a persistent unmet need for perinatal mental healthcare. Study findings underscore the idea that access is necessary but not sufficient for ensuring health equity.
    Date: July 1, 2023
  • Rural-Urban Telemedicine Disparity among Veterans Worsens Following Onset of COVID-19 Pandemic
    This study examined changes over time in rural-urban differences in telemedicine use for primary care and mental health integration services among nearly 64 million primary care and 4 million mental health integration visits. Findings showed that the pandemic exacerbated the rural-urban telemedicine divide across VA, possibly because underlying causes of digital inequity were not addressed as initiatives to expand telemedicine use across VA were instituted. Prior to the pandemic, telemedicine use for primary care services was higher at rural VA healthcare systems than urban ones (34% vs. 29%). Following the onset of the pandemic, usage rates switched (55% vs. 60%). The rural-urban telemedicine gap was even larger post pandemic for mental health integration than for primary care services, with unadjusted analyses showing 76% rural vs. 84% urban telemedicine use. Future telemedicine research, implementation efforts, and policy must address rural-urban structural disparities (e.g., internet bandwidth) and possibly tailor technology to encourage telemedicine adoption among rural users at the patient, provider, and healthcare system level.
    Date: March 7, 2023
  • Male and Female Veterans Differ in Attitudes to Referral to VA Care after Calling the Veterans Crisis Line
    This study described Suicide Prevention Coordinator (SPC) referral outcomes for Veterans who contacted the Veterans Crisis Line (VCL) with active thoughts of suicide during calendar years 2018–2019. Reasons given for declining SPC referral suggest that concerns about or discomfort with VA care were a key concern, particularly among women Veterans. Women had a higher rate of declining SPC referrals than men (6% vs. 5%). Men who expressed negative sentiment toward VA appeared to express anger broadly at VA. In contrast, women who expressed negative experiences or views of VA were more likely than men to express frustrations with VA treatment. Compared with men, women who reported a negative experience with or perception of VA care had concerns regarding potentially losing access to their children, being “locked up,” or even fear of retaliation or judgement from VA staff if they pursued an SPC referral. Veterans who called the VCL and were rated as lower risk were more likely to decline referral to future care. This suggests that the VCL interaction itself may have been sufficient in managing the Veteran’s needs at the time – and it helped mitigate an immediate mental health crisis.
    Date: January 1, 2023
  • Mental Health Staffing Affects Probability of Suicide-Related Events among Veterans
    This study sought to measure the effect of staffing on suicide-related events (SRE). Findings showed that mental health (MH) staffing had a large causal effect on the probability of a suicide-related event. From 2014 to 2018, the per-pay period probability of an SRE among this study cohort was 0.05%. A 1% increase in mental health staffing led to a 1.6 percentage point reduction in SREs. This effect was concentrated in the most capacity-constrained facilities, suggesting that staffing increases would have the largest effect in those facilities. There was substantial geographic variation in MH staffing levels across the facilities in this study. For example, in 2018, average mental health provider staffing ranged from 5 standardized clinic days per pay period per 10,000 enrollees to 21 standardized clinic days. There was a similar variation in Veterans’ engagement with VA services. In 2018, the average engagement ranged from virtually no engagement (0%) to 46% by facility-pay period.
    Date: September 11, 2022
  • Differences between VA- and Community-Provided Behavioral Healthcare
    This retrospective cross-sectional study examined differences in the amount and type of behavioral healthcare delivered in VA and purchased in the community. Findings showed that more than 25% of Veterans receiving inpatient behavioral healthcare used VA-purchased community care, but severe behavioral conditions were treated more frequently in VA. Only 4% of Veterans received outpatient behavioral healthcare in the community, but they saw less highly-trained providers. There were more highly-trained specialists, namely psychiatrists/behavioral neurologists (22% vs. 10%) and psychologists (25% vs. 18%) treating Veterans in VA compared to those treating Veterans in the community. There also was a greater presence of social workers in VA than in community care (36% vs 15%). The top two services provided during VA outpatient visits were group psychotherapy (14%) and individual psychotherapy (9%). The top two services provided in community care were individual psychotherapy (47%) and methadone administration (15%).
    Date: August 30, 2022
  • VA Outperforms Wait Times Compared to Community Care
    This study sought to describe geographic variation in wait times experienced by Veterans for three categories of care: primary care, mental health, and other specialties, comparing differences between VA-provided and community-provided care. Findings showed that mean VISN-level wait times were shorter for VA than for community care: 29 vs 39 days for primary care, 34 vs 44 days for mental health, and 35 vs 42 days for all other specialties. A sizeable proportion of Veterans experienced wait times that exceeded the VA standard (20 days or less): 44% of VA appointments and 50% of community care appointments. There was substantial geographic variation in appointment wait times. For example, the mean wait time for a mental health appointment in VISN 1 was 33 days for community care and 31 days for VA care, while the wait times were 55 days and 42 days for VISN 6. Findings suggest that increased access to community care under the Choice and MISSION Acts may not result in lower wait times in many areas of the country.
    Date: August 25, 2022
  • Factors Associated with Refusal of Lung Cancer Screening When Offered by VA Physicians
    This study sought to determine how frequently patients decline lung cancer screening (LCS) when it is offered by a physician – and to define patient and facility-level factors associated with their decision. Findings showed that in this study cohort of more than 43,200 Veterans, approximately one-third declined lung cancer screening following a discussion with their physician. The physician and facility offering LCS accounted for 19% and 36% of the variation in declining LCS, respectively. Rates of declining LCS varied from 4% to 62% across VA facilities. Older Veterans or those with serious comorbidities (e.g., mental health or cardiovascular conditions) were more likely to decline LCS. Variation in declining LCS was accounted for more by the facility and physician than by patient factors, suggesting a need to improve the quality of physician-patient discussions about LCS to increase the patient-centeredness of care. Groups that have long experienced worse lung cancer care and outcomes, including Black and Hispanic individuals and those receiving full VA benefits due to poverty, were more likely to accept screening. This suggests that screening may be a pathway to improve long-standing disparities.
    Date: August 16, 2022
  • Pharmacogenomic Testing Reduced Prescribing of Medications with Predicted Drug-Gene Interaction among Veterans with Depression
    The Precision Medicine in Mental Health Care (PRIME Care) randomized clinical trial was designed to evaluate clinical outcomes related to pharmacogenomic (PGx) testing in routine clinical practice. Investigators compared treatment for major depressive disorder guided by PGx testing to usual care. Findings showed that the provision of PGx testing for drug-gene interactions reduced prescription of medications with predicted drug-gene interactions compared with usual care. The estimated risks for receiving an antidepressant with none, moderate, and substantial drug-gene interactions for the pharmacogenomic-guided group were 59%, 30%, and 11% compared to 26%, 55%, and 20% in the usual care group. Remission of symptoms reached a maximum difference of 17% among the PGx group vs 11% in the usual care group at 12 weeks – but was not significantly different at 24 weeks. There were no identified harms to patients related to the intervention.
    Date: July 12, 2022
  • Gulf-War Era Veterans with Depression and/or PTSD were More Likely to Receive Mental Healthcare if They were Enrolled in VA
    The aim of this study was to explore factors associated with treatment utilization for depression and PTSD. Findings showed that Veterans who used VA healthcare were significantly more likely to receive mental health treatment than those who did not. VA enrollment was associated with three- and five-times higher odds of being treated for depression or PTSD, respectively. VA enrollment was the strongest predictor of receiving mental health treatment, after controlling for all other variables. Higher reported income was associated with a higher likelihood of receiving treatment for both PTSD and depression. Increased enrollment in VA healthcare may result in more Veterans receiving mental health treatment for diagnoses that often go untreated, such as depression and PTSD. Expanding eligibility and retaining enrolled Veterans may aid in increasing Veterans’ contact with the VA healthcare system.
    Date: July 4, 2022
  • Characteristics of the Rise in Telehealth During COVID Pandemic
    This study sought to examine patient, provider, and site-level characteristics of any virtual and video-based care in primary care (PC). Findings showed that before the onset of COVID-19, only 14% of PC patients used any telehealth services, and only 0.3% used video-based care. However, during the first 12 months of COVID-19, 63% of patients used telehealth services, and 11% used video-based care. Veterans at community-based clinics had a higher percentage of any telehealth use (38%) compared to Veterans receiving primary care at the main medical facility (30%). Conversely, video use was lower among community-based PC patients (10%) compared to PC patients at the medical facility (13%). Social workers, nutritionists, and pharmacists had the highest percentage of telehealth use (54%, mostly telephone) compared to primary care providers (34%), whereas mental healthcare providers were more likely to provide video-based care (43%) compared to PC clinicians (15%). Among all age groups except the oldest (75+), women were more likely to use telehealth or video. Additional research is needed to identify which PC outpatient services are better suited for telephone (e.g., case management) vs video-based care (e.g., integrated mental health visits).
    Date: June 18, 2022
  • PTSD-Multimorbidity in Recently Discharged Veterans Predicts Poor Social Functioning, Increasing Risk for Suicidal Ideation
    A growing body of literature suggests that problems experienced by Veterans during their transition from military to civilian life confer significant risk for suicidal ideation (SI). One of these problems is PTSD, which, along with chronic pain and sleep disturbance, can increase risk for SI. Findings from this study showed that at approximately 15 months post-separation, almost 91% of Veterans with probable PTSD also reported sleep disturbance and/or chronic pain. Relative to Veterans with PTSD alone, sleep disturbance and chronic pain did not confer greater risk for SI. Relative to Veterans without probable PTSD, Veterans with all three conditions (PTSD-multimorbidity: PTSD, chronic pain, and sleep disturbance) experienced the poorest social functioning and had greater risk for suicidal ideation. The impact of PTSD-multimorbidity on risk for SI was partially explained by its negative effect on social functioning. Given the additional risk for suicidal ideation associated with poor social functioning, clinicians should be mindful to not only support Veterans’ efforts to seek social support, but also to monitor the quality of support received and integrate social functioning aims into treatment planning.
    Date: June 2, 2022
  • Study Shows High Economic Burden of PTSD
    This study sought to estimate the economic burden of PTSD in the U.S. civilian and military (i.e., military and Veterans) populations from a societal perspective. Findings showed that the economic burden of PTSD goes beyond direct healthcare costs and has been found to rival costs for other expensive mental health conditions. The total excess economic burden of PTSD in the US was estimated at $232 billion for 2018 ($19,630 per individual with PTSD). A larger proportion of total excess costs was attributed to the civilian population ($190 billion, or 82%) than the military/Veteran population ($43 billion, or 18%). However, excess costs per individual with PTSD are lower for the civilian population ($18,640) than the military/Veteran population ($25,684). In the military/Veteran population, excess burden was driven by disability ($18 billion) and direct healthcare ($10 billion) costs. In the military/Veteran population, the annual all-cause mortality rate for those with PTSD was estimated to be 80% higher than those without PTSD, resulting in estimated excess costs of $1 billion annually.
    Date: April 25, 2022
  • Receipt of Video Tablets among Rural Veterans Associated with Increased Use of Mental Health Care and Less Suicidal Behavior
    This study sought to evaluate the association between the escalated distribution of VA’s video-enabled tablets during the COVID-19 pandemic and rural Veterans’ mental health service use and suicide-related outcomes. Findings showed that receipt of a video tablet was associated with the increased use of mental healthcare via video and increased psychotherapy visits across all modalities. Tablets also were associated with an overall 20% reduction in the likelihood of an ED visit, a 36% reduction in the likelihood of a suicide-related ED visit, and a 22% reduction in the likelihood of suicide behavior. VA and other health systems should consider leveraging video-enabled tablets for improving access to mental healthcare via telehealth and for preventing suicides among rural residents.
    Date: April 6, 2022
  • Specialized Primary Care Homes Effective in Treatment of Patients with Serious Mental Illness
    This project studied the implementation and effectiveness of a primary care medical home specifically designed to improve the healthcare of Veterans with serious mental illness. SMI PACTs (Patient Aligned Care Teams) include a specialized, integrated team that can provide both primary and psychiatric care. Findings showed that a primary care medical home for Veterans with SMI can be safe and more effective than usual care, as well as feasible to implement. Compared with Veterans who received usual care, those who received the SMI PACT intervention had greater improvement in screenings, treatment quality, chronic illness care (e.g., goal setting, counseling), care experience (e.g., doctor-patient interaction, care coordination, access), psychotic symptoms, and mental health-related quality of life at 12 months. Investigators saw no signs of worsening of mental health status under the SMI PACT model of care. This care model can be effective and should be considered among the interventions for improving medical care in patient populations with serious mental illness.
    Date: April 5, 2022
  • Gap between Veterans Screening Positive for Depression and Receiving Timely Guideline-Concordant Treatment
    This study examined adherence to guidelines for follow-up and treatment among Veterans in primary care who newly screened positive for depression. Findings showed that only a minority of Veterans in this study received timely follow-up after screening positive for and being clinically identified as having depression. While 77% met guidelines for completing at least minimal treatment in 1 year, only 32% received timely clinical follow-up within 3 months of screening. Younger age and comorbid mental illness were significant predictors of higher quality depression care. For example, predicted probabilities for timely follow-up among VA patients with and without PTSD were 38% and 24%, respectively, and 85% and 72% for treatment.
    Date: March 10, 2022
  • For High-Risk Veterans, Fragmented Care from Multiple Providers Does Not Increase Risk of Hospitalization and May Lower Hospitalization for Ambulatory Care-Sensitive Conditions
    This longitudinal study sought to examine outpatient care fragmentation and its association with future hospitalization among Veterans at high risk for hospitalization. Findings showed that among this cohort, fragmented outpatient care did not increase Veterans’ likelihood of future admission and, in fact, was associated with a lower likelihood of hospitalization for ambulatory care-sensitive conditions. Veterans with greater medical complexity and mental healthcare use experienced more outpatient care fragmentation, but the association between this fragmentation and all-cause hospitalization was close to zero after adjusting for clinical and sociodemographic factors. Findings suggest that dispersed care might not be problematic for patients with high levels of need, especially when they receive care within an integrated healthcare system, such as VA.
    Date: February 18, 2022
  • Impact of COVID-19 Pandemic on Healthcare Workers and First Responders
    This study examined the relationships between COVID-19 related occupational stressors, psychiatric symptoms, and occupational outcomes (likelihood of leaving current field and occupational functioning). Findings showed high levels of psychiatric symptoms and distress in healthcare workers during the COVID-19 pandemic. Half of the healthcare workers in this study – and 59% of all nurses – indicated a decreased likelihood of staying in their current occupation due to the pandemic. Nurses and emergency medical service workers reported the greatest burdens: more than 40% had PTSD symptoms and more than 80% had depression symptoms. Among all respondents, more than one-third (38%) had PTSD symptoms, and nearly three-quarters had depression (74%) and anxiety (75%) symptoms. More than 15% of participants reported thoughts of suicide or self-harm in the preceding two weeks. More than 18% of respondents reported trouble completing work-related tasks. The volume of critically ill patients, risk of COVID-19 exposure, and factors promoting demoralization were associated with psychiatric distress. Distress was associated with increased odds of planning to leave the profession. Demoralizing factors (e.g., feeling unsupported by one’s workplace, being asked to take unnecessary risks) were most strongly associated with distress. Healthcare staffing shortages are in and of themselves a COVID-19 stressor, so turnover could exponentially worsen HCW’s wellbeing and professional retention.
    Date: December 16, 2021
  • Significant Number of Veterans with Depression May Not Be Receiving their Preferred Treatment
    This study examined whether treatment preferences predict types of depression treatment received and adherence to those treatments. Findings showed that mismatches between treatment preferences and type received were common and associated with worse treatment adherence for psychotherapy: 32% of VA patients who preferred medication and 22% of VA patients who preferred psychotherapy did not receive those treatments. More patients reported strong positive preferences for psychotherapy compared to medication (51% vs 37%) and strong negative preferences for medication compared to psychotherapy (16% vs 2%). Patients did not prefer (25%) or adhere (18%) to combined psychotherapy/medication treatment. Patients in primary care settings without full-time embedded mental health staff had lower odds of receiving (but not adhering to) psychotherapy than patients in specialty mental healthcare settings. Future work should continue to explore where and for whom patient preferences are not being met when doing so is not clinically contraindicated – and how the match between preferences and treatments received can be increased in the service of improving treatment adherence and outcomes.
    Date: October 6, 2021
  • High Acute Inpatient Psychiatric Bed Occupancy Associated with Increased Rates of Suicide among Veterans
    This study examined the relationship between the incidence of suicide among Veterans and acute inpatient psychiatric bed availability using occupancy as a measure of hospital strain and access. Findings showed that high acute VA psychiatric bed occupancy (>95%), not beds per capita, was associated with a 10% higher incidence of death by suicide. Extrapolated over the 6-year study across 145 hospital quarters with occupancy >95%, this hospital strain contributed to an estimated excess of 64.5 suicides. The absolute number of acute VA inpatient psychiatric beds decreased by 13% from 4,419 in 2011 to 3,860 in 2016, while mean occupancy decreased from 68% to 65% over the same time period; the number of deaths by suicide increased from 2,193 in 2011 to 2,464 in 2016. The VA national average of 65.5 acute psychiatric beds per 100,000 Veterans was three times the US national average of 22/100,000 in 2016. Changes in VA acute psychiatric beds, non-VA (i.e., community) psychiatric beds, spending on community mental health per capita, and the proportion of Veterans with a mental health diagnosis were not associated with the incidence of suicide among Veterans enrolled in VA care. Measuring hospital occupancy and establishing occupancy benchmarks should be included in patient safety reports as psychiatric bed overcrowding joins overall hospital, emergency department, and intensive care unit occupancy as a risk for higher mortality.
    Date: August 16, 2021
  • Fewer than Two-Thirds of Veterans Receive Timely Lung Cancer Screening Follow-Up
    This retrospective cohort study sought to determine adherence to recommended next steps (i.e., annual screening or evaluation of screen-detected findings) in a national cohort of Veterans screened for lung cancer – and to identify factors associated with delayed or absent follow-up. Findings showed that less than two-thirds of Veterans received timely recommended follow-up after an initial lung cancer screening, with higher risk of delayed or absent follow-up among marginalized populations that have long experienced disparities in lung cancer outcomes. Of the 28,294 Veterans in this study, 63% underwent recommended follow-up, while 29% received delayed (13%) or no (16%) follow-up. Veterans with higher-risk findings and those in high-volume or academic centers were more likely to receive timely follow-up. Black Veterans, Veterans with mental health disorders or lower income were more likely to have delayed or absent follow-up.
    Date: July 8, 2021
  • Primary Care Intensive Management for High-Risk VA Patients Did Not Improve Long-term (12-24 Month) Outcomes or Costs
    This randomized trial tested whether primary care intensive management (PIM) teams could decrease acute care use, such as emergency department visits and hospitalizations, among high-risk Veterans during the second year of PIM implementation. Findings showed that offering an intensive case management program in addition to routine primary care services for high-risk patients increased outpatient use (e.g., primary care, mental health, home visits, case management, telehealth) during the 2nd year of implementation. But it did not significantly decrease inpatient use or healthcare costs, even when taking VA-covered community care costs into account. There were also no significant differences in VA healthcare use or costs for Veterans older than 65 years old or Veterans who were more frail and functionally impaired. Findings suggest approaches targeting VA patients based solely on high risk of hospitalization are unlikely to reduce acute care use or total costs beyond that provided by a well-functioning patient-centered medical home with additional support services.
    Date: June 18, 2021
  • Both “High-Needs” Patients and Facility Leaders Praise VA’s Intensive Primary Care Pilot Program
    This qualitative evaluation explored the perspectives of patients and healthcare facility leaders to identify additional important outcomes that could augment utilization and cost studies of intensive primary care (IPC) programs for high-needs patients. Findings indicated that IPC programs may yield benefits beyond healthcare cost and use, including improved quality of care, patient satisfaction, quality of life, and patient health behaviors. Patients perceived improvements in their experience of VA care, including improved patient-provider relationships and access to their healthcare team. Patients frequently reported feeling a sense of connection with their IPC team because they could rely on them for support with health and non-health-related issues. Primary care leaders also observed greater proactive patient engagement with the IPC team, increased motivation for health behavior change and self-care, and improvements in patient health behaviors, physical and mental health, and social needs. Despite benefits, patients and providers noted how some patient health characteristics (e.g., chronic health conditions) and contextual factors (e.g., housing insecurity) may have limited the effectiveness of the program on healthcare costs and utilization.
    Date: May 13, 2021
  • Food Insecurity in Veterans is Associated with Increased Depression Symptoms and Suicidal Ideation
    This study sought to investigate the association between food insecurity and suicidal ideation. Findings showed that food insecurity in Veterans was associated with increased depression symptoms and suicidal ideation. The odds for suicidal ideation among Veterans with very low food security – the most severe level of food insecurity – increased by nearly four-fold compared to those who were food secure. Adjusted results show that Veterans with marginal, low, or very low food security had statistically significant increased depression screening scores compared to Veterans who had full food security. Veterans with low or very low food security had statistically significant increased odds for suicidal ideation compared to Veterans with full food security. Food insecurity affected 12% of the Veterans surveyed and 4% of Veterans endorsed suicidal ideation. Given this evidence supporting the relationship between food insecurity and depression, organizations serving Veterans should integrate prevention, mitigation and treatment efforts for food insecurity, depression, and suicidal ideation.
    Date: March 26, 2021
  • Some Combat Experiences May Increase Risk of Attempting Suicide among Service Members
    This study sought to determine the association of combat exposure with suicide attempts among active-duty US service members who were deployed in Iraq and Afghanistan. Findings showed that when defined broadly, combat was not associated with suicide attempts after adjusting for demographic and military-specific factors. High combat severity was associated with an increased risk for suicide attempts, although this association was partly mediated by mental health disorders, specifically PTSD. Some individual combat experiences were associated with suicide attempts, but these associations were largely accounted for by mental disorders. Exceptions included being attacked or ambushed, seeing dead bodies or human remains, and being directly responsible for the death of a non-combatant, which showed significant associations with suicide attempts even after adjustment for mental disorders. Results suggest that certain types of combat experiences may have different implications for service members compared to other combat experiences, increasing individuals’ risk of attempting suicide.
    Date: February 2, 2021
  • Suicide Prevention for Women Veterans
    The articles in this supplement highlight the value of a wide range of data sources, from the macro-level surveillance data available through the DoD, VA, and the US National Violent Death Reporting System to the depth of qualitative data of individual experiences with suicide attempts. They also illustrate the complexities of studying gender and suicide, while generating a new understanding of important areas for suicide prevention among women. Articles included suggest that younger age, mental health concerns, experiencing violence, and medical comorbidities may all contribute to suicide risk among women.
    Date: February 1, 2021
  • Veterans Open to Discussing Firearms Storage Safety in Primary Care Setting
    This quality improvement project – part of a larger study to develop a training program on firearms storage safety (FSS) for VA primary care teams – describes Veterans’ perspectives on discussing FSS during primary care visits. Most Veterans in the study agreed that primary care is an acceptable setting for FSS discussions, but staff need to build rapport and trust by using a personal, caring, and non-judgmental approach. Veterans noted concerns about the legal consequences of disclosing firearm ownership and most did not support direct questioning about this, e.g., “Do you own a firearm?,” which may trigger fears of having firearms being taken away or limitations being placed on access to firearms. Veterans also noted the need to provide a clear reason for why a discussion on FSS was happening, such as promoting mental health or concern for household safety and wellbeing. Discussing FSS with Veterans in primary care settings is a promising upstream approach that can complement other suicide prevention efforts but must be conducted in a Veteran-centric manner.
    Date: January 26, 2021
  • VA Mental Health Use During Pregnancy/Postpartum Periods Remained Strong among Women with Prepregnancy Depression, PTSD, and Anxiety Diagnoses
    This study examined how prepregnancy psychiatric diagnoses could impact mental health treatment use during pregnancy and postpartum, given there is increased risk of symptom recurrence and/or medication discontinuation during pregnancy. Findings showed that there was a strong correlation between a prepregnancy diagnosis of major depressive disorder (MDD), PTSD, or anxiety and use of mental healthcare during pregnancy and the postpartum period. For women with these pre-pregnancy diagnoses, there was an increase in the use of psychotherapy during pregnancy and postpartum, while the percentage of women using antidepressants only or antidepressants plus therapy decreased during the same time periods; 42% of women reported stopping their antidepressants at the onset of the pregnancy.
    Date: November 18, 2020
  • VA’s Primary Care-Mental Health Integration Affects Access Differently for Women and Men Veterans
    This study of 5.4 million Veterans (including 448,455 women), who received care at one of 396 VA primary care clinics between FY2013 and FY2016, set out to answer the following question: Did VA’s national Primary Care-Mental Health Integration (PC-MHI) initiative improve access to care equally among men and women Veterans? Findings showed that PC-MHI was associated with greater use of all outpatient services among men but with lower use of services (except primary care visits) among women. Both men and women had more primary care visits (+22% and +40%, respectively) and total costs over time, but women had 74% fewer hospitalizations (versus +2% in men) related to mental health integration. Each percentage point increase in the proportion of Veterans who saw an integrated specialist was associated with 38% fewer mental health visits per year for women, but 39% more visits for men. Women Veterans had twice the rates of depression and anxiety and used more mental health and primary care services than men. Also, women Veterans were more likely than men to receive care in hospital-based (vs. community-based) clinics, where average PC-MHI penetration rates are higher and where women-only treatment settings are more commonly located.
    Date: October 20, 2020
  • Use of Community Outpatient Providers During the Choice Program was Associated with Less Attrition from VA Care
    This study examined the characteristics of patients and practices that used Choice outpatient care in the first year of implementation – and whether using Choice outpatient care was associated with attrition from VA primary care over a two-year period. Findings showed that overall, the attrition rate from VA primary care was low (4.4%), and Veterans who used Choice outpatient care were less likely to leave VA primary care than VA-only users. Compared to Veterans who used only VA outpatient care, those using Choice care were more likely to be female, white, or Hispanic, to live in the Continental or Pacific region, to have a higher service-connected disability rating, to have longer driving distances to all VA care, to not have a mental health condition, and to have greater primary care and total healthcare costs at baseline. Practices that sent more patients out for Choice care had lower mean scores for patient-centered medical home implementation, especially regarding access, and longer mean waiting times for appointments. Findings suggest that the use of community care more often supplements rather than replaces VA primary care, especially for practices that experience more difficulty in providing timely patient-centered primary care.
    Date: September 10, 2020
  • Better Patient Experience for Outpatient Care Delivered by VA vs Community Care on Every Measure but Access
    This study examined trends in Veterans’ experiences with outpatient community care (CC) compared with those in VA during the second and third years after Choice Act implementation. Findings showed that patient experiences were better for VA than community care in all respects except access. For specialty care, access scores were better in the community; and for primary and mental healthcare, access scores were similar in the two settings. There were significant differences in sociodemographic characteristics between VA and CC respondents across all types of outpatient care. Overall, VA respondents were older; had better perceived physical health status and mental health; had different distributions by race and ethnicity (i.e., higher portion of African American respondents); had lower education levels; lived in more urban areas; and were more likely to be insured. As purchased care further expands under the MISSION Act, the monitoring of meaningful differences between healthcare settings should continue, with the results used to inform both VA purchasing decisions and patients’ care choices.
    Date: August 1, 2020
  • Majority of High-Risk Veterans Assigned to General Primary Care Rather than Specialized Primary Care
    This study sought to characterize patterns of care for the top 5% highest-risk patients enrolled in VA healthcare nationally (based on Care Assessment Needs – CAN – score). Findings showed that most high-risk Veterans (88%) were cared for in general primary care rather than in specialized primary care; the remaining 12% were assigned to specialized primary care (i.e., women’s health, geriatrics, home-based primary care, homeless primary care). High-risk Veterans assigned to general primary care had more mental health and primary care visits than medical specialty care visits. Compared to low-risk patients, high-risk patients had 2.5 times the face-to-face, 4 times the telephone, and twice the number of secure messaging encounters in primary care during the year prior to being identified as being high risk for hospitalization. Approaches to support high-risk patients will likely need to be embedded within general primary care and mental healthcare if they are to improve outcomes for this population. This may be more beneficial than carve-out specialized or intensive primary care programs.
    Date: June 29, 2020
  • Both PTSD Symptoms and Moral Injury are Associated with Adverse Perinatal Outcomes among Women Veterans
    This longitudinal study is the first to examine the impact of PTSD symptoms and moral injury on adverse perinatal outcomes among women who became pregnant in the first three years after separating from military service. Findings showed that after adjusting for age, racial/ethnic minority status, socioeconomic status, and lifetime trauma, both PTSD symptoms and moral injury were associated with adverse perinatal outcomes. Only women with greater PTSD symptoms were more likely to report having postpartum depression/anxiety, and to describe their pregnancy as being more difficult. The new VA/DoD clinical practice guidelines on pregnancy management published in March 2018 incorporate the importance of screening for mental health conditions regularly during pregnancy, as well as the coordination of care between medical and mental health providers to prevent adverse perinatal outcomes. These findings specifically support increased screening for PTSD and moral injury, in order to increase access to treatment for these problems as warranted.
    Date: June 1, 2020
  • Use and Predictors of Healthcare among New Post-9/11 Veterans with Mental Health Conditions
    This study sought to identify the healthcare programs and services that new post-9/11 Veterans who screened positive for mental health problems used – and any factors that predicted that use within the first 90 days of military separation. Findings showed that Veterans from the most junior enlisted ranks were the least likely to access healthcare programs and services, whereas few differences emerged by gender or racial/ethnic minority status. Nearly half of Veterans in the sample (47%) used VA for their healthcare, while 19% sought services from non-VA providers. Veterans exposed to combat, those with a medical discharge, and those with a chronic medical or mental health problem were all more likely to report using VA healthcare services. Findings suggest that Veterans, particularly those from the junior enlisted ranks who are most at risk for poor transitions, should be encouraged to use programs and services provided by both VA and non-VA healthcare alternatives.
    Date: May 12, 2020
  • Positive IPV Screen Significantly Associated with Health Outcomes and Healthcare Use among Women Veterans Over 45
    This study examined the proportion of women older than childbearing age who screen positive when routinely screened for past-year intimate partner violence (IPV) at VA clinics, as well as associations of a positive screen with health conditions and use of healthcare services. Findings showed that of the study cohort, 255 middle-aged (45-59 years; 9%) and 79 older (60 years and older, 5%) women screened positive for past-year IPV. A positive screen was significantly associated with negative mental and physical health outcomes, as well as increased use of healthcare services. Those screening IPV+ in both the middle-aged and older groups were more likely than those screening IPV- to be diagnosed with each category of mental health condition (i.e., anxiety, PTSD, depression). Middle-aged women screening positive had more than twice the odds of having a diagnosis of depression, anxiety, PTSD, and substance use, and four times the odds of suicidal behaviors or self-harm, while older women screening positive had more than three times the odds of having a depression diagnosis. Middle-aged women screening IPV+ had more than double the rate of psychosocial visits in the subsequent 20 months, and older women had a near doubling. Middle-aged women who screened IPV+ also had increased rates of primary care and ED visits, as well as higher odds of having any inpatient admission. These associations were not seen for the older women. Screening for IPV in middle-aged and older women may improve detection and service delivery in this underserved population.
    Date: April 21, 2020
  • Patient Satisfaction with VA Virtual Care Delivered by Video-Enabled Tablet
    In 2016, VA’s Offices of Rural Health and Connected Care developed a pilot initiative to distribute video-enabled tablets to Veterans who did not have the necessary technology and who had a geographic, clinical, or social barrier to in-person healthcare. During this pilot, 5,000 tablets were distributed to 6,745 patients at 86 VA facilities, with approximately half of the tablet recipients living in rural areas. To help inform optimal tablet distribution and technical support, investigators evaluated patient experiences with tablets through baseline and follow-up surveys. Many recipients of VA-issued tablets reported that video care is equivalent to or preferred to in-person care. Among follow-up survey respondents, 32% of tablet recipients indicated that they would prefer to conduct their future VA appointments by video; 32% indicated they would prefer these visits in person; and 36% indicated their preference was “about the same.” The most common barriers to in person care were travel time (66%), travel cost (55%), health conditions (54%), bad weather (57%), and feeling uncomfortable or uneasy at VA (33%). Between baseline and follow-up surveys, there were statistically significant increases in patient satisfaction regarding overall VA care, as well as primary care and mental healthcare. Satisfaction regarding technology and technical assistance also was high: 86% agreed or strongly agreed with statements regarding the ease of using the equipment, receiving help needed to learn the technology (84%), and that it was easy to ask questions (88%) and understand instructions (87%). Strong satisfaction ratings for tablets and the fact that characteristics such as age, health literacy, and prior technology use were not significantly associated with tablet preference suggest that engagement in video-based care is possible for many types of patients, including those often considered part of the “digital divide.”
    Date: April 15, 2020
  • New Measure Shows VA Fulfilled Veterans’ Timely Care Requests 86% of the Time Across Three Years
    This study sought to leverage VA’s data infrastructure to generate an objective measure of the fulfillment of timely care requests, which could be tracked over time at multiple levels and adjusted for demographic, clinical, and geographic factors. Across 160 VA primary care clinics, requests for timely care were fulfilled 86% of the time. Of all timely care requests, 98% were fulfilled by VA, with 61-68% in primary care, followed by 26-31% in other VA clinics, and 3% in mental health clinics. Less than 1% of requests were fulfilled with secure messaging. Between 2014 and 2017, 32% to 39% of VA primary care patients requested timely care, with the number of patients making timely care requests increasing by 24%. The patient population requesting timely care was younger and more likely to be female, black, and living in urban settings. An estimated 12% of timely care requests were not fulfilled, and such delays may drive patients outside VA. Using this timely care measure may assist in identifying reasons underlying access variability – and inform strategies to bring greater consistency of timely care across clinics.
    Date: April 1, 2020
  • Among Veterans Who Experience Homelessness, Non-fatal Overdose is a Relatively Common Problem
    Overdose is one of the most common causes of death for younger homeless individuals, but the prevalence of non-fatal overdose among the homeless is unknown. Investigators in this study administered a survey to Veterans who had experienced homelessness (current or past) and received primary care at one of 26 VA medical centers across the nation asking if they had experienced an overdose within the past three years that required an ED visit or immediate medical care (and the substances involved in the overdose) – and/or if they had witnessed someone else experience an overdose during the same time period. Findings showed that 7% reported an overdose in the previous three years. Those who reported an overdose were nearly three times as likely to have witnessed an overdose. Compared to Veterans without overdose, those reporting an overdose were younger, more likely to be white, more likely to be homeless at the time of the survey, more likely to be taking medication for mental health issues, had greater psychological distress, and were more likely to report an alcohol or drug problem. Alcohol was the most common substance reported with overdose, nearly as common as all drugs combined and more than twice as common as opioids. Improving access to addiction treatment for homeless and recently-housed Veterans, especially for those who have experienced or witnessed overdose, could protect this population. Also, given the prevalence of high emotional distress in persons who experienced overdose, enhanced mental health services could mitigate some risk for individuals residing on the streets, in shelters, or newly in housing.
    Date: March 17, 2020
  • Veterans Reveal Positive Aspects of Routine VA Pain Screening
    Using data from a study that evaluated a strategy to improve the use of the “5th Vital Sign” of pain in primary care, investigators identified 36 Veterans from five primary care clinics and three VA healthcare systems who were interviewed about pain screening. Generally, Veterans believed that routine pain screening is positive. Findings revealed five themes that summarize Veterans’ experience and preferences of being screened for pain: 1) Pain screening can determine the tone and guide the focus of the visit; 2) Screening can initiate communication about pain, which is important because some Veterans feel that discussing pain indicates weakness; 3) Screening can facilitate patient recall and reflection, allowing the patient to bring up symptoms that may have been overlooked in the past or would have gone unmentioned; 4) Screening can help identify under-reported psychological pain, mental distress, and suicidality that might not come up without provider probing; and 5) Screening allows patients to offer recommendations to improve screening for pain; e.g., Veterans emphasized that screening language and specific word choices matter. Results indicate that Veterans perceive meaningful, positive impacts of routine pain screening, specifically, routine screening for pain may help capture mental health concerns that may otherwise not emerge
    Date: March 6, 2020
  • Veterans at Higher Risk of Overdose/Suicide Death After Stopping Opioid Treatment; Increasing Risk with Duration on Opioids
    This study examined the associations between stopping outpatient opioid treatment, length of opioid treatment, and overdose/suicide death among VA patients. Findings showed that Veterans were at a higher risk of overdose/suicide death after stopping opioid treatment, with increasing risk the longer they had been treated before stopping. Even patients treated for up to 30 days had a rise in risk of death after treatment was stopped. Factors independently associated with a higher risk for overdose/suicide death included: receiving prescriptions for long-acting or short-acting opioids compared to tramadol; maximum daily morphine milligram equivalents; number of medical diagnoses; and having a mental health disorder diagnosis or substance use disorder diagnosis. Older age, female gender, and being currently married were independently associated with a lower risk for overdose/suicide death. Risk of death from overdose or suicide was increased for 3 months after starting or stopping treatment with opioids, highlighting these vulnerable risk periods.
    Date: March 4, 2020
  • Computer-Based Cognitive Behavioral Therapy with Peer Support Provides Greater Improvement of Depression Symptoms
    This trial sought to determine whether computer-based cognitive behavioral therapy (cCBT) combined with peer support improved outcomes relative to enhanced usual care (EUC) for 330 primary care patients with depression who were treated at three Midwestern VA medical centers and two of their associated outpatient clinics. Findings showed that peer-supported cCBT as an add-on to usual primary care treatment for depression was associated with greater improvements in depression symptoms, quality of life, and mental health recovery at three months compared to enhanced usual care alone. Improvements in mental health recovery, although not the other outcomes, were sustained up to six months. Remission rates were 14% for Veterans in the peer-supported cCBT group and 6% for Veterans in the EUC group at three months, and 22% and 11%, respectively, at six months. The more modest benefits found with peer-supported cCBT should be considered in the context that more than 50% of Veterans also received antidepressant medication with high levels of adherence and over 30% received some in-person psychotherapy. Computerized CBT with peer support should be considered for implementation and evaluation in primary care, and adaptations to the computer CBT and peer support components should be considered to further improve effectiveness.
    Date: March 1, 2020
  • Rates of Mental Health Diagnoses are Higher among Veterans with Obesity
    The objective of this study was to examine rates of mental health diagnoses among a national cohort of women and men VA primary care patients with and without obesity. Findings showed that rates of any mental health diagnosis were higher among women than men and people with versus without obesity. Depression and PTSD diagnosis rates were higher for women and men with versus without obesity. For example, there was a 25% higher PTSD diagnosis rate among men with obesity versus without. Women with obesity had higher rates of psychotic disorder diagnoses than women without obesity; this was not found for men. Substance use disorder diagnosis rates were lower for women and men with versus without obesity. Anxiety diagnosis rates were slightly lower among women with versus without obesity; this was not found for men. A sizable proportion of women (46%) and men (62%) with obesity had no mental health diagnoses. Results provide further support for the finding that many Veterans have concurrent obesity and mental health diagnoses. Integrated treatments addressing obesity and mental health could benefit patients, providers, and the healthcare system by meeting patients’ physical and mental health needs in less time than separate treatments.
    Date: January 30, 2020
  • VA Healthcare Benefits May Reduce Racial/Ethnic Disparities in Seeking Mental Health Treatment among Veterans
    This study assessed whether racial/ethnic disparities in mental health treatment seeking for psychiatric conditions common in the Veteran population (PTSD, major depressive disorder, alcohol-use disorder or AUD) were attenuated for military Veterans compared to civilians, and whether attenuation was more pronounced among Veterans who had VA healthcare coverage in the past 12 months. Findings showed that unlike civilians, racial/ethnic minority Veterans did not differ from whites in time to initiate treatment for PTSD and depression, and showed a shorter time to initiate treatment for AUD. Racial/ethnic minority Veterans with past year VA healthcare coverage were the most likely to seek treatment for all three disorders, whereas racial/ethnic minority civilians were the least likely to seek treatment for all three disorders. Among racial/ethnic minority patients, shortened time to treatment initiation for Veterans relative to civilians remained significant after adjusting for additional demographic and clinical covariates for PTSD and major depressive disorder, but not alcohol use disorder. Findings suggest that military service and benefits available to Veterans may reduce racial/ethnic disparities in seeking mental health treatment seen in the civilian population.
    Date: January 27, 2020
  • Veterans Participating in a VA National Telehealth Tablet Initiative Save Both Time and Money
    In 2016, VA initiated a program to distribute video-enabled tablets to Veterans with geographic, clinical, and/or social access barriers to in-person care so that they could receive services in their homes or other convenient locations. As part of a national evaluation of this initiative, a patient experience survey was conducted with a subset of tablet recipients. Investigators in this study sought to determine patient-reported monetary and time savings, as well as characteristics associated with those savings. Findings showed that 92% of respondents reported that the tablets saved them money or time; 89% reported saving money, and 71% reported saving time. Among those who reported monetary savings, 41% reported saving $25-50 and 31% reported saving >$50 per appointment. Monetary savings were most pronounced among Veterans living a greater distance from VA or experiencing travel barriers and those without mental health conditions.
    Date: December 26, 2019
  • History of Military Sexual Trauma Common among Older Women Veterans
    This study sought to determine the prevalence of military sexual trauma (MST) among older women Veterans – and investigate associations between MST and medical and mental health diagnoses. Findings showed that a history of MST was common among older women Veterans. Positive MST screens were observed in nearly 1 in 5 women aged 55-64, and 1 in 10 aged 65-74. [This is similar to the 23% prevalence found in previous studies in women younger than age 55. Accounting for demographic risk factors, MST was associated with increased odds of a range of medical and mental health diagnoses. Most notably, MST was associated with 7.25 times the odds of PTSD and over two-fold odds of depression and suicidal ideation, as well as increased odds of anxiety, alcohol use disorder, substance use disorder, opioid use disorder, sleep disorders, and chronic pain. Thus, older women Veterans remain at risk for the effects of potentially remote MST. Findings call attention to the need for additional research in this understudied population, and the importance of trauma-informed care approaches for women across the lifespan.
    Date: November 11, 2019
  • Special Medical Care Supplement Features VA/HSR&D Research on Evidence Synthesis in a Learning Healthcare System
    Titled “Evidence Synthesis in a Learning Health Care System,” this Medical Care supplement includes 14 original articles that present new insights and perspectives from HSR&D’s Evidence Synthesis Program (ESP). Articles discuss optimal evidence synthesis methods and applications in a learning healthcare system; some articles target the effect in one area (i.e., mental health, primary care), while others discuss a broader, system-wide effect. As the editors note, “The articles in this series demonstrate what can be accomplished when research synthesis is integrated with qualitative information from health system personnel and patients and quantitative data from health systems in the context of an overarching framework for health system learning."
    Date: October 1, 2019
  • Video Telehealth Tablet Initiative Improves Access to and Continuity of Mental Healthcare for Veterans
    In 2016, VA initiated a program to distribute video-enabled tablets to Veterans with geographic, clinical, or social access barriers to in-person care so that they could receive services in their homes or other convenient locations: 75% of tablet recipients had a mental health diagnosis, providing a unique opportunity to assess the effectiveness of this national dissemination of tablets. Findings showed that distributing the tablets to Veterans with mental health conditions appeared to improve access to and continuity of mental health services while also improving clinical efficiency. Compared to the control group, tablet recipients experienced an increase of 1.9 psychotherapy encounters; an increase of 1.1 medication management visits; a 19% increase in their likelihood of receiving recommended mental healthcare continuity; and a 20% decrease in their missed opportunity rate (i.e., missed appointments) six months post-tablet receipt.
    Date: August 5, 2019
  • Mental Health Integration in VA Primary Care Settings Increased Access to Care – and Costs
    This study examined the effect of the Primary Care-Mental Health Integration Program (PC-MHI) on healthcare use and cost patterns among 5.4 million primary care patients in 396 VA clinics (FY2014-FY2016), while also accounting for the implementation of VA’s Patient Aligned Care Team (PACT) model of care. Investigators assessed VA outpatient and inpatient care and total cost of VA care as a function of attending a clinic with a high vs. low PC-MHI penetration rate. Findings showed that Veterans treated in clinics with higher proportions of primary care patients seen by PC-MHI providers received more outpatient care than those treated in clinics with lower PC-MHI penetration, but at a higher total cost. Each percentage-point increase in the proportion of clinic patients seen by PC-MHI providers was associated with 11% more mental health and 40% more primary care visits, but also 9% higher average total costs per patient per year. Among patients with serious mental illness, increasing PC-MHI penetration was associated with greater use of specialty-based mental health and all other healthcare visits. Among patients seen in hospital-based clinics, increasing PC-MHI penetration was associated with fewer emergency visits per person per year.
    Date: August 1, 2019
  • Healthcare Processes Linked to Suicide Risk Following Discharge from VA Residential Substance Abuse
    This study examined 39 root-cause analysis (RCA) reports of suicide in Veterans occurring within three months of discharge from a residential drug treatment program that were reported to any one of 140 VA medical centers between 2001 and 2017. RCA is a well-known and robust approach to elucidating the contribution of systems and organizational processes to adverse events such as suicide after hospital discharge. Findings showed that most suicides occurred in close proximity to discharge from a treatment program, with 56% occurring within seven days of discharge and 36% occurring within 48 hours of discharge. The most common method of suicide was overdose (33%), followed by hanging (28%). Categories of root causes ranged from problems with suicide risk assessment to non-engagement in treatment. The largest number of root causes of suicide pertained to problems with risk assessment, breakdowns in communication, and problems with the discharge process. This was followed by problems with treatment of mental health disorders and non-engagement with treatment during the residential stay – and after discharge. Lack of patient engagement was related to willingness to participate in treatments that might mitigate suicide risk – and to involve family or loved ones in discharge planning. Efforts to prevent suicide after discharge from a treatment program should focus on addressing suicide risk factors during admission and helping patients engage more fully in SUD treatment.
    Date: June 28, 2019
  • Veterans with PTSD and/or Depression More Likely to Participate in Cardiac Rehabilitation than Veterans without These Disorders
    This study sought to determine whether Veterans with depression and/or PTSD were more or less likely than those without depression or PTSD to participate in cardiac rehabilitation (CR) programs following hospitalization for heart attack or coronary revascularization. Findings showed that Veterans with PTSD and/or depression were more likely to participate in CR than Veterans without these mental health disorders. Between 2010 and 2014, cardiac rehabilitation participation rates were consistently higher in patients with PTSD or depression (9-12%) than in those without either condition (7-11%). Investigators found that in comparison to Veterans without PTSD or depression, the odds of participation in CR were 24% greater in patients with depression alone, 38% greater in patients with PTSD alone, and 57% greater in patients with both PTSD and depression. Investigators were not able to determine why patients with mental disorders were more likely to participate in cardiac rehabilitation. Overall participation in cardiac rehabilitation is low in patients with coronary heart disease, but the presence of PTSD or depression does not reduce participation further.
    Date: June 4, 2019
  • Intervention Helps Identify Specialty Mental Health Patients Ready for Transition to Primary Care
    This pilot project tested the implementation of electronic medical record (EMR)-based criteria to identify Veterans currently receiving treatment in the specialty mental health (MH) setting who might be considered for transition to primary care. The intervention, called FLOW (not an acronym), espouses a process of shared decision-making in which MH providers, patients, and, ideally, primary care (PC) providers collaboratively determine whether primary care is the most appropriate setting for ongoing treatment once a patient has recovered or stabilized from his/her MH treatment. Findings showed that FLOW combined with sound clinical practices can be used to identify mental health patients who are candidates for primary care and foster their effective transition. During the 12-month pilot study, 424 Veterans with mental illness transitioned from MH to PC; of those patients only 9 (2%) returned to MH care after the transition. VA’s Office of Mental Health is supporting development of a national version of the online MH-FLOW report and the FLOW development team is developing a national implementation plan based on knowledge gained from this pilot.
    Date: March 14, 2019
  • Post 9/11 Veterans Less Likely to Delay Mental Health Treatment
    This study compared delay of treatment for PTSD, major depressive disorder (MDD), and/or alcohol-use disorder (AUD) among post-9/11 Veterans relative to pre-9/11 Veterans and civilians. Findings showed that post-9/11 Veterans were less likely than both pre-9/11 Veterans and civilians to delay mental health treatment for PTSD and depression. Median time to PTSD treatment was 2.5 years for post-9/11 Veterans compared to 16 years and 15 years, for pre-9/11 Veterans and civilians, respectively. Median time to depression treatment was 1 year for post-9/11 Veterans compared to 7 years and 5 years, for pre-9/11 Veterans and civilians, respectively. No differences in treatment delay were observed between post-9/11 Veterans and pre-9/11 Veterans or civilians for alcohol-use disorder. Increased engagement in PTSD and depression treatment for post- vs. pre-9/11 Veterans could be attributable to a host of recent historic, cultural, and policy changes, including: DoD’s universal post-deployment mental health screening; educational public health initiatives; enhanced eligibility for VA benefits for post-9/11 Veterans; VA’s suicide prevention hotline; VA mobile health resources (e.g., PTSD Coach); and VA’s integration of mental health services into primary care settings.
    Date: March 7, 2019
  • Positive Effect of Collaborative Chronic Care Model on Mental Health Clinical Teams
    This is one of the first studies to evaluate Collaborative Chronic Care Model (CCM) implementation for individuals treated in mental health clinics, and the first CCM trial to assess implementation impact in a multi-diagnosis mental health population. Findings showed that implementation efforts at the clinician level enhance evidence-based care organization, which may result in improvements in outcomes for more complex individuals and those at risk for hospitalization. Mental health hospitalizations decreased significantly for Veterans treated on facilitated teams compared to Veterans treated in other mental health clinics in those facilities. Although no improvement in population-level Veteran self-ratings of health status was seen, mental health status improved in Veterans with >3 treated mental health diagnoses versus others. This implementation initiative used existing clinical staff, with external facilitation the only added research-supported effort, totaling less than 3 hours per week per facility, and still decreased hospitalization rates and, for complex individuals, improved mental health status.
    Date: March 1, 2019
  • Over-Prescribing of Medication for Insomnia, Particularly among Women Veterans
    Zolpidem, a non-benzodiazepine sedative hypnotic, is extensively prescribed in the U.S. for short-term treatment of insomnia. FDA recommends cutting the dose for women in half because women metabolize the same dose of zolpidem more slowly than men; VA’s national Pharmacy Benefits Management service policy is in line with FDA guidelines. This study examined prescribing patterns among all VA patients who received zolpidem from FY2012-FY2016. Findings showed that there was inappropriate prescribing of zolpidem in terms of both guideline-discordant dosage and co-prescribing with benzodiazepines, with female Veterans affected more than male Veterans. In 2016, among Veterans who were prescribed zolpidem, 30% of female Veterans received an inappropriately high guideline-discordant dosage compared to 0.1% of male Veterans. Further, more women than men had overlapping benzodiazepine and zolpidem prescriptions (19% vs. 14%). For both male and female Veterans, having a substance use disorder was associated with an inappropriate high dose. Further, mental health conditions, including anxiety and PTSD, were associated with co-prescribing of zolpidem with benzodiazepines for both male and female Veterans.
    Date: March 1, 2019
  • Cardiovascular Care and Research for Women Veterans
    This review presents important information on five areas of cardiovascular disease (CVD) care for women Veterans: 1) rapidly changing demographics; 2) prevalence of traditional risk factors; 3) prevalence of less traditional risk factors (i.e., homelessness, military sexual trauma, and mental health disorders); 4) treatment and outcomes of CVD; and 5) the current state and future directions of women’s health research. The rapidly growing population of women Veterans represents a specific at-risk population with characteristics that set them apart from their male counterparts as well as civilian women regarding CVD risk factors and CVD recognition, diagnosis, treatment, and possibly outcomes. Significant advancements have been made over the past decade in better characterizing CVD in women Veterans, but there remains a large gender gap and paucity of prospective, randomized, interventional clinical trials.
    Date: February 19, 2019
  • Brief Cognitive Behavioral Therapy Reduces Suicidal Ideation among Veterans with Chronic Illness
    Brief cognitive behavioral therapy (bCBT) intervention delivered by VA mental health providers in primary care settings is effective for depression, anxiety, and improves physical health quality of life. Investigators in the current study determined the effect of bCBT on suicidal ideation among Veterans with cardiopulmonary chronic illness receiving mental health treatment in a VA primary care setting. Findings showed that bCBT in primary care reduced suicidal ideation in Veterans with chronic medical illness. Veterans in the bCBT group were less likely to have high suicidal ideation than Veterans in the EUC group post-treatment and at 8-month follow-up after accounting for baseline suicidal ideation. Results suggest that exposure to a brief evidence-based psychotherapy intervention in primary care may significantly reduce distress and suicidal ideation over a prolonged period of time, potentially reducing future suicide-related distress and/or attempts among a high-risk Veteran population.
    Date: February 8, 2019
  • Reduced Psychiatric Symptoms among Veterans Associated with More In-Person Social Contact but Not More Facebook Contact
    This study sought to determine whether social contact on Facebook—or in-person—is associated with a lower risk of screening positive for psychiatric disorders or suicidality in Veterans. Findings showed that although Veterans who frequently use Facebook also are typically social in their offline life, it is their offline (in-person) social interaction – not their social contact on Facebook – that is associated with reduced psychiatric symptoms. More frequent in-person social interaction was associated with significantly decreased risk of symptoms of major depression and PTSD, compared with contact every few weeks or less. In contrast, increased frequency of social interaction on Facebook had no associations with mental health outcomes. Neither social contact on Facebook nor in-person contact was associated with suicidality. Results suggest that “face-to-face” time may matter more than “Facebook” for Veterans trying to harness the mental health-promoting benefits of social contact with friends and family.
    Date: January 15, 2019
  • Links Between Opioid Use and Suicide
    This review describes what is known about the links between suicide and overdoses, with a focus on pathways through opioid use, issues of intent, risk factors, prevention strategies, and unresolved issues. Many factors promote the initiation and persistence of opioid use, but several specific pathways toward vulnerability to overdose and suicide are highlighted. Interventions that address shared causes and risk factors, such as programs to improve the quality of pain care, expanding access to psychotherapy, and increasing access to medication-assisted treatment for opioid use disorders, have the potential to be high-value investments by addressing both problems.
    Date: January 3, 2019
  • Web-Based Program Helps Empower Veterans Who Read their Mental Health Notes Online to Actively Participate in Care
    The VA OpenNotes initiative has expanded patient access to health information and VA now allows patients to access their electronic health record progress notes online. To reduce unintended harms and increase benefits, investigators developed a web-based educational program with the goal of increasing Veterans’ understanding of their mental health notes and providing guidance on communicating with clinicians about notes. This study sought to evaluate whether the program improved patient-clinician communication and increased patient engagement in their care. Findings showed that overall, improvements were observed among Veterans post-training in patient activation, perceived efficacy in healthcare interactions, and trust in their physician. This web-based educational program may help Veterans who read their mental health notes feel more empowered in their healthcare and improve perceptions of their clinician relationships.
    Date: January 1, 2019
  • Comparisons between VA and Non-VA Hospitals May Not Accurately Account for Mental Health Diagnoses
    While CMS publishes performance metrics on Hospital Compare, the risk-adjustment algorithms underlying these metrics are often unclear. Further, recently published literature questions whether existing risk-adjustment algorithms accurately adjust for mental health comorbidities. This study sought to determine whether current risk-adjustment algorithms fairly compare VA hospitals with non-federal hospitals. In their analysis, investigators used the CMS Hierarchical Condition Categories (HCC) risk adjustment system version 21 (V21) because it is publicly available and has been used to adjust metrics published on the CMS Hospital Compare website. Investigators also measured mental health comorbidities using the PsyCMS (Psychiatric Case Mix System). Findings showed that current comparisons between VA and non-VA hospitals are flawed because the risk adjustment algorithms used to make patients comparable do not adequately control for mental health issues. Of 5,472,629 VA patients, the V21 model identified 694,706 as having mental health or substance use HCCs. The PsyCMS identified another 1,266,938 Veterans with mental health diagnoses. The top 10 mental health diagnoses missed by the V21 model included nicotine dependence (40%), depression not otherwise specified (31%), PTSD (27%), and anxiety (10%). Overall, the V21 model under-estimated costs for patients with low costs and over-estimated costs for patients with above average costs except for the top decile. For Veterans with a mental health diagnosis, the V21 model under-estimated the cost of care by $2,314 per patient. Risk scores may need to be developed based on a broader set of hospital data. Without such efforts, safety net hospitals, such as VA, may be penalized and patients and policymakers misled.
    Date: December 14, 2018
  • VA Geriatric Patient Aligned Care Teams Need Additional Mental Health Integration for Older Veterans
    Geriatric Patient Aligned Care Teams (GeriPACT) provide healthcare for a subset of older Veterans with chronic disease, functional dependency, cognitive decline, and psychosocial challenges. This study examines mental healthcare integration within GeriPACT by describing the role of psychiatrists/psychologists to help inform geriatric mental health policy. Findings showed that mental health integration was less than 50% in the GeriPACT teams in this study: only 43% of GeriPACT teams had a mental health provider – either a psychiatrist (29%) and/or psychologist (24%). Teams with psychiatrist/psychologist providers were more likely to endorse management of psychosocial issues, dementia, and depression, indicating the potential benefit of including mental healthcare providers on teams.
    Date: September 13, 2018
  • Prior to Choice Act Elderly Medicare-Enrolled Veterans Increased Use of VA Healthcare versus Medicare
    This study examined long-term trends in reliance on VA outpatient care at the system level among elderly Medicare-enrolled Veterans from FY2003 to FY2014. Findings showed that the number of elderly Veterans enrolled in VA and Fee-for-Service (FFS) Medicare was 1.7 million in 2003, decreasing to 1.5 million in 2014. Medicare-enrolled Veterans, who had a choice of using VA or Medicare providers, steadily increased their reliance on VA outpatient services (all categories) prior to the Choice Act. Elderly Medicare-enrolled Veterans received most of their mental healthcare from VA (75% in 2003 to 77% in 2014), while receiving most of their primary care (76% in 2003, 65% in 2014), specialty care (86% in 2003, 78% in 2014), and surgical care (85% in 2003, 78% in 2014) through Medicare. The increase in VA reliance was driven by a decrease in Medicare-only users, and an increase in VA-only users. Among users during the study period, the proportion of VA-only users increased in primary care (28% to 40%), mental health (80% to 88%), specialty care (18% to 26%), and surgical care (18% to 28%). Similar trends were seen in seven high-volume medical subspecialties. Despite the recent controversies of access to VA care, elderly Medicare-enrolled Veterans were increasingly reliant on VA outpatient care across a diverse range of services at the life stage of growing healthcare needs. This may reflect their greater satisfaction with VA care.
    Date: August 27, 2018
  • Mantram Repetition Effective in Treatment of Veterans with PTSD
    Mantram teaches people to intentionally slow down thoughts and to practice “one-pointed attention” by silently repeating a personalized mantram – a word or phrase with spiritual meaning. This study compared Mantram therapy to Present-Centered Therapy – a supportive, problem-solving, non-trauma-focused treatment for PTSD. Findings showed that among Veterans with PTSD, individually-delivered Mantram was generally more effective than Present-Centered Therapy for reducing PTSD symptom severity. Moreover, significantly more Mantram participants than Present-Centered Therapy participants who completed the two-month follow-up no longer met criteria for PTSD (59% vs. 40%, respectively). There also were significant improvements for Veterans with insomnia who participated in the Mantram group as compared to the Present-Centered Therapy group. Mantram may appeal to Veterans who prefer therapies that are not trauma-focused, are shorter in duration than most treatments, include some element of spirituality, and/or that reduce sleep disturbances.
    Date: June 20, 2018
  • High-Risk Veterans with Access to Primary Care Intensive Management Receive Increased Outpatient Care without Increased Cost
    Intensive Management (IM) models aim to proactively reduce complex patients’ deteriorations in health and resultant high-cost hospitalizations through interdisciplinary teams, care coordination, and support for care transitions. This study evaluated the impact of outpatient primary care IM programs on health care utilization and cost at five VA medical centers. Findings showed that Veterans receiving IM care had higher utilization of outpatient care without an increase in total costs (including costs of the IM program) or differences in mortality over a 12-month period. Veterans in IM care had greater use of outpatient services such as mental health/substance abuse care, home care, and palliative/hospice care both in person and by telephone. Increased outpatient costs were attributed to higher use of these services. Veterans in IM care had a statistically significant reduction in nursing home days and non-significant trends toward lower mean inpatient costs, number of inpatient stays, and number of hospital days. IM programs appeared to improve access to necessary outpatient services and improve engagement in care.
    Date: June 19, 2018
  • Medical Records Flag for Suicide Risk Increases VA Healthcare Visits among Veterans with Substance Use Disorder
    VA has identified suicide prevention as a top priority and established policies to include high-risk suicide patient record flags (PRFs) in the electronic medical record to alert providers of patient risk and increase healthcare contacts. This study sought to identify predictors of new PRFs and to describe healthcare use before and after PRF initiation among VA patients who had received a substance use disorder (SUD) diagnosis. Findings showed that consistent with VA policy, 62% of Veterans with new suicide risk flags attended the recommended number of visits in months 1 to 3, with an additional 14% meeting recommended targets in month 1 only. Further, outpatient contacts in mental health and substance use disorder clinics increased 2 and 4 times, respectively, over the three-month follow-up period, with mean contacts in these services exceeding the minimum required one contact per week in month one. ED visits decreased by 45% in the three months following initiation of a PRF. Demographic predictors of PRF initiation included being younger than 35, White, and homeless. Clinical predictors were cocaine, opioid and sedative use disorders, PTSD, psychotic, bipolar, and depressive disorders, and suicide-attempt diagnoses. Suicide risk PRFs in an electronic medical record and subsequent follow-up increased service use for those Veterans with flags initiated.
    Date: June 8, 2018
  • Veterans Eligible for VA Purchased Healthcare Based on Distance from VA Facilities Face Shortage of Non-VA Providers
    This study examined the potential impacts of reforms to improve access to care for Veterans living in rural areas on these Veterans and healthcare providers. Findings showed that initiatives to purchase care for Veterans living more than 40 miles from VA facilities may not significantly improve their access to care, as these areas are underserved by non-VA providers. For example, about 16% of these Veterans lived in areas where there was a shortage of primary care providers, while 70% lived in areas where there was a shortage of mental healthcare providers; the majority of VA users eligible for purchased care lived in counties with no psychiatrists, cardiologists, pulmonologists, neurologists, PM&R specialists, or community mental health centers; and nearly half of these Veterans (47%) lived in counties with no community health center. Veterans eligible for purchased care based on distance were much more likely than the general population to live in counties with a median household income < $40,000 per year (40% vs. 11%) and very poor population health status (28% vs. 10%). VA should continue to develop telehealth programs and other strategies to deliver care to Veterans in rural areas underserved by both community and VA providers. Such programs are a necessary complement to initiatives to purchase in-person care from community providers.
    Date: May 29, 2018
  • Evaluating Care Coordination Program for Pregnant Veterans
    The VA Maternity Care Coordinator Telephone Care Program (MCC-TCP) was created to support MCCs and includes outlines to guide up to eight calls with Veterans on topics such as VA maternity care benefits, chronic health problems, substance use cessation, and depression and suicide screening. Investigators evaluated the program and assessed its feasibility, as well as facilitators and barriers to its implementation in 11 VA facilities. Findings showed that the VA Maternity Care Coordinator Telephone Care Program was successfully implemented and was perceived by the maternity care coordinators as valuable in meeting the care coordination needs of pregnant Veterans. MCC-TCP implementation barriers included limited information and communication technology tools to support the program – and lack of coordinator time for delivering telephone care. Consistent with prior research, pregnant women Veterans using VA maternity care had a high need for care coordination services due to their substantial burden of physical and mental health problems: 41% had pre-pregnancy chronic physical problem(s); 34% had mental health problem(s), particularly depression (28%) and PTSD/anxiety (21%); and 18% actively or recently smoked. Given the substantial and growing maternity care coordination needs among pregnant Veterans, especially those with chronic medical and mental illness, further investments in programs such as the Maternity Care Coordinator Telephone Care Program should be prioritized.
    Date: May 23, 2018
  • Most Women Veterans Report Timely Access to Mental Healthcare, Leading to High Satisfaction with VA Care
    This study evaluated access to mental healthcare by assessing women Veterans’ perceptions of the timeliness and quality of care. Findings showed that of the 419 women Veterans in this study cohort, 59% reported "always" getting an appointment for mental healthcare as soon as needed, and another 22% reported “usually” getting an appointment as soon as needed. Two problems were negatively associated with timely access to mental healthcare: 1) medical appointments that interfere with other activities, and 2) difficulty getting questions answered between visits. Average ratings of the quality of VA healthcare were high: 8.5 out of 10 regarding VA mental healthcare, 8.7 for VA primary care, and 8.2 for VA healthcare overall. Moreover, 93% of women Veterans reported that they would recommend VA healthcare to other women Veterans. This study highlights opportunities for addressing barriers to timely mental healthcare through practices such as non-traditional clinic hours, open access scheduling, telemedicine, and secure messaging.
    Date: April 5, 2018
  • Women Veterans Who Experienced Past-Year Intimate Partner Violence Significantly More Susceptible to Housing Instability
    This study used VA clinical screening data to assess the relationship between recent experience of intimate partner violence (IPV) and housing instability among women Veterans. Findings showed that female Veteran patients who screened positive for past-year IPV had up to four times the odds of experiencing housing instability. Women Veterans who screened positive for past-year IPV were significantly more likely to have an indicator of housing instability if they identified as Black or African American, previously screened positive for military sexual trauma, had a mental health diagnosis, or a substance use disorder. Women Veterans receiving compensation for a disability incurred during military service – and those who were married – were significantly less likely to have an indicator of housing instability. IPV interventions should assess for both physical and psychological housing needs, and housing interventions should coordinate with IPV programs to address common barriers to resources.
    Date: April 1, 2018
  • Veteran Status Significantly Moderates the Positive Effect of Collaborative Care Intervention for Depression versus Usual Care
    This study combined data from two collaborative care trials to determine whether there were significant differences in outcomes between Veterans with depression receiving collaborative care in VA community-based outpatient clinics (CBOCs) versus civilians receiving collaborative care in Federally Qualified Health Centers (FQHCs). Findings showed that Veterans randomized to collaborative care in community-based outpatient clinics (CBOCs) reported a significantly and substantially lower response rate at the 6-month follow-up compared to civilians randomized to collaborative care in FQHCs after controlling for socio-demographic and clinical variables. Significantly more FQHC patients compared to CBOC patients reported prior and current depression treatment, and rated depression treatment as acceptable. Overall, 19% of Veterans responded to treatment compared to 30% of civilians, and 20% of men responded to treatment compared to 29% of women.
    Date: April 1, 2018
  • Racial/Ethnic and Gender Variations in Veteran Satisfaction with VA Healthcare
    This study of Veterans’ satisfaction with outpatient, inpatient, and specialist care in a diverse sample of Veterans from predominantly minority-serving VAMCs sought to better understand racial/ethnic and gender variations in healthcare satisfaction. Findings showed generally high levels of healthcare satisfaction across 16 domains, with 83% of respondents somewhat or very satisfied with VA healthcare overall. The highest satisfaction ratings were reported for costs, outpatient facilities, and pharmacy services (74% to 76% were very satisfied); the lowest ratings were reported for access to care, pain management, and mental healthcare (21% to 24% were less than satisfied). Contrary to previous studies, there was little evidence of racial, ethnic, or gender disparities in satisfaction with care at minority serving VAMCs.
    Date: March 1, 2018
  • Homeless Population-tailored Patient-Aligned Care Team Can Reduce Acute Care Services and Healthcare Costs
    This trial compared healthcare service use and cost outcomes among homeless Veterans enrolled in a traditional (not tailored to a homeless population) PACT with outcomes among Veterans enrolled in a homeless population–tailored H-PACT. Findings showed that annual costs per patient were significantly higher in the PACT group than the H-PACT group ($37,415 vs $28,036), and most cost savings came from fewer VA and non-VA hospitalizations. A significantly greater percentage of Veterans in the PACT arm compared to H-PACT were hospitalized for any cause (35% vs 23%), had a mental health–related ED visit (48% vs 34%), or attended group therapy (54% vs 40%). In addition, there were significant differences in primary care provider–specific visits (H-PACT 5 vs PACT 4 visits), mental healthcare visits (H-PACT 9 vs PACT 13 visits), 30-day prescription drug fills (H-PACT 41 vs PACT 59 fills), and use of group therapy (H-PACT 40% vs PACT 54%). Results indicate that a population-tailored medical home approach for socially disadvantaged populations can both reduce reliance on acute care service use and generate significant cost savings.
    Date: February 15, 2018
  • Primary Care-Mental Health Integration Decreases Use of General Mental Health Services among Veterans with Mental Illness
    This study examined the relationship between primary care clinic engagement in Primary Care-Mental Health Integration (PC-MHI) and patient use of different mental health services (MHS). Findings showed that there was increasing clinic engagement in PC-MHI services over time, accompanied by a reduction in general MHS visits – but no change in more specialized mental health services. Analyses showed that a one percentage-point higher PC-MHI engagement rate was associated with a 1.2% lower general MHS visit rate per year. Reductions in general MHS visits were not observed in patients with serious mental illness (i.e., schizophrenia, bipolar disorder). PC-MHI targets the most common mental illnesses (i.e., depression) faced by VA primary care patients. Findings suggest that these Veterans are receiving PC-MHI services, particularly in clinics that more highly engaged in PC-MHI. PC-MHI programs appear to reduce reliance on general MHS clinics, and thus may be effective in engaging those reluctant to seek mental healthcare.
    Date: December 15, 2017
  • Women Veterans Screening Positive for Intimate Partner Violence More Likely to Receive Mental Illness Diagnosis
    This cross-sectional study is the first large-scale investigation into the associations between intimate partner violence (IPV) and mental health using IPV clinical screening and mental health diagnosis data from VA medical records. Findings showed that female VA patients who screened positive for past-year IPV were more than twice as likely to have a mental health diagnosis – or more than two mental health diagnoses – compared to those who screened negative. More than half (54%) of the women who screened positive for IPV had a mental health diagnosis, compared with less than one-third (33%) of those who screened negative for IPV. Each category of IPV exposure (psychological, physical, and sexual violence) was significantly associated with having a mental health diagnosis or comorbidity. Associations remained after adjusting for military sexual trauma and combat trauma. IPV assessment and response needs to address all forms of IPV, including psychological violence in the absence of physical or sexual violence, and the particularly strong associations between mental health and experiences of sexual intimate partner violence.
    Date: December 1, 2017
  • VA Experience with Implementing Intensive Primary Care Programs for Veterans at Highest Risk
    This case study describes VA’s experience with implementing intensive primary care programs, as well as the program elements that appear to be necessary to meet the complex care needs of these high-risk Veterans. Findings showed that the PACT Intensive Management program (PIM) has been successfully implemented for more than three years at five demonstration sites in the VA healthcare system. The PIM program has evolved over time, eventually converging on implementation of the following elements: an interdisciplinary care team, chronic disease management, comprehensive patient assessment and evaluation, care and case management, transitional care support, preventive home visits, pharmaceutical services, chronic disease self-management, caregiver support services, health coaching, and advanced care planning. PIM teams also found that including social workers and mental health providers on the interdisciplinary teams was critical to effectively address the psychosocial needs of these complex patients. In addition, having a central implementation coordinator facilitated the convergence of these program features across diverse demonstration sites.
    Date: October 25, 2017
  • Evidence-based Psychotherapy Template Use Associated with Treatment Quality for Veterans with PTSD
    This study measured the prevalence of evidence-based psychotherapy (EBP) templated notes in VA, testing the hypothesis that template use would be associated with quality of care for Veterans with PTSD. Findings showed that facility-level EBP template use was associated with a greater proportion of PTSD-diagnosed patients treated in specialty clinics, greater facility-level rates of diagnostic assessment, and greater rates of psychotherapy adequacy (8 psychotherapy visits in 14 weeks). Overall, an average of 4% of Veterans with a PTSD diagnosis received at least one EBP template. Among Veterans receiving psychotherapy for PTSD, an average of 9% received an EBP template. VA facilities with a greater percentage of patients who were service-connected at 50% or higher administered EBP templates to a smaller proportion of Veterans diagnosed with PTSD. The overall reach of EBP template usage was low, indicating that greater efforts are needed to improve usage.
    Date: September 30, 2017
  • Effects of Cannabis among Adults with Chronic Pain
    This systematic review assesses the efficacy of cannabis for treating chronic pain, and provides a broad overview of the short- and long-term physical and mental health effects of cannabis use in chronic pain and general patient populations. Overall, investigators found low-strength evidence that cannabis may improve pain in some patients with neuropathic pain and insufficient evidence to characterize the effects of cannabis on pain in patients with multiple sclerosis. Moderate-strength evidence suggests that light to moderate cannabis smoking does not adversely impact lung function over about 20 years, however, the limited evidence examining the effects of heavy use suggests a possible deleterious effect on lung function over time. There is a consistent association between cannabis use and the development of psychotic symptoms over the short and long term, and cannabis appears to be associated with at least small, short-term deleterious effects on cognition in active users.
    Date: August 5, 2017
  • Higher Risk of Suicidal Ideation and Suicidal Self-Directed Violence following Discontinuation of Long-term Opioid Therapy
    The primary objective of this study was to identify predictors of suicidal ideation (SI) and non-fatal suicidal self-directed violence (SSV) following clinician-initiated discontinuation of long-term opioid therapy. Findings showed that a substantial proportion of Veterans with substance use disorder diagnoses and similar matched patients experienced suicidal ideation or suicidal self-directed violence following discontinuation of long-term opioid therapy by their opioid-prescribing clinicians, most of whom represent new onset cases. Approximately 12% of patients in this sample had SSV and/or SI documented in the medical record in the 12 months following discontinuation of opioid therapy: 47 patients had SI only, while 12 had SSV. Half of patients with SSV attempted suicide by overdose, most commonly with benzodiazepines. Mental health diagnoses associated with having SI/SSV included PTSD and psychotic disorders. The majority of patients (75%) were discontinued from opioid therapy due to aberrant behaviors. Healthcare providers should pay special attention to safety when patients are discontinued from long-term opioid therapy, particularly patients with PTSD or psychotic disorders.
    Date: July 1, 2017
  • A Positive Psychological Intervention Improves Outcomes for Veterans with Knee or Hip Osteoarthritis
    This study sought to determine whether patients randomized to a program designed to boost positive affect and develop positive psychological skills (e.g., gratitude and kindness) would report greater improvements over time in osteoarthritis (OA) symptom severity and measures of psychosocial well-being compared with patients randomized to a neutral control program. Findings showed that the 6-week positive psychological intervention produced large reductions in OA symptom severity, decreased negative affect, and increased life satisfaction compared to a robust control program among Veterans with knee or hip osteoarthritis. Retention through both 6-week programs was high, with 79% of participants completing at least 5 of 6 weekly calls and 64% reporting that they completed 80% or more of their weekly activities. Participants rated the activities as highly beneficial, highly enjoyable, and low in difficulty. Results indicate the potential of a non-pharmacological therapy to improve symptom management in this population with moderate to severe pain and suggest that using positive activities as part of an overall treatment program for patients with OA could have a large impact.
    Date: June 27, 2017
  • Delivery of Brief Cognitive Behavioral Therapy in Primary Care Improves Mental Health Symptoms in Chronically Ill Veterans
    This trial sought to determine whether an integrated brief cognitive behavioral therapy (bCBT) intervention would improve depression, anxiety, and quality of life for medically ill Veterans. Findings showed that integrated bCBT resulted in significant immediate and 12-month improvements related to depression and anxiety. Brief CBT also resulted in significant short-term improvements related to physical health quality of life for Veterans with chronic lung conditions. Delivery of bCBT in VA primary care clinics resulted in Veterans receiving an average of 3.9 sessions with high levels of Veteran engagement (84% receiving care) and treatment completion (63% with 4 or more sessions). Veterans and VA providers reported very high satisfaction with bCBT.
    Date: June 20, 2017
  • Systematic Review of Suicide Risk Assessment and Prevention
    This systematic review evaluated studies assessing the accuracy of methods to identify individuals at increased risk for suicide, and the effectiveness and adverse effects of healthcare interventions relevant to Veteran and military populations in reducing suicide and suicide attempts. Findings showed that suicide rates were reduced in 6 of 8 observational studies of various types of multiple-component population-level interventions, including two studies in Veteran and military populations. Only 2 of 10 trials of individual-level psychotherapy reported statistically significant differences between treatment and usual care, however, most trials were inadequately designed to detect differences. No studies described the adverse effects of risk assessment methods or interventions for suicide prevention. Risk assessment methods are sensitive predictors of subsequent suicide and suicide attempts in studies, but the frequency of false positives limits their clinical utility. Future research should continue to refine these methods and examine their clinical applications.
    Date: June 15, 2017
  • Meta-Analysis of Interventions to Prevent Suicide
    This study conducted a meta-analysis of randomized controlled trials (RCTs) that compared the efficacy of various interventions versus control to prevent death by suicide among adults. Of the studies included in this review, 29 RCTs reported on complex psychosocial interventions, with 3 reporting on the WHO Brief Intervention and Contact (BIC) intervention, which includes an educational session on suicide prevention followed by regular contact with a trained provider (phone or in-person) for up to 18 months. The WHO BIC intervention was associated with significantly lower odds of death by suicide. No other suicide prevention intervention showed a statistically significant effect in reducing death by suicide.
    Date: June 1, 2017
  • Factors Associated with Suicide within One Week of Discharge from VA Psychiatric Facilities
    To better understand system and organizational factors associated with post-discharge suicide, this study reviewed root-cause analysis (RCA) reports of death by suicide within seven days of discharge from all VA inpatient mental health units between FY2002 and FY2015. Findings showed that risk for suicide in the week following hospital discharge may be highest during the first few days after discharge. There were 141 reports of suicide within seven days of discharge: 40% occurred during the first day of discharge; 67% within 72 hours of discharge, and nearly 80% within four days of discharge. Further, 43% of suicides followed an unplanned discharge. Root causes for suicide fell into three major categories: 1) challenges for clinicians and patients following the established process of care, 2) awareness and communication of suicide risk, and 3) flaws in the established process of care. No association was found between length of hospital stay and days to suicide. Authors suggest that current VA policies mandating mental health follow-up within 7 days of discharge may be insufficient and that other methods of intervention to better reach this vulnerable patient population may need to be considered (e.g., tele-monitoring). The authors also suggest that inpatient teams be aware of the potentially heightened risk for suicide in patients whose discharge is unplanned.
    Date: June 1, 2017
  • Study Identifies which VA Mental Health Program Characteristics are Associated with Patient Satisfaction
    This study examined the relationships between a set of patient satisfaction measures and a large collection of mental health program characteristics for Veterans with a recent mental health encounter in the VA healthcare system. Findings showed that broad measures of mental healthcare program reach (i.e., proportion of patients served) and intensity (i.e., number of visits) – and nearly all measures of treatment continuity were consistently and positively associated with patient satisfaction. More narrow performance measures – those that focus on specific diagnostic populations (e.g., those with PTSD and serious mental illness) – were less likely to be positively associated with satisfaction. Satisfaction with access to VA healthcare among Veterans with mental health conditions was higher than satisfaction with care encounters.
    Date: May 19, 2017
  • Current Diagnosis of PTSD is Risk Factor for Pregnant Women
    This analysis evaluated the associations between PTSD and antepartum complications to explore how PTSD’s pathophysiology impacts pregnancy in a large cohort of women Veterans. Findings showed that a current diagnosis of PTSD increases the risk of hypertensive/ischemic placental complications of pregnancy, specifically preeclampsia, and is a risk factor for gestational diabetes. PTSD also was associated with an increased risk of prolonged (>4 day) delivery hospitalization and repeat hospitalization. Authors suggest that pregnancies in women with currently active PTSD should be identified as potentially high-risk, high-need pregnancies.
    Date: May 1, 2017
  • Impact of Comprehensive Caregiver Support Program on VA Healthcare Utilization and Cost
    The Program of Comprehensive Assistance for Family Caregivers (PCAFC) supports caregivers of Veterans from the post-9/11 era who need assistance with activities of daily living (ADLs) or supervision or protection because of the residual effect of injuries sustained during their service. A monthly stipend is provided to caregivers based on Veterans’ care needs. In this study, investigators examined the early impact of PCAFC on VA healthcare utilization and costs. Findings showed that Veterans in PCAFC had similar acute care utilization when compared with those in the control group, but significantly greater primary, specialty, and mental health outpatient care use at least 30 – and up to 36 months post-application. Compared with Veterans in the control group, over time, Veterans in the PCAFC group had about a 10 percentage point higher probability of receiving any VA primary care. In the first six months, Veterans in the PCAFC group had an increased probability of using any VA specialty care (75% vs. 64%). Veterans in the treatment group also had an increased probability of using mental healthcare in the first 6 months (84% vs. 77%) and this increase was sustained through 31-36 months. Estimated total healthcare costs for Veterans in the PCAFC group were $1,500 to $3,400 higher per Veteran per 6-month interval than for Veterans in the control group. Findings suggest that comprehensive supports for family caregivers can increase patient engagement in outpatient care in the short term, which may enhance long-term health outcomes.
    Date: April 1, 2017
  • Discontinuation of Long-Term Opioid Therapy among Veterans is Overwhelmingly Initiated by VA Clinicians
    The aim of this study was to compare reasons for discontinuation of long-term opioid therapy (LTOT) between Veterans with and without substance use disorder (SUD) receiving care within the VA healthcare system in the years following release of 2009 and 2010 clinical practice guidelines. Findings showed that the majority of Veterans (85%) discontinued opioid use because their clinician stopped prescribing, rather than the patients deciding to stop. For patients whose clinicians initiated discontinuation, 75% were discontinued due to opioid-related aberrant behaviors (i.e., suspected substance abuse, aberrant urine drug test). Veterans with SUD diagnoses were more likely to discontinue LTOT due to aberrant behaviors, particularly abuse of alcohol or other substances, compared to Veterans without SUD. High proportions of patients received diagnoses for mental health disorders in the year prior to discontinuation of LTOT, including PTSD, anxiety disorders other than PTSD, and depressive disorders (25%). Increasing rates of opioid discontinuation are likely to occur due to policies and programs that encourage close monitoring of Veterans on LTOT for opioid misuse behaviors. Integrating non-opioid pain therapies and SUD treatment into multiple settings such as primary care and specialty SUD care is one possible approach to enhance their care.
    Date: March 1, 2017
  • Quality Improvement Tool Shows Organizational Factors Related to Access and Quality Measures in VA Mental Healthcare
    This study analyzed performance on measures included in the Mental Health Management System (MHMS) – a performance data and quality improvement tool used by VA to increase the value of mental healthcare for Veterans. The MHMS quality improvement tool showed that organizational factors were associated with performance on key access and quality measures related to VA mental healthcare. Better access was associated with higher staff-to-patient ratios for psychiatrists and other outpatient mental health providers, and with lower mental health provider staffing vacancies. Higher mental health staff-to-patient ratios were associated with higher performance on nearly all patient and provider satisfaction measures. Higher continuity of care was associated with lower no-show rates to appointments, better wait times, higher staff-to-patient ratios, lower mental health provider vacancies, and more space available for clinical work. Over the past decade, VA’s mental health population has grown rapidly compared to its overall patient population (71% vs. 21%, respectively), so these findings are important in showing that MHMS is a robust informatics and quality improvement tool that can serve as a model for health systems planning to adopt a value perspective.
    Date: February 1, 2017
  • “Virtual Hope Box” Smartphone App Helps Veterans Regulate Emotion and Cope with Distress that Can Lead to Suicide
    Investigators in this study developed a smartphone app, Virtual Hope Box (VHB), to provide a portable and easily accessed suite of tools to enhance coping self-efficacy. They then assessed the impact of VHB on stress coping skills, suicidal ideation, and perceived reasons for living in patients at elevated risk of suicide and self-harm. Findings showed that VHB users reported significantly greater ability to cope with unpleasant emotions and thoughts (i.e., coping, self-efficacy) at 3 and 12 weeks compared with Veterans in the control group. There was no significant advantage of treatment augmented by the VHB for other outcome measures. The most frequently cited reasons for using VHB by Veterans were for distress, when emotions were overwhelming, when they felt like hurting themselves, and for relaxation, distraction, and/or inspiration. Data suggested that clinicians appreciated the VHB's capacity to serve as an additional therapeutic tool – and valued the fact that the VHB served to reinforce patients' existing coping skills and gave them an outlet to practice these skills. Because the Virtual Hope Box smartphone app is easily disseminated across a large population of users, investigators believe it has broad, positive utility in behavioral healthcare.
    Date: November 15, 2016
  • OEF/OIF/OND Veterans that Currently Smoke More Likely to Receive Opioid Prescription than Non-Smokers
    This study sought to determine if smoking status is associated with the receipt of opioids among OEF/OIF/OND Veterans – and to examine important covariates of smoking (i.e., current pain intensity, gender, and mental health diagnoses) and receipt of opioids. Findings showed that compared to non-smokers, OEF/OIF/OND Veterans who were current smokers were more likely to receive an opioid prescription, even after controlling for covariates including: pain intensity, age, gender, service-connection, substance use disorder, mood disorders, and anxiety disorders. Veterans who reported a higher current pain intensity and those with pain diagnoses also were more likely to receive an opioid prescription. Among this young cohort of Veterans (mean age=30 years), more than one-third (34%) reported moderate to severe current pain intensity within +/-30 days of smoking status, with approximately 8% receiving at least one opioid prescription.
    Date: September 21, 2016
  • Lithium or Valproate Associated with Better Outcomes Compared to Second-Generation Antipsychotics for Bipolar Disorder
    This study assessed a nationwide population of Veteran outpatients with bipolar disorder treated at VAMCs, who were newly initiated on an antimanic agent between 2003 and 2010. The primary outcome was likelihood of all-cause hospitalization during the year after initiation. Findings showed that after extensive control for covariates, initiation of lithium or valproate alone – compared to initiation of an second-generation antipsychotic (SGA) alone – was associated with a significantly lower likelihood of all-cause hospitalization, a longer time to hospitalization, and fewer hospitalizations in the subsequent year. Veterans receiving combination treatment (i.e., SGA + lithium, SGA + valproate) had a significantly higher likelihood of hospitalization, although they also had a longer time to addition of another antimanic agent or antidepressant. Among monotherapies, the only significant differences were found in psychosis, with it being more likely in those initiated on SGAs rather than those initiated on lithium, valproate, or carbamazepine/oxcarbazepine.
    Date: September 1, 2016
  • Higher Risk of Suicidal Ideation among Veterans Seeking Mental Health Treatment from both VA and non-VA Facilities
    VA researchers developed the Veterans Health Module (VHM) to be implemented within the Centers for Disease Control and Prevention’s (CDC) Behavioral Risk Factor Surveillance System (BRFSS). This report presents data from the 2011-2012 VHM telephone survey. Findings showed that after adjusting for sociodemographic and VHM variables, Veterans who sought mental health treatment from both VA and non-VA facilities had more than four-fold increased odds of suicidal ideation than Veterans who sought mental health treatment from VA facilities only. Overall, 5% of the study cohort reported recent suicidal ideation, and 1% reported attempting suicide. There were no sex differences in prevalence of suicidal ideation or attempt. In the overall sample, lifetime diagnosis of depression, anxiety, or PTSD was the strongest correlate of both suicidal ideation and attempt.
    Date: June 24, 2016
  • Racial and Ethnic Differences in Primary Care Experiences for Veterans with Mental Health and Substance Use Disorders
    This study examined racial and ethnic differences in positive and negative experiences in VA Patient-Centered Medical Home (PCMH) settings among Veterans with mental health or substance use disorders (MHSUDs) who completed VA’s 2013 PCMH Survey of Healthcare Experiences of Patients. Findings showed that positive experiences were reported least often for access. Negative experiences were reported most often for self-management support and comprehensiveness, defined as provider attention to MHSUD concerns. One or more racial/ethnic minority groups reported more negative and/or fewer positive experiences than Whites in the following 4 domains: access, communication, office staff helpfulness/courtesy, and comprehensiveness. Solutions are needed to improve access to care for all Veterans with MHSUDs, with additional attention on improving access for Black, Hispanic, and AI/AN Veterans.
    Date: June 20, 2016
  • Use of Clozapine for Veterans with Treatment-Resistant Schizophrenia Could Result in Significant Cost Savings
    This cost-benefit analysis sought to simulate potential cost savings for VA that would result from increasing the use of clozapine among Veterans with treatment-resistant schizophrenia. Findings showed that modest increases in clozapine use could result in significant cost savings for VA. Among Veterans with treatment-resistant schizophrenia, VA would save $22,444 per Veteran over the first year of treatment, primarily from 18.6 fewer inpatient hospitalization days per patient. Given this finding, if current clozapine use was doubled from 20% of patients with treatment-resistant schizophrenia to 40%, VA would accrue an estimated cost savings of $80 million over the first year. Moreover, full utilization of clozapine would save VA $320 million over the first year. Findings suggest VA should strongly consider initiatives to substantially increase clozapine use among Veterans with treatment-resistant schizophrenia. Deaths from clozapine-related adverse events are more than balanced out by decreased incidence of suicide attempts, with a net result of slightly fewer deaths with increased use of clozapine.
    Date: June 15, 2016
  • Barriers and Facilitators to Use of Clozapine for Treatment-Resistant Veterans with Schizophrenia
    This study sought to identify facilitators and barriers to clozapine use – and to inform the development of interventions to maximize appropriate use. Findings showed that factors associated with high utilization of clozapine for Veterans with schizophrenia included: providing access to transportation for Veterans; having sufficient capacity to enroll patients; use of multi-disciplinary teams, including non-physician providers; better coordination of care through mental health intensive case management (MHICM) or clozapine clinics; and creation of systems to reduce reliance on too few individuals. Factors associated with low utilization of clozapine included lack of champions to support clozapine processes and limited-capacity care systems. Barriers identified at both high- and low-utilization facilities included time-consuming paperwork, reliance on few individuals to facilitate processes, and issues related to transportation for Veterans living far from VA care facilities.
    Date: June 15, 2016
  • Military Sexual Trauma is Independent Risk Factor for Homelessness among Veterans, Particularly Male Veterans
    This study examined the relationship between military sexual trauma (MST) and post-deployment homelessness among a large cohort of OEF/OIF Veterans, including whether the relationship varied by sex, and whether MST was a predictor of homelessness independent of other risk factors (i.e., mental health and/or substance use disorders). Findings showed that a positive MST screen was independently related to post-deployment homelessness. In unadjusted models, Veterans with a positive screen had odds for homelessness that were approximately double those who screened negative. Moreover, findings in the 30-day and 1-year follow-up cohorts suggested a greater risk for homelessness among men with a history of MST than among women. After adjusting for mental health and substance use diagnoses, MST screening status remained a significant predictor of homelessness, with Veterans who had a positive MST screen having approximately 1.5 times greater odds for homelessness than those who screened negative. Findings of greater risk among men also remained. Among Veterans with a positive MST screen, the incidence of homelessness was 2% within 30 days, 4% within one year, and 10% within five years. The stronger risk conferred by MST for homelessness among men suggests that men with a positive MST screen are a particularly vulnerable group.
    Date: June 1, 2016
  • Prescription Opioid Use among Patients with Recent History of Depression Increases Risk of Recurrence
    This study examined whether patients in depression remission who were prescribed opioids for non-cancer pain had an increased risk of depression recurrence. Investigators analyzed two patient populations: Veterans treated in the VA healthcare system, and patients treated by a non-profit integrated healthcare system located in Texas. Findings showed that prescription opioid use among patients with a recent history of depression increased the chance of depression recurrence, and this effect was independent of pain diagnoses and pain intensity scores. Patients with remitted depression who were exposed to opioid analgesics at any point during the follow-up period were 77% to 117% more likely to experience a recurrence of depression than those who remained opioid free, after controlling for other factors. Among VA patients with depression remission, those who received opioids during follow-up were younger, had more psychiatric comorbidities, and had more painful conditions and higher pain scores than those who didn’t receive opioids.
    Date: April 1, 2016
  • Prescription Use of Codeine Associated with Greater Risk of New Onset Depression among Veterans
    This study sought to determine whether the hazard of new depression diagnosis differs among VA patients prescribed only codeine, only hydrocodone, or only oxycodone. Findings showed that Veterans prescribed only codeine for 30 days or longer had a 29% increased risk of a new diagnosis of depression compared to Veterans prescribed only hydrocodone for 30 days or longer. Those prescribed only oxycodone for 30 days or longer were not significantly more likely to develop a new depression diagnosis compared to patients prescribed hydrocodone only. Opioid use of 30-90 days was most common among oxycodone users, and opioid use of more than 90 days was most common among hydrocodone users. The distribution of individual comorbid conditions did not significantly differ across the three types of opioids.
    Date: March 22, 2016
  • Central Nervous System Polypharmacy May Increase Risk of Overdose and Suicide-Related Behavior among OEF/OIF Veterans
    This study examined the prevalence of central nervous system (CNS) polypharmacy and its association with drug/alcohol overdose and suicide-related behaviors in a national cohort of OEF/OIF Veterans. Findings showed that of the Veterans in this study, 8% had received five or more CNS-acting medications in 2011. CNS polypharmacy was most strongly associated with PTSD, depression, and TBI – and was independently associated with overdose and suicide-related behaviors after controlling for known risk factors. Women and Veterans between ages 31 and 50 years were more likely to have CNS polypharmacy. Findings suggest that CNS polypharmacy may be used as a “trigger tool” to identify individuals who may benefit from referral to a tailored inter-disciplinary treatment team comprised of experts from relevant fields. Ideally, these teams would work together to optimize medication profiles and treatment plans, and to examine non-pharmacological treatment options.
    Date: March 1, 2016
  • Factors Associated with VA and Non-VA Mental Health Service Use among National Guard Soldiers
    This study sought to determine the associations between mental health need, enabling, and predisposing factors and mental health service use among National Guard soldiers in the first year following a combat deployment to Iraq or Afghanistan. Findings showed that overall mental health service use was strongly associated with need, including higher number of mental health conditions and worse physical health. Among those using services, predisposing factors (middle age and female gender) and enabling factors (employment, income greater than $50,000, and private insurance) were associated with greater non-VA service use. Among the survey respondents reporting mental health treatment in the prior 12 months, 81% received any VA treatment and 19% received only non-VA treatment. Approximately 30% of those receiving VA treatment also had received treatment from a non-VA source.
    Date: February 3, 2016
  • Impact of Evidence-based Quality Improvement Strategy on VA Patient-Aligned Care Team Implementation
    This study assessed changes in VA healthcare utilization and costs for Veterans from six practices in three different medical centers using an evidence-based quality improvement (EBQI) approach to implement PACT and 28 comparison practices over a five-year period (FY2009 to FY2013). Findings showed that after PACT implementation, the overall use of primary care, specialty care, and mental health/substance abuse care decreased, while the use of telephone care increased. Decreased outpatient care use occurred more rapidly for VA practices that employed an EBQI approach to PACT implementation, including outpatient visits for primary care, specialty care, and mental health and substance abuse care that appeared to augment the effects of PACT. EBQI practice was significantly associated with a 15% reduction in primary care encounters over the study period. For specialty care, there was a 17% decrease in encounters associated with EBQI overall, but the rate of decrease slowed each year after the implementation of PACT. There was no significant effect of EBQI status on emergency department visits, all-cause hospitalizations, or prescription drugs. Total VA healthcare costs per patient decreased by 5% each year across all practices, but there was no effect of EBQI practice on costs.
    Date: February 1, 2016
  • Mental Health Conditions Common among Patients Seeking and Undergoing Bariatric Surgery
    This systematic review had three aims: 1) to estimate the prevalence of mental health conditions among bariatric surgery candidates and recipients; 2) to evaluate the association between preoperative mental health conditions and weight loss after surgery; and 3) to evaluate the association between surgery and the clinical course of mental health conditions. Findings showed that mental health conditions are common among patients seeking and undergoing bariatric surgery, particularly depression and binge-eating disorder (BED). Prevalence estimates for mood disorders (22%), depression (19%), and BED (17%) were higher than published rates for the general U.S. population, (10%, 8%, and 1-5%, respectively) suggesting that special attention should be paid to these conditions among bariatric patients. There was moderate-quality evidence to support an association between bariatric surgery and lower rates of depression post-operatively. Depression improved following surgery in 11 of the 12 studies, including two randomized controlled trials evaluating preoperative behavioral health interventions.
    Date: January 12, 2016
  • Increased Dose of Prescription Opioids Raises Risk of Suicide among Veterans with Chronic Non-Cancer Pain
    This study examined the association between prescribed opioid dose and suicide in a national sample of VA patients with a chronic non-cancer pain condition who received opioid therapy. Findings showed that increased dose of opioids was found to be a marker of increased suicide risk, even when relevant demographic and clinical factors were statistically controlled. Type of opioid dosing schedule (i.e., regularly scheduled, as needed, or both) did not significantly affect suicide risk after accounting for other factors. Similar to the U.S. population and other large studies of VA patients, the vast majority of suicides involved firearms (64%), with overdose accounting for 20% of all suicides.
    Date: January 5, 2016
  • Veterans Exiting Prison Have Extensive Treatment Needs, Particularly for Mental Health and Substance Use Issues
    This study determined incarcerated Veterans’ contact with VA healthcare in the year after a Health Care for Reentry Veterans (HCRV) visit (prior to release from prison), the prevalence of mental health and substance use disorder (SUD) diagnoses, and rates of mental health or SUD treatment entry and engagement in the first month after diagnosis. Findings showed that of the Veterans with an HCRV outreach visit, 56% had contact with VA healthcare within one year, including primary care, mental health or SUD treatment, or other VA services. Among Veterans with an HCRV outreach visit who had contact with VA healthcare, 69% were diagnosed with at least one mental health or substance use disorder, and 35% were diagnosed with co-occurring mental health and substance use disorders. The three most common disorders were depressive disorders, alcohol use disorder, and PTSD. Of Veterans diagnosed with a mental health disorder, 77% entered mental health treatment in the first month after diagnosis and 28% engaged in treatment. At one year after diagnosis, 93% of Veterans had entered and 52% had engaged in mental health treatment. Of those Veterans diagnosed with a SUD, 37% entered and 24% engaged in SUD treatment in the first month, while 57% had entered and 39% engaged in treatment at one year following diagnosis.
    Date: December 21, 2015
  • Sexual Trauma during Military Service Increases Risk of Subsequent Suicide among Veterans
    This was the first large-scale, population-based study of sexual trauma and suicide mortality that examined risks associated with military sexual trauma (MST) among both male and female Veterans receiving VA care. Findings showed that women and men who reported MST had an increased risk of suicide, and MST remained an independent risk factor even after adjusting for other known risk factors for suicide among Veterans, including mental health conditions, medical morbidity, and demographic characteristics. Among Veterans who reported MST, those who died by suicide were significantly more likely to be treated for mental health conditions determined by their provider to be related to MST experiences: men 50% vs. 36%, and women 67% vs. 48%. Overall, 2% of the Veterans in this study reported MST when screened (1% of men, and 21% of women), with 97% reporting no MST, and 0.3% declining to complete the screen.
    Date: December 14, 2015
  • Alcohol Misuse among Female Veterans
    This study examined the demographic/military, interpersonal violence, and mental health correlates of alcohol misuse among female Veterans seeking VA healthcare. Findings showed that younger age, adulthood physical abuse, military sexual trauma, past-year psychological aggression by an intimate partner, and PTSD and depression symptom severity showed significant associations with alcohol misuse. Two of these associations – younger age and past-year psychological intimate partner violence – remained significant when examined in logistic regression models. Female Veterans at risk for alcohol use disorders may benefit from screening and intervention efforts that take into account exposure to interpersonal violence and mental health symptoms.
    Date: December 7, 2015
  • Effect of Childhood Physical and Sexual Abuse on Female Veterans’ Health and Healthcare Use
    This study sought to investigate whether childhood physical abuse and childhood sexual abuse predict health symptoms and healthcare use. Findings showed that childhood physical abuse was an important contributor to both physical and mental health for female Veterans. After adjusting for age, race, military branch, childhood sexual abuse, and MST, childhood physical abuse was predictive of poorer physical health, greater depressive and PTSD symptoms, and more frequent use of medical healthcare. No significant association was found between childhood sexual abuse and poor physical or mental health, and it was not a predictor for healthcare use. Screening for adverse childhood experiences may facilitate access to appropriate physical and mental health treatment, as well as inform mental health assessment and treatment planning, among female Veterans.
    Date: October 1, 2015
  • Systematic Review of PTSD Screening Instruments
    Investigators in this study conducted a systematic review of self-report screening instruments for PTSD among primary care and high-risk populations. Findings showed that the Primary Care Post-Traumatic Stress Disorder screener (PC-PTSD) and the 17-item PTSD-Checklist (PCL) were the best performing instruments. Both show reasonable performance characteristics for use in primary care clinics or in community settings with high-risk populations. Both also are easy to administer and interpret, and can readily be incorporated into a busy practice. Two multi-condition instruments (My Mood Monitor, and the Provisional Diagnostic Interview-4 Anxiety) and three anxiety/general distress instruments (K6, GAD-7, and the Anxiety and Depression Detector) were evaluated in primary care settings, but performed less well than instruments that were specifically designed to detect PTSD. Both patients and physicians felt that screening facilitated discussion of mental health issues in the subsequent primary care visit, and 80% of primary care physicians reported that the screen was helpful in interactions with their patients.
    Date: August 4, 2015
  • Telemedicine-Delivered Psychotherapy for Older Veterans with Depression as Effective as In-Person Psychotherapy
    This study assessed the efficacy of psychotherapy delivered to older Veterans via telemedicine in their homes. Findings showed that telemedicine-delivered psychotherapy for older Veterans with major depression produced outcomes that were no worse than in-person treatment delivery. Treatment response did not differ significantly between the telemedicine and same-room therapy groups on any of the instruments used. A high proportion of Veterans were rural residents (71%) and average session attendance was high (81% of Veterans in the telemedicine group completed all 8 sessions as did 79% of Veterans in the same-room group).
    Date: August 1, 2015
  • Receipt of Opioid Analgesics and Benzodiazepines Associated with Increased Risk of Death Due to Drug Overdose
    This study sought to describe the relationship between the receipt of concurrent benzodiazepines and opioid analgesics and death due to drug overdose in patients receiving prescription opioids for acute, chronic, and non-terminal cancer pain. Findings showed that during the study period, 27% of Veterans who received opioid analgesics also received benzodiazepines. Among those receiving opioid analgesics, receipt of benzodiazepines was associated with an increased risk of death due to drug overdose. About half of the overdose deaths occurred when Veterans were concurrently prescribed benzodiazepines and opioids. Patients who were prescribed concurrent opioids and benzodiazepines –and then stopped receiving benzodiazepines had higher rates of overdose than those patients who had only received opioids. Veterans who received benzodiazepines were more likely to be female, middle-aged, white, and to reside in wealthier areas. Veterans who received benzodiazepines were also more likely to have had a recent mental health or substance use disorder-related hospitalization, a diagnosis of a substance use disorder, or a number of psychiatric disorders (i.e., PTSD, depression, anxiety). These findings provide empirical support for the goal of the VA Opioid Safety Initiative (OSI) to reduce unnecessary co-prescribing of opioids and benzodiazepines, for which there had been limited evidence prior to this study.
    Date: June 10, 2015
  • Post-Menopausal Symptoms among Women Veterans with and without Type 2 Diabetes
    This study sought to describe the postmenopausal symptom experience in women with type 2 diabetes – and to examine the association between glucose control and symptom severity. Findings showed that, despite higher BMI and increased comorbidities in women Veterans with diabetes compared to those without diabetes, the pattern of menopause symptoms did not differ by group. Symptom severity scores were highest for muscle and joint aches, followed by hot flashes and trouble sleeping, while headaches received the lowest severity scores. Measures of mental health (i.e., anxiety, depressed mood) were similar across groups. Among women Veterans with diabetes, worse glucose control, smoking, and a diagnosis of altered mood demonstrated a positive association with perceived menopause symptom severity, even after adjusting for other covariates. Women without diabetes were younger, of lower BMI, had fewer self-reported comorbid conditions, and reported better physical health.
    Date: June 1, 2015
  • Substantial Proportion of Homeless and Unstably Housed Veterans with Minor Children has Serious Mental Illness
    This study examined the prevalence of homeless and unstably housed Veterans with minor children and compared sociodemographic characteristics, as well as medical and mental health conditions of homeless and unstably housed Veterans with and without children. Findings showed that unstably housed Veterans were more likely to have children than homeless Veterans, and women more likely than men. Among both homeless and unstably housed male Veterans with minor children, only about one-third to one-half had custody of their minor children, whereas among women, nearly all had custody of their minor children. Both homeless male and female Veterans with children were younger and less likely to have chronic medical conditions and psychiatric disorders than their homeless counterparts. However, 72% of male and 67% of female Veterans with children had a psychiatric diagnosis, and 11% of both men and women were diagnosed with a psychotic disorder. Men also were more likely to have PTSD and other anxiety disorders compared to male Veterans without children. Veterans with minor children were more likely to be referred and admitted to VA’s permanent supported housing program than other Veterans, and women with minor children in their custody were even more likely to be referred and admitted than men. Rates of referrals to mental health services were relatively low (22% and 25% for Veterans with and without children, respectively) given the high prevalence of psychiatric diagnoses in the sample.
    Date: May 15, 2015
  • Prevalence of Alcohol Misuse among Women Veterans High Regardless of Care Setting
    This study sought to estimate the prevalence and correlates of alcohol misuse in women Veterans – and to assess the associations between alcohol misuse and mental health use in a group comprising both VA healthcare system users and non-users. Findings showed that women Veterans who did not use VA healthcare had a higher prevalence of alcohol misuse (32%) compared to women Veterans who did use VA healthcare (27%). The prevalence of binge drinking was similar for VA non-users (26%) and VA users (24%). The prevalence of past-year mental healthcare among women Veterans with alcohol misuse was higher for VA users than for non-users: 26% versus 5% for mild alcohol misuse, and 43% versus 17% for moderate-to-severe alcohol misuse. Among VA non-users, 46% of women Veterans with PTSD and 66% of those with sexual assault in the military screened positive for alcohol misuse. Among VA healthcare users, the prevalence of alcohol misuse was notably high among younger women (ages 18-44, 43%), those who served in OEF/OIF (51%), and those with combat exposure (41%).
    Date: May 1, 2015
  • NEJM Perspective Discusses Withholding of CMS Data Related to Substance Use Disorder and Its Impact on Research
    In November 2013, the Centers for Medicare and Medicaid Services (CMS) began to withhold from research data sets any Medicare or Medicaid claim with a substance use disorder (SUD) diagnosis or related procedure code. This move — the result of privacy-protection regulations overseen by the Substance Abuse and Mental Health Services Administration — affects about 4.5% of inpatient Medicare claims [recent research suggests this figure is closer to 7%] and about 8% of inpatient Medicaid claims from key research files, impeding a wide range of research evaluating policies and practices intended to improve care for patients with substance use disorders. As a consequence, VA researchers cannot see the full utilization of Veterans who also use Medicare- or Medicaid-financed healthcare. This Perspective summarizes the problem, quantifies it, describes how it arose, and argues that research access to such data should be restored.
    Date: April 15, 2015
  • VA Maintains Access to Care as Need for Substance Use Treatment Grows
    VA has enhanced funding of mental health programs and substance use disorder (SUD)-specific treatment and also has directed approximately $152 million toward hiring additional SUD staff. This study examined the relationship between dedicated SUD funding and SUD performance measures from 2005 and 2010 for VA medical centers. Findings showed that, overall, access and quality of care kept pace with the demand for SUD services in the VA healthcare system. There was a statistically significant and generally positive correlation between additional, dedicated SUD resources and access and treatment intensity. The number of VA patients with an SUD diagnosis grew from about 310,000 in 2005 to 439,000 in 2010 – an increase of 42%. Average dedicated SUD funding per facility grew from $65,870 in 2005 to $324,416 in 2007, falling to $147,151 in 2009 and 2010. However, not all VAMCs received funding in each year.
    Date: March 12, 2015
  • Having Dependent Children Associated with Increased Risk of PTSD among OEF/OIF Veterans
    This is the first study to examine whether being the parent of a dependent child was, in itself, associated with the likelihood of post-deployment PTSD diagnosis among Veterans. Findings showed that after controlling for demographics, mental healthcare use, and other serious mental illness, OEF/OIF Veterans with dependent children were about 40% more likely to carry a diagnosis of PTSD. This association was stronger among men than women. Other variables associated with increased odds of PTSD diagnosis included male gender, white race, Hispanic ethnicity, younger age, Priority 1 status, more than one dependent child, depression or SUD diagnosis, greater use of mental health services, and more medical comorbidities. Veterans with dependent children had greater VA mental healthcare utilization, including inpatient psychiatric admissions and mental health counseling visits. Thus, it may be of value for clinicians to consider parental status when treating Veterans with PTSD.
    Date: January 19, 2015
  • Increasing VA Rates of Psychotherapy among Rural- and Urban-Dwelling Veterans with Mental Illness
    This retrospective study evaluated changes in rural-dwelling Veterans’ use of psychotherapy during a period of widespread organizational efforts to engage this patient population in mental health service use – and compared their use of psychotherapy with urban-dwelling Veterans. Findings showed that VA psychotherapy use is increasing among both urban- and rural-dwelling Veterans with a new diagnosis of depression, anxiety, or PTSD. Over the four-year study period, the proportion of Veterans receiving any psychotherapy increased from 17% to 22% for rural Veterans and 24% to 28% for urban Veterans. With respect to psychotherapy dose, the proportion of both rural- and urban-dwelling Veterans receiving 4+ and 8+ psychotherapy sessions increased from 2007 to 2010. And although rural-dwelling Veterans received, on average, fewer psychotherapy sessions than urban-dwelling Veterans, this gap decreased over time. By 2010, the mean number of sessions attended by rural Veterans (5 sessions) was only 1 session less than their urban counterparts (6 sessions). Rates of PTSD diagnosis were higher among urban-dwelling Veterans, whereas rates of depression and anxiety were higher among rural-dwelling Veterans.
    Date: December 3, 2014
  • Rates of Suicide Higher among Transgender Veterans
    This study sought to document all-cause and suicide mortality among VA healthcare users with an ICD-9-CM diagnosis consistent with transgender status. Findings showed that the crude suicide rate among Veterans with transgender-related diagnoses across the 10-year study period was approximately 82/100,000 person-years, which approximated the crude suicide death rates for Veterans with serious mental illness (e.g., depression, schizophrenia). However, this rate was higher than in both the general VA and U.S. populations. Comparisons of age at time of death suggest Veterans with transgender-related diagnoses may be dying by suicide at younger ages than Veterans without such diagnoses. The average age of transgender Veterans at the time of death by suicide was 49 years compared with studies that show the average age of death among non-transgender Veterans who die from suicide was between 55 and 60 years. Diseases of the circulatory system and neoplasms were the first and second leading causes of death among transgender Veterans, however, the other ranked causes of death differed somewhat from patterns among the general U.S. population for the same time period. For example, certain infectious and parasitic diseases were the 6th leading cause of death among transgender Veterans, whereas they ranked 9th among the general U.S. population. Authors suggest future research is needed to examine how transgender Veterans seek or receive mental health services and that programs aimed at suicide prevention may benefit from clinical education and training about transgender populations.
    Date: December 1, 2014
  • Characteristics Associated with Suicide among Male Veterans Treated in VA Primary Care
    This study sought to identify characteristics of Veterans who received VA primary care in the six months prior to suicide (in 2009) – and compare these to control patients who also received primary care at the same 41 VA facilities in 11 geographically diverse states. Findings showed that compared to controls, Veterans who died by suicide were significantly more likely to be unmarried, white, and to have major depression, bipolar disorder, anxiety disorder other than PTSD, and/or an alcohol or other substance use disorder diagnosis. Veterans who died by suicide also were more likely to have documented functional decline, sleep disturbance, expressions of anger, and suicidal ideation. The odds of dying by suicide were greatest among Veterans with anxiety disorder diagnoses and functional decline. A diagnosis of PTSD was not significantly associated with suicide, nor was a pain diagnosis or general medical comorbidity. Also, non-white race and a VA service-connected disability rating were associated with decreased odds of suicide. The assessment of anxiety disorders and functional decline, in particular, may be important for determining suicide risk among Veterans. The authors suggest continued development of interventions that support identifying and addressing these conditions in primary care.
    Date: December 1, 2014
  • Racial/Ethnic Disparities in Treatment Retention for Veterans with PTSD
    This study of Veterans recently diagnosed with PTSD sought to determine whether the odds of premature mental health treatment termination varied by patient race/ethnicity and, if so, whether such variation is due to differential access to services or beliefs about mental health treatment, or whether there is a disparity in the provision of treatment. Findings showed that compared to White Veterans, African-American and Latino Veterans were less likely to receive a minimal trial of pharmacotherapy and, overall, African-Americans were less likely to receive a minimal trial of any treatment in the six months after being diagnosed with PTSD. Controlling for beliefs about mental health treatments diminished the lower odds of pharmacotherapy retention among Latino Veterans but not African-American Veterans. As expected, positive beliefs about psychotherapy or pharmacotherapy facilitated treatment retention. Access barriers did not contribute to treatment retention disparities. They significantly impacted psychotherapy participation, but equally across the entire sample. To improve treatment equity, clinicians may need to directly address patients’ treatment beliefs and preferences.
    Date: November 24, 2014
  • Study Highlights Mental Health Services Important to Women Veterans
    Investigators in this study identified a subset of women Veteran primary care users who were potential stakeholders for mental health services, and then quantified their priorities for these services. Treatment for depression, pain management, coping with chronic conditions, sleep problems, weight management, and PTSD emerged as the top six mental healthcare priorities for women. The majority of women Veterans in this study (98%) selected at least one of these services as important, and 80% selected at least three of these six services as important. The majority of women who prioritized each of these six services reported that they had either used this type of service in the past year or were quite a bit or extremely likely to use the service within the next six months, ranging from 62% for weight management to 96% for chronic conditions. Findings suggest that women’s primary care clinics, which are available at many VA healthcare facilities, are a strategic setting to enhance the implementation of women’s health services through primary care-mental health integration.
    Date: November 17, 2014
  • VA PACT Implementation Increases Primary Care among Veterans with PTSD
    This study assessed the association between PACT and the use of health services among Veterans with PTSD. Findings showed that the period following PACT implementation was associated with lower rates of hospitalization and specialty care visits and a higher rate of primary care visits for Veterans with PTSD, indicating enhanced access to primary care. Adjusted results show a 9% decrease in hospitalizations, an 8% decrease in specialty care, and an 11% increase in primary care visits in the post-PACT period. No significant effects were found on mental health, ED, or urgent care visits. For Veterans younger than 65 years, findings mirrored the full sample, with significantly lower hospitalizations and specialty care visits and higher primary care visits in the post-PACT period. However, for Veterans older than 65 years, there were significant increases in both primary and specialty care visits, significant decreases in urgent care visits, and no significant decrease in hospitalizations.
    Date: November 10, 2014
  • Gender Differences in Attitudes and Their Relationship to VA Mental Healthcare Use
    This study explored gender differences in attitudinal barriers to and facilitators of care for OEF/OIF Veterans, and determined the relationship of those factors to VA mental health service use among female and male Veterans with probable mental health conditions. Findings showed that Veterans were similar in their perceptions of VA healthcare and their perceived fit within the VA healthcare setting. Men held slightly more negative attitudes about mental illness and treatment than women. For both women and men, perceived entitlement to VA care was associated with increased likelihood of service use, and negative beliefs about treatment seeking (e.g., a problem would have to be really bad to seek mental health treatment) were associated with a reduced likelihood of seeking mental healthcare in the past six months. For female Veterans only, positive perceptions of VA healthcare were associated with increased likelihood of seeking VA mental health treatment. For male Veterans only, researchers found a positive relationship between VA service use and negative attitudes toward mental health treatment (e.g., mental health treatment does not work). Perceived similarity to other VA healthcare users was also associated with increased likelihood of service use, while negative beliefs about mental illness (e.g., people with mental health problems are violent or dangerous) were associated with lower likelihood of service use.
    Date: November 3, 2014
  • JGIM Supplement Highlights VA’s Partnered Research
    In this JGIM Supplement, 12 articles describe partnered research at various stages – from conceptualizing partnered research to examples of findings borne from bi-directional collaborations with investigators and leaders from clinical operations. These articles cover a wide range of topics highly relevant to VA policy and practice, including performance measure implementation on provider motivation, opioid management, suicide prevention, homelessness, medical home models, and communication of adverse events.
    Date: November 1, 2014
  • Predictors of Worsening Mental Health among OEF/OIF Veterans
    This study sought to identify predictors of worsening mental health, including PTSD and alcohol use, as well as variables that are protective (resilience factors) against worsening mental health in a national sample of OEF/OIF Veterans. Findings showed that 14–25% of these returning OEF/OIF military personnel showed clinically worse mental health, PTSD, or alcohol use at 6-month follow-up. Eleven variables were significantly associated with a decline in overall mental health status from Time 1 to Time 2: Black race, being in the National Guard, more bothersome physical health problems, worse mental health at Time 1, less PTSD symptom severity, lack of psychiatric care between Time 1 and Time 2, more difficult deployment environment, less perceived threat, less sexual harassment, higher levels of hardiness, and lower levels of self-efficacy. Nine variables predicted a worsening of PTSD symptom severity: being younger than 26 years old, unemployed, divorced or separated, higher PTSD symptom severity at Time 1, lack of any psychiatric treatment between Time 1 and Time 2, difficult childhood family environment, greater sexual harassment in one’s unit, lower levels of deployment preparedness, and higher levels of post-deployment social support. Fourteen variables predicted worsening alcohol use, including being male, under 26 years old, less educated, Hispanic, separated or divorced, and being in the National Guard or Marines. National Guard and other Reserve soldiers worsened on both the general mental health and alcohol use measures from Time 1 to Time 2 compared to active duty soldiers, suggesting that these groups may require help with reintegration. Higher education, self-efficacy, unit support, and deployment preparedness had a protective effect on both worsening PTSD and alcohol use.
    Date: October 1, 2014
  • Adverse Childhood Experiences More Common among Men with Military Service
    Those with a history of military service may be a specific subpopulation of interest regarding adverse childhood experiences (ACE), as some may enlist to escape personal problems, potentially elevating the prevalence of ACE among military populations. This study sought to compare the prevalence of ACE among individuals with and without histories of military service based on service during the draft era (enlisted prior to 1973) or during the all-volunteer era (enlisted on/after 1973). Findings showed that men with military service during the all-volunteer era had a higher prevalence of all 11 ACE items than men without military service in this era. Notably, men with military service during this era had more than twice the odds of men without military service history of reporting household drug or alcohol abuse while growing up, suffering physical abuse or witnessing domestic violence, or some form of sexual abuse (being touched or being forced to touch, or to have sex before age 18). During this era, men with military service had more than twice the prevalence of experiencing 4 or more ACE categories (27% vs. 13%) compared to those without military service. Markedly fewer differences in ACE were found among women with and without military service histories across either era. Women with military service histories from both eras had similar patterns of elevated odds for physical abuse, household alcohol abuse, exposure to domestic violence, and emotional abuse compared with women without military service. Identifying the presence of ACE among military service members and Veterans may aid in better understanding the etiology of trauma-related mental and behavioral health conditions as well as the cumulative impact of trauma.
    Date: September 1, 2014
  • Providers’ Endorsement of Stigma Regarding Mental Illness Is Related to Patient Treatment Options
    This study examined provider response to two treatment options that might be offered to a male patient with schizophrenia who was seeking help for low back pain due to arthritis: 1) referral for specialist consult, or 2) refilling the patient’s prescription for Naproxen. Findings showed that healthcare providers who endorsed more stigmatizing attitudes about mental illness were likely to be more pessimistic about the patient’s adherence to treatment. Stigmatizing attitudes were greater among those providers who were relatively less comfortable with using mental health services themselves. Greater perceived treatment adherence was positively associated with both health decisions: referrals and prescription refill. Thus, poor perceived adherence was partly a proxy for stigmatizing attitudes providers held about people with mental illness, which in turn led to different treatment decisions in patients with serious mental illness. Providers from mental health backgrounds showed no difference in expectations about treatment response than primary care professionals, suggesting that both primary care and mental health providers should be targets of interventions aimed at decreasing disparities in clinical care.
    Date: August 15, 2014
  • Detection of Suicidal Ideation Not Associated with Increased Mental Health Utilization in Year Following SI Assessment
    This study evaluated the impact of brief suicidal ideation (SI) assessments on mental healthcare use among new-to-care OEF/OIF Veterans. Findings showed that 32% of the Veterans in this study had positive SI assessment results. The detection and presence of suicidal ideation was not associated with subsequent mental healthcare utilization over the following year, when accounting for the severity of depression symptoms. In other words, SI itself was not found to be associated with increased Veteran engagement in specialty mental healthcare over and above depression symptom severity. When a Veteran’s inaugural visit to VA healthcare included a mental health clinician, the Veteran was more likely to attend more subsequent specialty mental health visits – and to receive an antidepressant medication – than Veterans who were seen by a primary care clinician only.
    Date: July 30, 2014
  • Risk Factors for Suicide-Related Behavior among OEF/OIF Veterans with “Polytrauma Clinical Triad”
    The co-occurrence of PTSD, TBI, and chronic pain is known as the “Polytrauma Clinical Triad” (PCT). This study examined the association of these conditions, independently and in interaction with other conditions, with the risk of suicide-related behavior (SRB) among OEF/OIF Veterans. Findings showed that the PCT was a moderate predictor of suicide-related behavior, but did not appear to increase risk for SRB above that associated with PTSD, depression, or substance abuse alone. Moreover, PTSD comorbid with either depression or substance abuse significantly increased risk for suicidal ideation. Veterans with a diagnosis of bipolar disorder, anxiety, substance abuse, schizophrenia, depression, or PTSD were significantly more likely to be diagnosed with all three categories of SRB. Female Veterans were less likely than male Veterans to exhibit suicidal ideation, which contradicts prior research and may suggest that females are less comfortable reporting ideation within VA. Risk for SRB was highest in the 18-25 year old age group.
    Date: July 17, 2014
  • Only Small Percentage of Veterans with Mental Illness Access VA Employment Services
    This study sought to assess the reach of Therapeutic and Supported Employment Services (TSES) over one year by examining the percentage of VA healthcare users with psychiatric diagnoses that accessed any TSES services, as well as specific types of services (i.e., supported employment, transitional work, incentive therapy, and vocational assistance). Findings showed that only a small percentage of Veterans with psychiatric diagnoses (4%) accessed even one VA employment service in FY10. Among Veterans who accessed at least one visit for employment services, 35% received transitional work, 30% vocational assistance, 28% supported employment (considered the gold standard, evidence-based practice), and 8% incentive therapy. Veterans with schizophrenia and bipolar disorder were more likely to receive any employment services and to receive supported employment than Veterans with depression, PTSD, or other anxiety disorders. Veterans with depression and PTSD were more likely to receive transitional work and vocational assistance than those with schizophrenia. African Americans, and those with a substance use disorder or an indication of homelessness were more likely to receive employment services, but were less likely to receive supported employment, specifically.
    Date: July 1, 2014
  • High Prevalence of Reintegration Difficulty among OEF/OIF/OND Veterans, Particularly among VA Healthcare Users
    This study sought to estimate the prevalence of perceived reintegration difficulty in the entire population of OEF/OIF/OND Veterans. Findings showed that the estimated prevalence of “at least a little” reintegration difficulty among this population was 54% and was higher among VA healthcare users than among non-users (62% vs. 45%). Among those with at least a little reintegration difficulty, VA healthcare users reported higher levels of combat exposure and were more likely to meet criteria for probable TBI and PTSD compared to non-users. [Veterans with probable TBI were more than twice as likely to be VA healthcare users.] VA users also reported higher levels of psychological distress, physical symptoms, and reintegration difficulty, and were much more likely to report having sought medical care for physical or mental health problems over the past three months. Veterans with reintegration difficulty who also had service-connected mental and physical health conditions were two to four times more likely to be VA healthcare users. And as time since deployment increased, the likelihood of being a VA user also increased.
    Date: June 11, 2014
  • Trends in Healthcare Use and Costs after VA’s Implementation of Patient-Aligned Care Teams
    This study analyzed data for 11 million VA primary care patients treated from FY03 through FY12 to assess how trends in healthcare use and costs changed after the PACT implementation. Findings showed that PACT implementation was associated with modest increases in primary care visits – and with modest decreases in both hospitalizations for conditions like heart failure that might be avoided with better ambulatory care, and outpatient visits with mental health specialists. It is estimated that these changes avoided $596 million in costs compared to the investment in PACT of $774 million, for a potential net loss of $178 million during the study period. The investment in PACT was overwhelmingly attributed to hiring personnel to staff primary care teams. Although PACT has not generated a positive financial return, it is still maturing and trends in costs and use are favorable. Thus, adopting patient-centered care does not appear to have been a major financial risk for VA.
    Date: June 1, 2014
  • Negative Mental Health Beliefs are a Significant Barrier to Care for OEF/OIF Veterans with Mental Health Problems
    The primary aim of this study was to document concerns about stigma and personal beliefs about mental illness and treatment among OEF/OIF Veterans. Findings showed that OEF/OIF Veterans endorsed a variety of mental health beliefs that may serve as barriers to care. Concerns about stigma in the workplace were most commonly reported, followed by negative beliefs about treatment-seeking, concerns about stigma from loved ones, and negative beliefs about mental illness. Although more than one-third of the Veterans in the study generally disagreed with survey items reflecting negative beliefs about mental health treatment, 50% of the survey respondents were classified in the “neither agree nor disagree” category, suggesting that they may be neutral or undecided in their beliefs about treatment. Veterans with probable mental health problems were more likely to report negative mental health beliefs than Veterans without mental health problems. Specifically, Veterans with probable diagnoses of depression and PTSD were more concerned about stigma from loved ones and in the workplace than Veterans without these conditions. Negative beliefs about treatment-seeking were related to lower likelihood of seeking mental healthcare for Veterans with probable PTSD, depression, and alcohol abuse. Although concern about stigma in the workplace was most commonly reported, it was unrelated to healthcare use.
    Date: June 1, 2014
  • Factors Related to Use of Psychotherapy among Veterans
    This study sought to examine predisposing, enabling, and need factors related to low, moderate, high, and very high levels of psychotherapy use among Veterans newly diagnosed with PTSD, depression, and anxiety. Findings showed that need factors appeared to be most strongly linked to psychotherapy utilization. Very high psychotherapy users had higher rates of PTSD and substance use disorders (SUD), more comorbid psychiatric diagnoses, and more inpatient psychiatric stays. In the year after initiating psychotherapy, half of the sample received only 1-3 psychotherapy sessions (low-users); 42% received 4-18 sessions (moderate-users); 5% received 19-51 sessions (high-users), and 2% received more than 52 sessions (very high-users). Low-users predominantly received individual psychotherapy; very high-users received relatively more group psychotherapy. Younger (<35) and older (65+) Veterans were proportionately more likely to be low-users. Low-users also had lower psychiatric comorbidity, fewer inpatient days, and were less likely to be diagnosed with PTSD and SUD. Results suggest many Veterans may not receive a clinically optimal dose of psychotherapy, highlighting the need to enhance retention in therapy for low utilizers and examine whether very high utilizers are benefitting from extensive courses of treatment.
    Date: May 19, 2014
  • “Virtual” Hope Box Smartphone App Delivers Patient-Tailored Coping Tools to Help Veterans at Risk for Suicide
    Tools that assist patients in accessing and affirming their reasons for living can enable them to mitigate suicidal thoughts. One such tool has been labeled a “hope box”: a physical representation of the patient’s reasons for living, reminders of individual accomplishments and future aspirations, or things the individual finds soothing, e.g., a worry stone, family photographs, or letters. However, a conventional hope box can by physically unwieldy and inconvenient; thus, the investigators in this study developed a “Virtual” Hope Box (VHB) for service members and Veterans that expands the reach of the hope box modality to a smartphone app. This study compared the VHB with a Conventional Hope Box (CHB) integrated into VA behavioral health treatment. Compared with a CHB, more Veterans used the Virtual Hope Box regularly and found it to be beneficial, helpful, and easy to set up. Veterans stated that they would recommend the VHB to their peers, and twice as many preferred the VHB over the CHB for future use. Written comments from Veterans cited the helpfulness of the VHB with managing distress, negativity, hopelessness, anger, and various other symptoms. Moreover, mental health clinicians were unanimous in their praise for the VHB as an eminently usable therapeutic tool.
    Date: May 15, 2014
  • PTSD Treatment via Video-Teleconferencing as Effective as In-Person Treatment
    This study is the first randomized controlled trial to compare the efficacy of delivering “cognitive processing therapy-cognitive only” (CPT-C) via video-teleconferencing (VTC) to in-person delivery among a sample of rural Veterans. Findings showed that the use of clinical video-conferencing services to provide CPT-C therapy to Veterans with PTSD who lived in rural settings was as effective as face-to-face treatment. Significant reductions in PTSD symptoms were identified at post-treatment and 3- and 6-month follow-ups. High levels of therapeutic alliance, treatment compliance, and satisfaction, and moderate levels of treatment expectancies were reported, with no differences between groups. VTC technology evidenced very few disruptions, and no sessions were canceled due to technological difficulties. There were no adverse events associated with delivering CPT-C through videoconferencing.
    Date: May 1, 2014
  • Benefits for Veterans with Dementia who Participate in VA Program Integrating Healthcare and Community Services
    This study tested the effectiveness of a telephone-based care-coordination program – Partners in Dementia Care (PDC) – that integrated healthcare and community services through structured coaching and support. PDC targeted both Veterans and their primary informal caregivers. Findings showed that compared to usual care, PDC was associated with significantly lower levels of self-reported adverse outcomes among Veterans. Improvements in all but one outcome (embarrassment about memory problems) were restricted to Veterans who were more cognitively impaired or had more difficulties with personal care. Beneficial effects after 6 months were evident in reduced relationship strain, depression, and unmet needs for more impaired Veterans – and reduced embarrassment about memory problems for all Veterans. In addition, between months 6 and 12, there were further reductions in unmet needs for more impaired Veterans.
    Date: February 28, 2014
  • Social Network Encouragement Helps Veterans with PTSD Seek VA Mental Healthcare
    This study sought to determine whether beliefs about mental health treatment and/or social encouragement to seek treatment influence initiation of mental healthcare among Veterans with PTSD. Findings showed that whether Veterans initiate mental healthcare after a PTSD diagnosis depends not only on symptom severity and access to treatment, but also on encouragement by those in their social network, whether the Veteran perceives the need for treatment, how they view treatment for PTSD (e.g., positive beliefs about the efficacy of antidepressants), as well as their ability to follow treatment recommendations. Encouragement to get mental healthcare by individuals in their social network increased the odds of getting treatment, even after controlling for beliefs, particularly if encouragement was given by both family and friends/other Veterans. While not the focus of this study, investigators noted that for all outcomes, older VA healthcare users, Veterans with service connection, and those who were diagnosed in non-mental health clinics were less likely to receive treatment. In addition, Veterans who were seen in PTSD specialty clinics, though less likely to receive medication than those in general mental health clinics, were more likely to receive psychotherapy.
    Date: February 3, 2014
  • Anxiety Disorders and Depression Associated with Risk of Future Heart Failure among Veterans
    This study sought to determine if the risk of heart failure (HF) was greater in Veterans with: 1) a diagnosis of one or more anxiety disorders but who were free of major depressive disorder (MDD); 2) MDD but free of anxiety disorders; or 3) comorbid anxiety and depressive disorders. Findings showed that in the model that corrected for age only, Veterans with anxiety disorders, MDD, or both were each about 20% more likely to develop HF compared to Veterans without these conditions. This effect remained significant after adjusting for other HF risk factors (e.g., sociodemographics, nicotine use, substance use disorders), and was even greater after adjusting for psychotropic medications. Compared to Veterans without HF, patients with HF were significantly older and more frequently male, non-white, unmarried, holders of supplemental insurance, and were significantly more likely to have diagnoses of hypertension, diabetes, and obesity. Veterans with both anxiety and MDD were more likely to have a diagnosis of substance abuse or dependence and history of nicotine use – and to receive a prescription for psychotropic medication.
    Date: February 1, 2014
  • Increasing Number of Women Veterans Use VA Maternity Benefits
    This study examined the number and cost of inpatient deliveries in VA over a five-year period – from FY2008 to FY2012. Findings showed that the volume of women Veterans using VA maternity benefits increased by 44% – from 12.4 to 17.8 deliveries per 1,000 women Veterans. Also, the number of deliveries increased during each year – from 1,442 delivery claims in FY2008 to 2,730 in FY2012. A majority of women using VA maternity benefits were age 30 and older, resided in urban areas, and had a service-connected disability. Also, 42% were OEF/OIF/OND Veterans. Over the five-year study period, VA paid more than $46 million in delivery claims to community providers for deliveries of women Veterans ($4,993 per Veteran). The rate of C-section delivery was 34%, which is similar to the national average of 32%. Given the sizeable increase in delivery rates, the authors suggest that VA increase its capacity for pregnant Veterans and ensure care coordination systems are in place to address the needs of pregnant Veterans with service-connected disabilities. Coordinating community-based maternity care with ongoing VA care is critical because many women Veterans have complex medical and mental health conditions that may increase their risk of adverse pregnancy outcomes.
    Date: January 1, 2014
  • Chronic Opioid Therapy Common among Hospitalized Veterans, Associated with Increased Risk of Death and Re-Admission
    This study sought to determine the prevalence of prior chronic opioid therapy (COT) among hospitalized medical patients, in addition to examining characteristics associated with inpatients that had previous opioid therapy compared to those with no opioid therapy prior to hospital admission. Findings showed that COT is common among hospitalized Veterans; moreover, occasional and chronic opioid use was associated with increased risk of hospital readmission and COT was associated with increased risk of death. Nearly 1 in 4 hospitalized Veterans had current or recent COT at the time of hospital admission for non-surgical conditions, and nearly half had been prescribed any opioids. Among the Veterans in this study, 26% had received COT in the prior 6 months, and 20% had occasional opioid therapy. Diagnoses more common in Veterans with COT included COPD, complicated diabetes, PTSD, and other mental health disorders.
    Date: December 6, 2013
  • Ethnic Differences in Receipt of Depression Care
    This study sought to characterize differences in treatment for multiple racial/ethnic groups of Veterans with ongoing depression. Findings showed that there were significant differences in the receipt of depression care between multiple racial/ethnic groups of chronically depressed Veterans. Compared to white Veterans, nearly all minority groups had lower odds of adequate antidepressant use; adequate psychotherapy was more common among minority Veterans in initial analyses but differences between Hispanic, AI/AN, and white Veterans were no longer significant in adjusted analyses. Primarily due to lower use of antidepressants, nearly all minority groups had lower rates of guideline-concordant care than white Veterans with depression. Overall, 51% of Veterans received adequate antidepressant care for the 6-month period following their most recent VA healthcare visit for depression; 10% of Veterans attended at least 6 psychotherapy visits within the same time period; and 55% received guideline-concordant care. Further research is needed to determine whether the observed differences in treatment arise from patient-centered preferences for care (for example, lower willingness to take anti-depressant medication among minority patients) or from providers’ failure to adhere to best-care practices.
    Date: November 1, 2013
  • Veterans with Non-Specific Anxiety Diagnosis Less Likely to Access Mental Healthcare than Veterans with Specific Anxiety Disorders
    This study sought to determine the rates of specific and non-specific anxiety diagnoses in a national sample of Veterans receiving outpatient care at VAMCs – and to examine patterns of mental healthcare use in the year following diagnosis. Findings showed that “Anxiety Disorder Not Otherwise Specified” (anxiety NOS) was diagnosed in 38% of this Veteran cohort. Most Veterans with a specific anxiety diagnosis received mental health services, with treatment rates for patients with the most frequently diagnosed specific anxiety disorders (PTSD, generalized anxiety disorder, and panic disorder) ranging between 60% and 67%. In contrast, only 32% of patients with anxiety NOS received mental health services during the 12 months following diagnosis. Most Veterans with an anxiety NOS diagnosis did not go on to receive a specific diagnosis in the next 12 months. However, most anxiety NOS patients who later received a diagnosis of a specific anxiety disorder (87%) received mental health services in the year following their index date, compared to 29% of Veterans who did not receive a subsequent specific anxiety disorder diagnosis. Patient factors that increased the likelihood of an anxiety NOS diagnosis included: female gender, older age, the absence of specific comorbid diagnoses (i.e., substance-use disorders, bipolar disorder), and absence of service-connected disability. Veterans diagnosed in specialty mental health or integrated primary care-mental health settings were less likely to receive an anxiety NOS diagnosis than patients in primary care.
    Date: October 22, 2013
  • Increase in Psychotherapy Since 2004 Corresponds with VA’s Efforts to Improve Access to Mental Health
    This study examined longitudinal changes in VA psychotherapy use corresponding with widespread programmatic change targeting increased availability and quality of mental healthcare. Findings showed that the number of Veterans newly diagnosed with depression, anxiety, or PTSD increased by nearly 40% between 2004 and 2010. Rates of PTSD grew most substantially, increasing by more than 2-fold. During this time, the proportion of Veterans with depression, anxiety, or PTSD receiving psychotherapy grew from 21% to 27%. In addition, psychotherapy dose increased – a growing proportion of Veterans received eight or more psychotherapy sessions. More Veterans engaged in individual than group psychotherapy across all study years. However, Veterans who engaged in group psychotherapy received more sessions of psychotherapy than those in individual psychotherapy. Treatment delays decreased across study time points. The median time between index diagnosis and psychotherapy dropped from 56 days in 2004 to 47 days in 2010. Although Veterans with PTSD consistently had shorter delays than Veterans with depression or anxiety, diagnostic disparities in time until treatment grew smaller across the study time points. Consistent with VA expansion efforts, more substantial increases in psychotherapy access, dose, and timeliness occurred between 2007 and 2010 relative to 2004 and 2007.
    Date: October 1, 2013
  • Home Safety Intervention Improves Caregiver Competence for Individuals with Alzheimer’s Disease
    This trial sought to give informal caregivers the knowledge and resources to prevent risky behaviors and accidents in the homes of persons with dementia of the Alzheimer’s type (DAT) or a related dementia. Investigators designed a Home Safety Toolkit that includes a booklet on high-frequency/high-severity risks for accidents and injuries in the home, and sample items (i.e., smoke alarm, night lights, slide bolt lock, medicine case) that allow caregivers to make easy home safety modifications. Findings showed that all outcome variables improved more for caregivers in the Home Safety Toolkit intervention group than for caregivers in the control group. For example, caregivers in the intervention group had significantly improved home environmental safety compared to those in the control group, and patients in the intervention group had fewer risky behaviors and accidents compared to patients in the control group. The intervention group had 80% overall confidence in their ability to make a home safer compared to 75% for caregivers in the control group. Caregivers in the intervention group also had lower perceived strain in caregiving compared to caregivers in the control group.
    Date: October 1, 2013
  • Veterans with PTSD or Major Depression Less Likely to Undergo Four Major Invasive Procedures
    This study examined whether PTSD, after controlling for major depression, was associated with the likelihood of having four common types of major invasive procedures. Findings showed that Veterans with PTSD only and with depression only were less likely to undergo all types of procedures examined in this study. Having both PTSD and depression was associated with lower odds of hip/knee, CABG/PCI, and vascular procedures, but not digestive procedures. Vascular procedures had the strongest effect. The odds of undergoing CABG/PCI or vascular procedures for patients with depression only were 35% to 40% lower than for patients with neither PTSD nor depression, while patients with PTSD only were about 25% less likely to receive the procedures. African American and women at-risk patients (those with a pre-existing condition likely to be alleviated by a procedure) were less likely to undergo hip/knee, vascular, and CABG/PCI procedures. Given that African-Americans are more likely than non-Hispanic whites to die of heart disease, their reduced odds of receiving CABG/PCI or vascular procedures could be problematic.
    Date: October 1, 2013
  • OEF/OIF Veterans with PTSD Experience More Pain Complaints than Veterans without PTSD
    This study sought to extend previous work by evaluating the association among PTSD, major depressive disorder (MDD), and pain among Iraq and Afghanistan war era Veterans. Findings showed that Veterans with PTSD reported pain-related complaints at greater rates than Veterans without PTSD. PTSD – with or without MDD – was associated with increased risk of back, muscle, or headache pain. The highest rate of pain complaints was found in Veterans with comorbid PTSD and MDD. Women Veterans were more likely to report back pain, muscle aches, and headaches, but the relationship between psychiatric diagnsoses and pain did not differ in men and women. Veterans with PTSD/MDD were less likely to be employed, more likely to be receiving disability compensation, and more likely to report combat-related injury than Veterans without either disorder. Observed associations of PTSD and MDD with pain complaints suggest that integrated, multidisciplinary treatment may be beneficial, particularly for Veterans with multiple mental health comorbities and pain.
    Date: August 7, 2013
  • Women Veterans who Experience Intimate Partner Violence are at Higher Risk for Some Medical and Mental Health Conditions
    This study sought to fill gaps in knowledge by examining demographic and clinical characteristics of women Veterans who have disclosed intimate partner violence (IPV) victimization to a VA healthcare provider. Findings showed that lifetime IPV was documented in about one-quarter (24%) of women Veterans’ medical records and was associated with higher risk of many medical conditions and with increased healthcare use. Women Veterans with documented IPV had higher rates of military sexual trauma, injury/poisoning, mental health disorders, infectious or parasitic diseases, and digestive system disorders. More than 95% of women Veterans with documented IPV had a mental health diagnosis, including: 60% with episodic mood disorders, 57% with neurotic disorders, 48% with PTSD, and 72% with other depression. In addition, 45% reported military sexual trauma. Compared with women who had no documented IPV, those with documented IPV had a higher average number of healthcare encounters per month and were more likely to have visited the emergency department – and to have had a mental health/behavioral health/social work visit during the study period.
    Date: August 5, 2013
  • Low Rates of VA Vocational Service Use among OEF/OIF Veterans with Mental Health Conditions
    This study assessed nationwide patterns of supported employment and vocational service use among OEF/OIF Veterans with the top four mental health conditions: PTSD, depression, substance use disorder, or traumatic brain injury (TBI). Findings showed that of the Veterans with mental health diagnoses included in this study, only 8% had a vocational services encounter during the study period, with 2% of these receiving evidence-based supported employment. Moreover, retention was low, with most Veterans attending just one to two appointments. Veterans with TBI – and those with more mental health conditions overall – were more likely to access vocational services. Among Veterans whose employment was tracked, 51% with at least one supported employment encounter worked competitively, compared to 21% of those who did not receive supported employment. Thus, supported employment was effective when it was provided. Results indicate that recovery-oriented, evidence-based, supported employment is the best way to assist unemployed Veterans with mental health conditions to achieve competitive employment. However, resources are limited for Veterans without psychosis and those who are not homeless. Given that OEF/OIF Veterans with TBI are more likely to need vocational services, the authors suggest supported employment could be effectively integrated into VA polytrauma clinics.
    Date: August 1, 2013
  • Study Assesses VA/Alzheimer’s Association Care Coordination Program for Informal Caregivers of Veterans with Dementia
    A new initiative targeting caregivers of Veterans with dementia is “Partners in Dementia Care” (PDC) — a care-coordination program delivered via a partnership between VA and Alzheimer’s Association chapters. This study assessed the effectiveness of the PDC program. Findings showed that the PDC program is a promising model that improves linkages between VA healthcare services and community services for informal caregivers of Veterans with dementia. Compared to comparison caregivers, those who participated in the PDC program had significant improvement in outcomes representing unmet needs, all three types of caregiver strains, depression, and support resources. Most improvements were evident after six months, with more limited improvements from months 6 – 12. However, improvements after the first six months were maintained during the entire study. Some outcomes improved for all caregivers, while others improved for caregivers with more initial difficulties – or those who were caring for Veterans with more severe impairments.
    Date: August 1, 2013
  • Suicidal Ideation is Common among OEF/OIF Veterans who Receive VA Healthcare
    This study sought to determine the prevalence and correlates of suicidal ideation among OEF/OIF Veterans who screened positive for depression following implementation of required brief assessments. Findings showed that suicidal ideation is common among OEF/OIF Veterans who receive VA healthcare: one in three Veterans who screened positive for depression acknowledged possible suicidal ideation. High PHQ-2 scores (> 5) nearly doubled the odds of suicidal ideation, even when controlling for diagnoses of depression. Depression and bipolar or schizophrenia diagnoses significantly increased the odds of suicidal ideation. In addition, having a single diagnosed psychiatric disorder did not significantly increase the odds of suicidal ideation, but two disorders were associated with a 60% increase, and three or more disorders more than doubled the odds. In contrast to previous reports, this study found no increase in suicidal ideation for Veterans with PTSD, substance use disorders, anxiety disorders, or traumatic brain injury. However, the authors note that a recently published evidence-based synthesis concluded that despite mixed results, PTSD should be considered a risk factor for suicide attempts and completion among Veterans.
    Date: July 1, 2013
  • Homelessness More Prevalent among Female Veterans
    This review of the literature sought to assess and summarize the body of knowledge on homelessness among female Veterans, in order to inform policy and highlight important gaps in this literature that could be filled by future research. Findings showed that female Veterans now comprise a larger share of the homeless Veteran population than of the overall Veteran population. Homeless female Veterans are characteristically different from their male counterparts, both with respect to demographic and clinical factors. For example, homeless female Veterans are younger, have higher levels of unemployment, and have lower rates of drug or alcohol dependence or abuse, but they have higher rates of mental health problems than homeless male Veterans. Female Veterans are at an increased risk of homelessness relative to the non-Veteran female population. Studies identified factors that may increase the risk of homelessness among women Veterans, including: unemployment, disability, PTSD, sexual assault or harassment during military service, anxiety disorder, poor health status, and older age.
    Date: June 26, 2013
  • Significant Disparities among Women Veterans with and without Mental Illness in Delaying or Going without Medical Care
    This study examined associations of PTSD and depressive symptoms with unmet medical needs and barriers to care among women Veterans. Findings showed that there was a significant degree of disparities reported by women Veterans with and without mental health symptoms in delaying or going without needed medical care. The majority of those who screened positive for both PTSD and depressive symptoms had unmet medical care needs in the prior 12 months (59%) – compared to 30% of women with PTSD symptoms only, 18% of those with depressive symptoms only, and 16% of women with neither set of symptoms. This pattern remained the same after adjustment (e.g., for demographics, insurance, combat exposure). Overall, among women Veterans in this study who reported unmet medical needs (19% of the women surveyed), those with both PTSD and depressive symptoms were more likely than women in the other groups to identify affordability as a reason for going without or delaying care (69%). Being unable to take time off work (31%) was the second most common reason reported among this group. Women with PTSD symptoms (w/ or w/o depression) were less likely than all other groups to have health insurance to cover non-VA care.
    Date: May 1, 2013
  • Importance of Parenting Interventions for Veterans’ and their Children’s Health
    This study reviewed the literature to examine the links between deployment, child mental health, and Veteran mental health. Using an example treatment, Parent-Child Interaction Therapy (PCIT), investigators also outline the components needed to make a parenting intervention most useful to Veterans – and propose research directions which would lay the necessary groundwork for large-scale provision of this type of treatment for Veterans.
    Date: May 1, 2013
  • Psychiatrists’ Workplace Satisfaction Improved Despite Significant Changes in VA Mental Healthcare Services
    This study examined whether VA psychiatrists’ self-reported outcomes for work satisfaction and work environment perceptions changed during a period of transformation in which VA mental health resources were augmented, while direction and accountability for their use increased. Findings showed that extensive reorganization of VA mental health services was associated with improvements in psychiatrists’ workplace satisfaction, and these increases were sustained over time. Most of the increases in survey measures occurred between 2004 and 2006, with gains maintained thereafter. Pay satisfaction showed the strongest trend increase, and was significantly higher in all years subsequent to 2004. Ratings of management practices were also higher over time. Both skill development and workplace civility were higher in all years except 2007. Intention to leave, job autonomy, and turnover rates did not significantly change over the study period. However, the patterns for satisfaction with work amount and overall job satisfaction differed; values increased from 2004 to 2006 but declined significantly between 2006 and 2010, ending up close to their baseline levels.
    Date: March 15, 2013
  • High TBI Screening Rates among OEF/OIF Veterans
    This study describes the early results of VA’s TBI screening program, and identifies patient and facility characteristics associated with receiving a TBI screen. Findings showed that TBI screening rates are high in VA, with more than 90% of eligible Veterans screened. Of Veterans who were screened, 21% met the VA definition of a positive screen, with blast or explosion the most common exposure reported. Factors associated with a positive TBI screen included: male gender, having served in the Army, having had multiple deployments, and having mental health diagnoses in the previous year. A positive TBI screen was less likely among Veterans who were separated from duty for more than 18 months, or Veterans who had a chronic disease diagnosis. The most common symptoms reported in the period after injury were sleep problems (78%), irritability (69%), and headaches (63%), and these symptoms continued to be current problems at time of screening.
    Date: March 1, 2013
  • More than One in Eight Women Veterans Screen Positive for PTSD and A Significant Segment Does Not Receive Treatment
    This study sought to identify PTSD prevalence and mental healthcare use in a representative national sample of women Veterans. Findings showed that more than one in eight women Veterans in this study (13%) screened positive for PTSD, and less than half of this group received mental health treatment (either VA or non-VA). VA healthcare was used by 31% of the women Veterans who screened positive for PTSD and by 11% of women Veterans who screened negative for PTSD. Among women Veterans who screened positive, 49% used mental healthcare services, including 66% of VA users and 41% of non-VA users. Predictors of mental healthcare use included having a diagnosis of depression and utilizing VA healthcare, while lacking a regular healthcare provider and household income below the federal poverty line predicted non-use of mental healthcare. Because the majority of women Veterans utilize non-VA healthcare, and these providers may be unaware of their Veteran status and PTSD risk, the authors suggest that more effective efforts be made to help identify women Veterans with PTSD – and to engage them in care.
    Date: February 23, 2013
  • Most OEF/OIF Veterans who Screen Positive for Depression Receive Timely Assessments for Suicidal Ideation
    This study describes brief structured assessment (BSA) processes for suicidal ideation, including frequency of administration, among OEF/OIF Veterans who screened positive for depression – and identifies individual and system factors that are associated with BSA completion. Findings showed that overall, 81% of Veterans received a BSA for suicidal ideation within one month of screening positive for depression, and 94% of BSAs were conducted within one day of positive screens. Assessment for suicidal ideation was 50% to 80% more likely to occur when Veterans received a diagnosis of PTSD or depression, respectively, on the day of assessment. Neither race/ethnicity nor age was associated with BSA receipt.
    Date: January 23, 2013
  • Prolonged Exposure or Cognitive Processing Therapy May Reduce Use of Mental Health Services in Veterans with PTSD
    This study evaluated the impact of a course of Prolonged Exposure (PE) or Cognitive Processing Therapy (CPT) on VA mental health and medical service utilization and healthcare costs. Findings showed that Veterans who had successfully completed PE or CPT for PTSD experienced a reduction of both PTSD and depression symptomatology; they also reduced their mental health service utilization by 32% in the year following treatment when compared to the year prior to the initiation of PE or CPT. There was a slight, non-significant decline in primary care usage among Veterans who had completed therapy, while emergency department usage remained virtually the same. Per Veteran, there was a 39% reduction in total costs – from an average of $5,173 in the year prior to treatment to $3,133 in the year following treatment. These preliminary findings suggest that the successful completion of PE and CPT for the treatment of PTSD significantly reduces mental health service use and outweighs the cost of treatment.
    Date: January 1, 2013
  • Same-Day Receipt of Integrated VA Primary Care-Mental Health Services Increases Odds of Subsequent Mental Health Visit
    This study evaluated whether same-day receipt of Primary Care-Mental Health Integration (PC-MHI) services was associated with the likelihood of receiving a mental health encounter in the following 90 days. Findings showed that of the Veterans in this study, 7% received same-day PC-MHI services. Those who received same-day PC-MHI services had more than twice the odds of receiving a subsequent mental health encounter within 90 days compared with Veterans who did not receive same-day PC-MHI services, after adjustment for other covariates. Overall, 48% of the Veterans in this study had a subsequent visit for a mental health condition within 90 days of their initial visit. Among those with same-day PC-MHI, 74% had a follow-up, as compared to 45% who did not receive same-day services. OEF/OIF Veterans had greater odds of a 90-day return visit compared with non-OEF/OIF Veterans. Also, Veterans in the two younger age groups (18-44 yrs and 45-64 yrs) had greater odds of a return visit than Veterans in the oldest age group (65+yrs). Each of the mental health disorders, with the exception of alcohol use disorder, was positively associated with a 90-day return visit, while Veterans with a physical comorbidity were less likely to return in the following 90 days.
    Date: January 1, 2013
  • Majority of Veterans with Serious Mental Illness Prefer Family Involvement in their Care
    This article reports on baseline data from the Recovery Oriented Decisions for Relative’s Support (REORDER) intervention, an innovative, manualized protocol that uses a shared decision-making process to facilitate a patient’s consideration of family involvement in care. Findings showed that the majority (78%) of Veterans in this study wanted their family involved in their care. Veterans were concerned about the impact family involvement would have on themselves and their family. Veterans also expressed concerns about the negative effects of involvement, including a loss of personal privacy and decreased time for the involved family member to attend to other responsibilities. The degree to which a Veteran expected benefits from family involvement in care predicted the degree of desired family involvement, whereas anticipating barriers did not.
    Date: December 15, 2012
  • Many OEF/OIF Veterans Delay Initiating Mental Health Care and Completing Effective Mental Health Treatment
    This study sought to describe time to initiation (and predictors of time to initiation) of first primary care visit, mental health outpatient visit, and minimally adequate mental healthcare among Veterans with mental health diagnoses seeking VA healthcare post-deployment. Findings indicate delays in initiating and completing minimally adequate mental healthcare among OEF/OIF/OND Veterans using VA services. Among these Veterans, the median time to engagement in mental healthcare was more than two years from the end of the last deployment. Further, after more than three years post-deployment, 75% of Veterans with mental health diagnoses – who were in the VA healthcare system for at least one year – had still not engaged in minimally adequate mental healthcare. There was a median lag time of 7.5 years between coming in for an initial mental health treatment session and beginning a course of minimally adequate mental healthcare. All of the mental health diagnoses, as well as number of comorbid mental health diagnoses, were associated with an increased chance of initiating minimally adequate mental health outpatient care sooner. PTSD had the strongest association with early initiation. Male Veterans waited nearly two years longer to initiate minimally adequate mental healthcare compared to female Veterans. Younger Veterans (<25 years of age) took longer to initiate and seek minimally adequate care; racial/ethnic minorities also took longer than their White counterparts.
    Date: December 1, 2012
  • OEF/OIF Veterans Most in Need of Psychiatric Care are Accessing Mental Health Services, Primarily at VA
    In this study, investigators conducted the first survey to employ a random sample of U.S. military post-9/11 that examined treatment use and perceived problems with treatment, including both VA and non-VA service users. Findings showed that 43% of the Veterans in this study screened positive for PTSD, major depression, or alcohol misuse. Overall, 40% of Veterans had ever received VA inpatient mental health care, 46% had ever received VA outpatient care, and 16% had ever received inpatient or outpatient care in both VA and non-VA settings. Nearly 70% of Veterans with probable PTSD or major depression and 45% of Veterans with probable alcohol misuse reported accessing mental health care in the past year. Authors suggest that Veterans who are ambivalent about accessing mental healthcare may be more willing to do so if they are made aware that a substantial number of Veterans are getting the help they need. Veterans with mental health needs who did not access treatment were more likely to believe that they had to solve problems themselves and that medications would not help. Those who had accessed treatment were more likely to express stigma beliefs and concern about being seen as weak. This suggests barriers to accessing care may be distinct from barriers to engaging in care. Veterans with higher PTSD and depression symptoms were more likely to access care. This finding suggests that, above a certain threshold of symptoms, Veterans were significantly more likely to seek mental health services, even if they viewed those services in a negative light.
    Date: November 15, 2012
  • Same-Day Primary Care-Mental Health Integration Services May Facilitate Timely Receipt of Treatment for Depression
    This study assessed whether VA patients with same-day Primary Care-Mental Health Integration (PC-MHI) services were more likely to receive depression treatment within 12 weeks, as compared to similar patients who did not receive same-day PC-MHI. Findings showed that a greater percentage of Veterans seen in either PC-MHI or specialty mental health (SMH) settings were diagnosed with depression on the same day of screening (68% and 60%, respectively), compared with Veterans seen in PC-only settings (30%). Also, Veterans who received same-day PC-MHI services were more likely to initiate depression-related treatment than were those receiving only PC services. By six months, the probability of diagnosis had increased in all groups, but PC-only patients had the lowest percentage of depression diagnoses (44%). Being seen in PC-MHI or SMH on the day of the depression screen increased the probability of receiving both psychotherapy and antidepressant treatment.
    Date: November 13, 2012
  • Telemental Health Expands in VA between 2006-2010
    This is the first large scale study to describe the types of telemental health services provided by the VA healthcare system. Findings show that each type of telemental health encounter increased substantially across the five years; for example, the number of encounters for medication management increased from 13,466 in FY06 to 32,284 in FY10, representing a 140% increase over the five-year period. Psychotherapy with medication management was the fastest growing type of telemental health service, increasing from 14,188 encounters in FY06 to 45,107 encounters in FY10, a 218% increase. The use of videoconferencing technology has expanded beyond medication management alone to include telepsychotherapy services (individual and group psychotherapy) and diagnostic assessments. The increase in telemental health services is encouraging, given the large number of returning Veterans who live in rural areas and may have difficulty accessing mental healthcare.
    Date: November 1, 2012
  • Factors Associated with Increased Aggression in Veterans with Dementia
    This study sought to examine the factors predicting the development of aggression among Veterans with dementia. Findings show that potentially mutable factors were associated with the development of aggression in Veterans with newly diagnosed dementia. Mutable factors that predicted increased risk of aggression included: higher levels of baseline caregiver burden, worst patient pain, declining patient-caregiver relationship, and increasing non-aggressive physical agitation. Baseline dementia severity and depression were indirectly related to the onset of aggression.
    Date: October 26, 2012
  • Risk of Suicide and Mental Disorder Comorbidity among Male Veterans Using VA Healthcare
    This study examined mental disorder comorbidity and suicide in a large national cohort of Veterans who use VA healthcare, particularly the association between differing two-way combinations of mental disorders and suicide risk. Findings showed that among Veterans who died by suicide between FY00 and FY06 (0.25% of the study cohort), 47% had been diagnosed with a mental disorder(s) including 19% with one mental disorder and 27% with two or more. Each mental disorder was associated with increased risk for suicide. However, nearly all two-way combinations of mental disorders showed a smaller increase in risk for suicide than would be expected by considering the risk associated with each disorder separately, which is interpreted to indicate sub-additive risk. Depression was the most common diagnosis among Veterans who died by suicide (31%), followed by substance use disorder (21%), anxiety disorder (15%), PTSD (12%), schizophrenia (9%), and bipolar disorder (9%).
    Date: October 22, 2012
  • Pre-Military Trauma Associated with Post-Recruit Training Suicide Attempts among Marines
    This study examined pre- and post-Marine recruit training risk factors for suicide attempts among current and former Marines in the 10 years following training. Findings showed that stressful and traumatic life events (e.g., childhood physical, sexual and emotional abuse, sexual harassment during recruit training) and suicide attempts made before recruit training had strong associations with suicide attempts after recruit training. Those who experienced at least one life stressor prior to joining the Marines had 4 times the odds of suicide attempt compared to those who did not report any life stressors prior to joining. Half of the Marines in this study who died by suicide (per death certificate) in the 10 years following recruit training (n=3) reported at least one significant life stressor prior to joining the Marines. Marines who experienced military sexual harassment during recruit training had 3 times the odds of suicide attempt in the 10 years following training compared with those who did not report this experience. Marines with PTSD symptoms consistent with a diagnosis had about double the odds of suicide attempts compared with those without PTSD symptoms.
    Date: October 20, 2012
  • Determinants of Implementing Depression Care Improvement Models in VA Primary Care Practices
    This study examined three VA-endorsed depression care models and tested the relationships between measures of organizational readiness and implementation of the models in VA primary care clinics. The three models include: 1) collocation of mental health specialists in primary care settings, 2) the Translating Initiatives in Depression (TIDES) model, and 3) the Behavioral Health Laboratory (BHL) model. Findings show that pre-existing demographic and readiness characteristics of primary care practices are associated with whether the practice chooses to implement a depression care improvement model – and with what type of model the practice chooses. Of the three approaches, primary care practices appear most ready to implement collocation, which had been present the longest (average 6 years) in practices adopting it. Moreover, the majority of practices that had not adopted it planned to do so. By 2007, 48% of clinics had implemented collocation, 17% had implemented TIDES, and 8% had implemented BHL. Having established quality improvement processes or a depression clinician champion was associated with collocation. Being located in a VA regional network that endorsed TIDES was associated with TIDES implementation. The presence of psychologists or psychiatrists on primary care staff, greater financial sufficiency, or greater space sufficiency was associated with BHL implementation.
    Date: October 5, 2012
  • Prescription Drug and Alcohol Misuse Associated with Higher Suicide Deaths among Veterans with Depression
    This study sought to assess the association between factors noted in the electronic medical record and suicide mortality for a cohort of Veterans who had received treatment for depression. Findings showed that suicidal behaviors and substance-related variables were the strongest independent predictors of suicide. Compared with Veterans without a suicide attempt or ideation, those with a suicide attempt in the prior year were 7 times more likely to die of suicide, and Veterans with suicidal ideation without an attempt were 3 times more likely to die of suicide. Veterans with prescription drug misuse and those with alcohol abuse were 7 times and 3 times, respectively, more likely to die of suicide than those without. Based on these findings, the authors suggest that prescription drug and alcohol misuse assessments should be prioritized in suicide assessments among Veterans diagnosed with a depressive disorder. Veterans for whom providers considered a hospitalization for psychological issues had 3 times higher risk of suicide death than those for whom hospitalization was not considered.
    Date: October 1, 2012
  • Perceptions of Coercive Treatment and Satisfaction with Care among Veterans Hospitalized for Severe Mental Illness
    This study examined associations between perceptions of coercive treatment and satisfaction with care among psychiatric inpatients at one VAMC. Findings show that both involuntary commitment status and perceptions of coercion were independently and negatively associated with patient satisfaction with psychiatric inpatient hospitalization. Among the Veterans who were psychiatric inpatients in this study, 15% were involuntarily admitted, 40% reported prior involuntary admissions, and nearly half endorsed the perception of some coercion during their index admission. In addition, self-reported history of being denied a requested medication during psychiatric hospitalization (a potentially coercive treatment) may influence appraisal of care during the current hospitalization. Self-reported lifetime rates of other coercive treatment experiences ranged from 22% reporting being forced to take medications to 46% reporting ever being transported to the ER or hospital by law enforcement.
    Date: September 28, 2012
  • Promoting Gun Safety and Delayed Gun Access to High-Risk Patients is Acceptable to Veterans and Providers
    This study explored VA stakeholders’ perceptions about gun safety and interventions to delay gun access among Veterans with a mental health diagnosis during high-risk periods. Findings showed that several measures to promote gun safety and to delay access to guns for high-risk patient groups are acceptable to VA patients and providers, if judiciously applied. For example, most patients and clinicians in this study indicated that routine screening for gun access was acceptable, particularly for patients receiving mental healthcare. Clinicians and patients reported having very little discussion regarding gun ownership during the course of routine treatment. Both groups indicated that gun access was typically discussed only during suicide or homicide risk assessments, and then only if the patient expressed suicidal/homicidal ideation that involved guns. However, nearly all patients felt that clinicians should routinely speak to their patients about guns. One of the most widely suggested and accepted interventions – across all stakeholders – was further education on suicide, including risks related to guns, for VA patients, family members, and clinicians.
    Date: September 5, 2012
  • Higher Rates of Reproductive and Physical Health Problems in OEF/OIF Women Veterans with Mental Illness
    OEF/OIF women Veterans with any mental health diagnoses had significantly higher prevalence of nearly all categories of reproductive and physical disease diagnoses compared to women Veterans without mental health diagnoses. Women with mental health diagnoses had approximately two to four times the odds of receiving diagnoses of sexually transmitted infections, cervical dysplasia, dysmenorrhea, and gynecologic pain syndromes, as well as other reproductive and gynecologic health conditions, with prevalence being highest in women with comorbid PTSD and depression. The most striking difference was in sexual dysfunction (a relatively rare outcome), in which women Veterans diagnosed with mental health disorders had 6 to 10 times the odds of receiving this diagnosis than women without mental disorders. Findings were similar after adjusting for demographics, military service characteristics, and distance to/type of nearest VAMC. The magnitude of the associations of mental and physical health diagnoses were reduced after adjusting for primary care utilization, but most remained significant.
    Date: September 1, 2012
  • Age Differences in PTSD Diagnoses and Treatment Seeking among Veterans
    Among the Veterans in this study sample who screened positive for PTSD, the percentage of positive screens decreased as age increased: 17% for Veterans aged 18-29 years, 13% for Veterans ages 30-44, 13% for Veterans ages 45-59, 6% for Veterans ages 60-74, and 2% for those ages 75 years and older. While older Veterans were less likely to screen positive for PTSD, they also were less likely to initiate specialty mental health treatment when they had positive screens. For example, 66% of Veterans ages 18-29 had mental health visits compared to 19% of Veterans ages 75 years and older. There also were significant differences by age in types of treatment received. Veterans ages 18-29 years received the most diagnostic visits, while Veterans ages 45-59 and 60-74 years received more visits for group psychotherapy than other age groups. Veterans ages 75 years and older received the fewest visits involving psychotherapy and medications or phone contact. The authors suggest that future research is needed to examine whether alternative approaches to PTSD in primary care settings may improve specialty treatment initiation rates, particularly among older Veterans.
    Date: August 13, 2012
  • No Advantage in Collaborative Care vs. Usual Care for Veterans with PTSD
    Over a 6-month period, primary care patients with PTSD in both the Three Component Model (3CM, collaborative care) and usual care groups showed small but clinically insignificant improvement in PTSD, depression, and functioning. No additional benefit was found for Veterans assigned to the 3CM treatment compared to those receiving usual care, despite the fact that 3CM patients were more likely to receive an antidepressant and had more mental health visits. Among Veterans who provided a numeric rating for PTSD care, half rated it as excellent or very good; however, 3CM was associated with lower perceived quality of PTSD care. Almost two-thirds of Veterans rated their overall care as excellent or very good, and the groups did not differ. Costs were similar for both groups, except that Veterans assigned to 3CM had higher outpatient pharmacy costs.
    Date: August 3, 2012
  • Collaborative Care Models Improve Physical and Mental Health Outcomes for Individuals with Mental Disorders
    Collaborative chronic care models (CCM)s can improve mental and physical outcomes for individuals with mental disorders across a wide variety of care settings and provide a robust clinical and policy framework for care integration. Meta-analysis of unadjusted outcomes demonstrated significant small-to-medium effects of CCMs across multiple disorders in clinical symptoms, mental and physical quality of life, and social role function, with no net increase in total healthcare costs. Systematic review of a broader range of studies largely confirmed meta-analytic findings. The authors suggest that CCMs provide a framework of broad applicability for management for a variety of mental health conditions across a wide range of treatment settings, as they do for chronic medical illnesses.
    Date: August 1, 2012
  • Warning Signs Associated with Suicide among Veterans Receiving VA Healthcare
    Of the 381 Veterans in this study who used VA healthcare in their last year of life, 67 (18%) died by suicide within one week of contact. Among these Veterans, documented suicidal ideation was the strongest predictor of suicide. Psychotic symptoms noted during the last VA healthcare visit also were associated with suicide. Of the 381 Veterans who used VA healthcare in their last year of life, 174 (46%) died within one month of contact. Among these Veterans, the warning signs noted above (suicidal ideation and psychotic symptoms) were also risk factors that predicted suicide within a month of contact. Authors note that assessment of suicidal ideation is critical to identifying Veterans at immediate risk, but that both suicidal ideation and psychotic symptoms may also suggest ongoing risk.
    Date: July 13, 2012
  • Effects and Costs of Mobile, Team-Based Outpatient Care Model for Veterans with Serious Mental Illness
    Assertive Community Treatment (ACT) – called Mental Health Intensive Case Management (MHICM) in VA – is a mobile, team-based outpatient service model for providing comprehensive psychiatric care and case management support to individuals with serious mental illness who intensively use inpatient psychiatric care. In this study, the proportion of ACT enrollees admitted to inpatient mental health care did not differ significantly from non-enrollees admitted (62% vs. 63%). However, compared to non-enrollees, ACT enrollees had 16 fewer mental health inpatient bed days during the first 12 months of enrollment. For ACT program participants, savings depended on new clients’ “intensity” of psychiatiric inpatient utilization prior to entering the ACT program. VA ACT services are cost-saving for Veterans with serious mental illness and more than 95 mental health inpatient bed days in the 12 months prior to entering ACT, but cost-increasing for Veterans with fewer than 95 bed days. Between FY01 and FY04, new VA ACT clients had just over 68 bed days in the 12 months prior to entering ACT on average, and their entry into ACT was estimated to result in an increase of $4,529 in VA mental health costs. Trends in psychiatric inpatient use among ACT program entrants remained stable after FY04, through FY10. However, eligibility for ACT declined by 37% because fewer Veterans met eligibility based on high prior inpatient use. Thus, authors suggest that the “high hospital use” criterion may impose a trade-off between program cost-effectiveness and program access. Fewer Veterans are attaining the high hospital use threshold as inpatient use falls. This winnowing of the target population may indicate a need to reconsider the administrative criteria for entry into VA ACT services.
    Date: May 17, 2012
  • Women Veterans Report Poorer Health Outcomes Compared to Civilian and Active Duty Women
    Veteran women reported consistently poorer health compared with other women, including poorer general health, greater likelihood of health risk behaviors (e.g., smoking), and greater likelihood of chronic conditions and mental health disorders. Veterans were most likely – and active duty least likely – to report frequent poor physical health. Veterans were more likely than civilian and active duty women to be obese or overweight – and to have cardiovascular disease. National Guard or Reserves (NG/R) women also were more likely to be overweight or obese than both civilian and active duty women. Veterans were more likely than civilians to report a history of depressive disorder and more likely than active duty women to report a history of anxiety disorder. NG/R women were more likely than civilian and active duty women to report both depression and anxiety. Tobacco use and lack of exercise were most commonly reported among Veterans and least commonly reported among active duty women. Compared to civilians, Veteran women were more highly educated and had higher incomes. Despite these protective factors, Veteran women reported faring better than civilians on only two indicators – health insurance and receiving clinical breast exams.
    Date: May 1, 2012
  • Changes in Health Conditions and VA Healthcare Costs among Women Veterans between 2000 and 2008
    The number of women Veterans treated in the VA healthcare system increased from 156,305 in 2000 to 266,978 in 2008; 88% of these women were under 65 years of age. The mean costs of care increased from $4,962 per woman Veteran in FY00 to $6,570 in FY08. Gender-specific, cancer, musculoskeletal, and mental health and substance abuse conditions accounted for a greater share of overall costs during the study period. Psychiatric conditions represented the largest share of costs for female VA patients during the study years. There was a modest rise in costs for psychiatric conditions among all female Veteran patients driven by the growing number of women treated for depression and PTSD. From 2000 to 2008, the proportion of women treated for PTSD increased by 133%, while the proportion of women treated for depression increased by 41%.
    Date: May 1, 2012
  • Integration of Primary Care and Mental Health Improves both Mental and Medical Care Utilization for OEF/OIF Veterans
    There was a significant association between VA’s Primary Care-Mental Health Integration (PC-MHI) program and OEF/OIF Veterans’ receipt of short- or long-term mental or medical care. Of the 181 Veterans who participated in the PC-MHI program, 60% sought mental health care within one month after their initial encounter in PC-MHI, and 82% after one year, while 18% sought medical care within one month, and 74% within one year. The average length of time to a subsequent specialty mental health care visit after the Veterans’ first PC-MHI encounter was about 5 months. The average length of time to a subsequent medical care visit after the first PC-MHI encounter was about 10 months. While PTSD was the primary condition associated with OEF/OIF Veterans remaining in VA care for mental health care, retention in long-term medical care was not associated with mental health disorders measured in this study (PTSD, substance use disorder, major depressive disorder, and anxiety/phobia).
    Date: April 30, 2012
  • Using Natural Language Processing to Evaluate Evidence-Based Treatment for Veterans with PTSD
    Investigators analyzed the content of clinical notes using the automated retrieval console (ARC). ARC identified psychotherapy notes and classified the type of therapy performed in a treatment session as reliably as expert human raters. Evidence-based psychotherapies appear to be infrequently used as an initial treatment in VA outpatient PTSD clinics in New England. Of the Veterans in this study, ony 6% received at least one session of one of the evidence-based psychotherapies outlined in the VA/DOD guidelines for PTSD during the initial six months of treatment.
    Date: April 26, 2012
  • Killing Experiences Independently Associated with Suicidal Ideation among Vietnam Veterans
    Vietnam Veterans in this study with war-related killing experiences were twice as likely to report suicidal ideation as those who did not kill, even after accounting for PTSD, depression, substance use disorder diagnoses, and combat exposure. This is the first study demonstrating that killing experiences are independently associated with suicidal ideation, after taking mental health diagnoses into account. In regression analyses that included demographic variables, PTSD, depression, substance use disorders, combat experiences, and killing experiences, PTSD was the only variable significantly associated with suicide attempts. Nearly 14% of Veterans in this study met diagnostic criteria for current PTSD.
    Date: April 13, 2012
  • Journal Issue Targets Veterans’ Sexual Health and Functioning
    The International Journal of Sexual Health is the first scientific journal to devote an issue to the sexual health and functioning of military Veterans. Articles in this issue, many authored or co-authored by HSR&D investigators, describe the effects of combat experiences on American Veterans’ sexual functioning, sexual risk behavior, mental health, health status, and relationships. In addition, articles describe the effects of sexual assault on women’s sexual health, and healthcare use among transgender Veterans.
    Date: April 1, 2012
  • Caregiver Satisfaction with VA Dementia Care
    On average, caregivers reported about 17 unmet care needs, indicating that they needed more information about or help with approximately one-third of the care needs used in the study analyses. Total unmet need was the only significant predictor of satisfaction with physician care, indicating that as the number of unmet needs increase, satisfaction with physician care suffers. Similarly, total unmet need was the strongest predictor of satisfaction with VA care, indicating that as the number of unmet needs increase, satisfaction with VA healthcare also suffers. Behavior problems and VA site were additionally predictive of satisfaction with VA care.
    Date: April 1, 2012
  • Factors Associated with Increased VA Preventable Acute Care Use
    Prior mental health diagnoses and medication use were independent risk factors for ambulatory care sensitive condition- (ACSC) related acute care. These risk factors will require focused attention if the full benefits of new primary care models, such as PACT, are to be achieved. The highest rate of ACSC admissions was among Veterans with drug use disorders (46 admissions per 1,000 patients), followed by those with depression (35 admissions per 1,000 patients), compared to 21 admissions per 1,000 patients for those with no mental health diagnoses. The rate of ED visits for ACSCs was also higher among those with mental health diagnoses (70 visits per 1,000 vs. 44 visits per 1,000 for those without mental health diagnoses). Patients without mental health conditions experienced significantly lower rates of both all-cause and ACSC admissions than patients with mental health conditions. The mean cost and length of stay of ACSC admissions, however, was similar and not statistically different between the two groups.
    Date: March 20, 2012
  • Meditation-Based Mantram Intervention Shows Potential as Adjunctive Therapy for Veterans with PTSD
    The Mantram Repetition Program (MRP) shows potential when used as an adjunct to treatment as usual (TAU) for mitigating chronic PTSD symptoms in Veterans. In this study, twice as many Veterans in the MRP + TAU group had clinically meaningful reductions in PTSD symptoms compared to Veterans in the TAU alone group: 24% vs. 12%, respectively, and PTSD symptoms continued to improve in the MRP + TAU group at six-week follow-up. Compared to Veterans in the TAU alone group, Veterans in the MRP + TAU group also experienced significant reductions in depression and greater improvements in mental health-related quality of life and spiritual well-being. Reductions in anxiety were equivalent between groups. Of Veterans in the MRP + TAU group, 97% reported moderate or high satisfaction with MRP, and dropout rates were equivalent and low (7%) in both groups.
    Date: March 12, 2012
  • Use of Mental Health and Non-Mental Health Outpatient Care by OEF/OIF Veterans with Military Sexual Trauma
    The most notable factor that influenced the receipt and intensity of MST-related care was gender. Male Veterans used less care than female Veterans and had a lower intensity of MST-related care compared to women, even after controlling for total number of healthcare visits. Other sociodemographic and military variables associated with less use and/or less intensity of MST-related care were younger age, unknown race/ethnicity, being in the Marines or Air Force, and being in the National Guard or Reserve. Among all Veterans who screened positive for MST, the majority (76%) received at least one MST-related care visit within a year of the positive screen. In examining diagnostic characteristics of MST-related care, the most common primary diagnoses related to a Veterans’ MST-related care were mental health diagnoses. Overall, more than half of all Veterans received MST-related care with an associated mental health primary diagnosis (57% of women and 50% of men); the most common diagnoses were PTSD, depression, and other anxiety disorders. The authors note that the high proportion of Veterans accessing MST-related care confirms the effectiveness of VA’s universal screening program to promote the use of mental health services for Veterans with positive MST screens.
    Date: March 7, 2012
  • Mental Health Diagnoses Associated with Opioid Prescription, High-Risk Use, and Adverse Outcomes among OEF/OIF Veterans
    Among OEF/OIF Veterans with pain, mental health diagnoses, especially PTSD, were associated with an increased risk of receiving opioids, high-risk opioid use, and adverse clinical outcomes. Compared to those without mental health diagnoses, Veterans with PTSD who were prescribed opioids were more likely to receive higher-dose opioids (16% vs. 23%), receive two or more opioids concurrently (11% vs. 20%), receive sedative hypnotics concurrently (8% vs. 41%), and to obtain early opioid refills (20% vs. 34%). Receiving prescription opioids (vs. not) increased risk for serious adverse clinical outcomes for Veterans (10% vs. 4%) across all mental health categories and was most pronounced in Veterans with PTSD. Of the 141,029 Veterans with pain diagnoses, 15,676 (11%) received prescription opioids for = 20 consecutive days; 77% of which were prescribed by VA primary care providers. Veterans with PTSD and mental health diagnoses excluding PTSD were significantly more likely to receive opioids for pain (18% and 12%) compared to Veterans without mental health diagnoses (7%).
    Date: March 7, 2012
  • Older Veterans Less Likely to Receive Treatment for Depression
    In this study, 64% of Veterans with a new diagnosis of depression received some form of treatment within 12 months; however, one third (36%) of the Veterans in this study did not receive any treatment for their depression. Of those Veterans who did receive treatment, most received both antidepressants and psychotherapy (27%), followed by 21% who received antidepressants only, and 16% who received psychotherapy only. The odds of receiving any kind of treatment decreased notably with increasing age. Veterans ages 50 to 64 were more likely to receive antidepressants, psychotherapy, or both compared to those in the older age groups. Results also showed that depressed older adults with no medical comorbidities were more likely to receive both antidepressants and psychotherapy compared to no treatment. This study highlights the importance of continued outreach and intervention efforts for depressed older Veterans who are vulnerable to being under-treated.
    Date: March 1, 2012
  • Gender Differences in Healthcare Utilization among Veterans with PTSD
    Overall, female OEF/OIF Veterans with PTSD were more likely to have slightly higher mental health, primary care, and emergency care utilization compared to male Veterans with PTSD. Women Veterans with comorbid PTSD and depression were 12.5 times more likely to have a mental health inpatient hospitalization compared to their female counterparts without depression, and they were twice as likely to have a mental health hospitalization compared to male Veterans with comorbid PTSD and depression. Diagnoses of comorbid PTSD and depression were present in 72% of women and 57% of men. Both men and women with PTSD and alcohol use disorders had more than double the mean number of mental health outpatient visits compared to their counterparts with PTSD but without alcohol use disorders. Comorbid PTSD and alcohol use disorders diagnoses were present in 8% of women and 29% of men. Regardless of gender, Veterans with comorbid PTSD and depression or comorbid PTSD and alcohol use disorders had higher healthcare utilization in all areas, as compared to their counterparts with PTSD but without these comorbid disorders.
    Date: February 7, 2012
  • Multi-Component Support Program Helps Lessen Burden for Caregivers of Aging Veterans with Disabilities
    A multi-component support services program that allowed Veterans aging with a disability to remain in the home, while also addressing the unmet needs of caregivers, was implemented and evaluated in one VA facility in 2009. Caregivers experienced meaningful improvements in burden after support services were rendered. Although there were no changes in caregivers’ physical health status, the support services program had a positive impact on mental health that was reflected in significant improvements in caregiver scores on the mental health components of the SF-12 health status scale. Satisfaction with services increased from baseline to follow-up.
    Date: February 1, 2012
  • Veterans with Serious Mental Illness Using Co-Located/Integrated Primary Care and Outpatient Mental Health Clinic Care have Reduced Cardiovascular Risk
    Veterans with serious mental illness (SMI) were more likely to attain cardiovascular risk goals after being enrolled in a primary care clinic co-located and integrated into an outpatient mental health clinic. Compared to prior to enrollment, Veterans enrolled in SMIPCC had significantly more primary care visits over six months – and significantly improved BP, LDL, triglycerides, and BMI. There were no significant differences in the attainment of goals for HDL or HbA1c. Prior to enrollment, 49% of primary care visits were on the same day as any scheduled mental health visit; this increased to 86% post-enrollment. Among the 28 Veterans in this study with coronary artery disease and/or diabetes, SMIPCC enrollment was associated with a significant improvement in BP goal attainment, but not with any other measures.
    Date: February 1, 2012
  • Increased Risk of Mortality Following Heart Attack for Veterans Insufficiently Treated for Major Depressive Disorder
    This study sought to determine if mortality following acute MI was associated with treatment-resistant depression (TRD). Findings show that all-cause mortality following an acute MI is greatest in Veterans with depression that is insufficiently treated – and is a risk in Veterans with treatment-resistant depression. Veterans who were insufficiently treated were 3.04 times more likely to die than those who received treatment. Veterans with TRD were 1.71 times more likely to die; however, this risk was partly explained by comorbid disorders.
    Date: January 12, 2012
  • Majority of OEF/OIF Veterans with Traumatic Brain Injury also Diagnosed with Mental Illness and Head, Neck or Back Pain
    This study examined the prevalence and VA healthcare costs of TBI with and without comorbid psychiatric illness and pain among OEF/OIF Veterans who used VA healthcare services (inpatient or outpatient) during FY09. Findings showed that 7% of the Veterans who used VA healthcare received a diagnosis of TBI. Among this patient subgroup, the vast majority (89%) also had a psychiatric diagnosis (most frequently PTSD: 73%), and 70% had a diagnosis of head, neck or back pain. More than half had both PTSD and pain (54%). Overall, depression was the second most common (45%) mental health diagnosis. Annual costs for OEF/OIF Veterans with TBI were four times greater than for those without TBI ($5,831 vs. $1,547), and costs increased as clinical complexity increased. For example, Veterans with TBI, PTSD, and pain demonstrated the highest median cost per patient ($7,974).
    Date: January 4, 2012
  • AJPH Features Articles on Veterans and Suicide
    This special supplement of AJPH focuses on Veterans and mental health, and includes four articles on suicide among Veterans.
    Date: January 1, 2012
  • Mental and Physical Health – and Substance Use in Veterans One Year after Deployment to Iraq or Afghanistan
    Within one year of returning from deployment, OEF/OIF Veterans in this study reported significantly worse mental health functioning than the general population. In addition, 39% screened positive for “probable alcohol abuse,” which is considerably higher than numbers reported based on mandated screening of VA outpatients. OIF (Iraq) Veterans reported more depression/functioning problems, as well as alcohol and drug use than OEF (Afghanistan) Veterans. Marine and Army Veterans reported worse mental and physical health than Air Force or Navy Veterans. Men reported more alcohol and drug use than women, but there were no gender differences in PTSD or other mental health domains. The authors suggest that continued identification of Veterans at risk for mental health and substance use problems is important for the development and implementation of evidence-based interventions intended to increase resilience and enhance treatment.
    Date: January 1, 2012
  • Gender Differences in Combat Exposure, Military Sexual Trauma, and Mental Health among Active Duty Soldiers
    This study examined gender differences in combat exposure, military sexual trauma (MST), and their associations with mental health outcomes among OEF/OIF active-duty personnel. Findings showed that although men reported greater exposure to high-intensity combat experiences than women, results indicate that women are experiencing combat at higher rates than observed in prior cohorts. For example, 7% of women reported injury in the war zone, and 4% reported killing in war, compared to 2% and 1%, respectively, for a Gulf War cohort. MST was a significant predictor of both PTSD and depression symptoms: 12% of women and less than 1% of men reported MST in the war zone. There were no gender differences in PTSD symptoms; however, there was a stronger association between injury in combat and PTSD symptoms for women than for men. Men were more likely to report hazardous alcohol use, while female gender was more likely to be associated with depression symptoms.
    Date: December 13, 2011
  • Diabetes Managed More Intensively in Older Veterans with Dementia and Cognitive Impairment
    This study sought to examine and compare anti-glycemic medication use, glycemic control, and risk of hypoglycemia in older Veterans with and without dementia or cognitive impairment. Findings showed that diabetes was managed more intensively in older Veterans with dementia or cognitive impairment than in those with no impairment, with more patients on insulin (30% vs. 24%) among those with cognitive problems. These conditions were independently associated with a greater risk of hypoglycemia. Of all Veterans taking insulin, the incidence of hypoglycemia was higher among those with dementia (27%) or cognitive impairment (20%) than among those with neither condition (14%). Veterans with dementia or cognitive impairment also had a greater decline in HbA1c over the 2-year study period. These findings suggest that providers were less likely to pursue individualized glycemic goals, as recommended by VA-DoD clinical practice guidelines (updated in 2010), when patients had cognitive problems.
    Date: December 8, 2011
  • History of Military Sexual Trauma Increases Risk of Sexual Health Diagnoses among OEF/OIF Veterans
    This study examined the prevalence rates of sexually transmitted infections (STIs) and sexual dysfunction disorders (SDDs) among OEF/OIF Veterans with and without reported military sexual trauma (MST). Investigators also explored whether the presence of a co-existing mental health diagnosis (e.g., PTSD, depression, substance use disorder) was associated with higher rates of STIs and SDDs among Veterans who screened positive for MST. Findings show that a number of STI and SDD diagnoses were more common among OEF/OIF Veterans who reported a history of MST compared to Veterans without a history of MST. There were no instances in which any of the sexual health diagnoses were significantly higher among Veterans who did not report a history of MST, even after controlling for age and length of time in VA healthcare. Moreover, among Veterans with a history of MST, the risk of having an STI or SDD increased in the presence of certain mental health diagnoses. Among women with a history of MST, those with a diagnosis of PTSD, depression, or a substance use disorder were significantly more likely to have an STI than women without these diagnoses. Among men with MST, only substance use disorder increased their risk for an STI. Among women with a history of MST, those with a diagnosis of depression were significantly more likely to have an SDD than women without a depressive disorder. Among men with MST, those with a diagnosis of PTSD or depression were more likely to have an SDD diagnosis than men without either disorder. This study emphasizes the importance of sexual health screening, particularly among Veterans with a history of MST.
    Date: December 5, 2011
  • Telemedicine-Based Collaborative Care Intervention for Depression has Greater Effect on Minority vs. White Veterans
    The Telemedicine Enhanced Antidepressant Management (TEAM) study was a randomized trial of telemedicine-based collaborative care tailored for small, rural primary care practices. Investigators in the current study evaluated racial differences in clinical outcomes among 360 Veterans with depression who were randomized to usual care or the TEAM intervention. Findings showed that in the usual care group, minority Veterans had a lower treatment response rate (8%) than Caucasians (18%), but this was not significant. In contrast, minority Veterans in the TEAM intervention group had a significantly higher treatment response rate (42%) than Caucasians (19%) in the intervention group. Veterans in the minority group were significantly less likely to report that antidepressants were an acceptable form of treatment, and were significantly less likely to have had prior or current depression treatment. However, none of these variables were significantly related to treatment outcomes. Thus, the study was not able to determine why minorities responded better to the intervention than Caucasians.
    Date: November 1, 2011
  • Barriers to Healthcare Access for Women Veterans
    This study examined the association of general and Veteran-specific barriers on access to healthcare among women Veterans. Findings showed that overall, almost 1 in 5 women Veterans (19%) delayed healthcare or went without needed care in the prior 12 months, including 14% of insured and 55% of uninsured women Veterans. VA healthcare users comprised 21% of those with and 13% of those without delayed healthcare or unmet needs. Younger age groups were associated with a higher prevalence of delayed care or unmet need. Among women Veterans delaying or going without care, barriers that varied by age group were: unaffordable healthcare; inability to take time off work; and transportation difficulties. A higher percentage of women with delayed care or unmet need, compared to those without, were racial/ethnic minorities, lacked a regular source or provider of healthcare, were uninsured, had low income, fair or poor health status, were disabled, and had mental health diagnoses. With respect to Veteran-related factors, women Veterans with delayed care or unmet need were more likely than those without to be OEF/OIF Veterans, in a high-priority group for VA enrollment, and to have experienced military sexual assault.
    Date: November 1, 2011
  • Survey-based vs. Chart-based Screening Yields Significantly Higher Rates of Depression among Veterans in Primary Care
    This study sought to characterize the yield of practice-based screening in 10 diverse VA primary care clinics (rural and urban), as well as the care needs of Veterans assessed as having depression. Findings showed that practice-wide survey-based depression screening yielded more than twice the positive-screen rate demonstrated through chart-based VA performance measures. Practice-wide depression screening yielded 20% positive depression screens and 12% probable major depression. This is substantially higher than most previously reported VA rates. In addition, comorbid medical and mental illness were highly prevalent.
    Date: October 6, 2011
  • VA Mental Health Care Staff More Satisfied and Suffer Less Burnout Compared to Non-VA Community Mental Health Staff
    This study compared burnout and job satisfaction between VA staff and non-VA community mental health staff working in the same large Midwestern city in 2009. Findings show VA staff reported significantly greater job satisfaction and accomplishment, less emotional exhaustion, and lower likelihood of leaving their job. VA and non-VA community mental health clinic (CMHC) staff also differed significantly in two categories. CMHC staff were significantly more likely to report job-related aspects as being challenging, such as lack of flexibility in the schedule and little pay. VA staff were more likely than CMHC staff to report administrative issues as being challenging, e.g., bureaucracy, red tape, and policies. Authors suggest that while CMHC leadership may need to find ways to address concerns related to job responsibilities (e.g., pay, schedule), VA may need greater focus helping workers navigate administrative concerns.
    Date: October 5, 2011
  • Depression and Race may Independently Affect Receipt of Some Surgeries
    This study examined race and ethnicity as factors potentially associated with surgeries experienced by Veterans with and without major depressive disorder (MDD). Findings show that Veterans with pre-existing MDD were less likely to undergo digestive, hip/knee, vascular, or CABG surgeries than Veterans without MDD. Minority Veterans were slightly less likely to receive vascular operations compared to white Veterans, but were more likely to undergo digestive system procedures. The effect of depression was independent of race and ethnicity; thus, depression and race would have an additive but not synergistic effect on the odds of receiving surgery. In addition, a gender effect was noted: women Veterans were more likely to have digestive procedures but were less likely to undergo CABG or vascular operations. Authors note that the lack of information regarding severity of illness makes it difficult to determine whether or not diagnostic differences explain differences in surgery.
    Date: October 1, 2011
  • Variation in Attitudes and Practices among VA Clinicians Conducting Disability Assessment for PTSD
    This study examined the beliefs and practices of VA mental health professionals performing PTSD examinations as part of VA’s Compensation and Pension (C&P) Program. Findings showed that there was wide variation in the beliefs and practices of individuals conducting PTSD examinations, primarily in two areas: 1) preferences and practices related to psychological assessment, and 2) beliefs related to symptom under-reporting and exaggerating. In a high percentage of cases, attitudes and practices conflicted with recommended best practices. For example, 59% of clinicians reported rarely or never using testing, and only 17% indicated routinely using standardized clinical interviews. Less than 1% of clinicians reported using functional assessment scales. [Note: VA does not require use of standardized testing; it is an option.] Standardized interviews were seldom employed, with 85% and 90% reporting that they “never” or “rarely” used the Clinician Administered PTSD Scale or the Structured Clinical Interview for DSM IV Axis I Disorders, respectively. Less than half of clinicians reported having received training in administering diagnostic interviews for PTSD. Nearly all clinicians (96%) believed that they were qualified in the skills needed to conduct a PTSD examination. On the other hand, clinicians held varying opinions about the authenticity of Veterans’ psychiatric conditions. For example, 25% of respondents reported that at least 15% of Veterans exaggerate PTSD symptoms, while 25% of respondents also reported that at least 15% of Veterans minimize or under-report their symptoms.
    Date: September 12, 2011
  • Military Sexual Trauma Associated with Increased Rate of Mental Health Disorders among Male and Female Veterans with Comorbid PTSD
    This study examined correlates of PTSD in OEF/OIF Veterans, as well as mental health comorbidities by gender among Veterans with PTSD – with and without military sexual trauma (MST). Findings showed that overall, MST was associated with a nearly three-fold increase in odds of PTSD in men, and more than a four-fold increase in women Veterans. Among women Veterans with PTSD, 31% screened positive for MST, and 1% of men with PTSD screened positive for MST. Among Veterans with PTSD, those with military sexual trauma also had more comorbid mental health diagnoses than those without MST. Three-quarters of women Veterans with PTSD and MST had comorbid depression, more than one-third had another anxiety disorder, and 4% were diagnosed with eating disorders. Male Veterans with PTSD and MST were more likely to have comorbid depression and substance use than male Veterans with PTSD, but without MST.
    Date: September 8, 2011
  • Quality of VA Mental Health Care Following Psychiatric Hospitalization for Veterans with Depression
    This study sought to assess the quality of depression care (e.g., antidepressant treatment, psychotherapy) during the high-risk period following a psychiatric hospitalization. Findings show that less than half of Veterans hospitalized for major depression had outpatient mental health follow-up within 7 days of discharge (39%), which is similar to rates found in the general U.S. population among Medicare (38%) and Medicaid (43%) beneficiaries in 2008. Mental health follow-up within 30 days for Veterans in this study was substantially more common (76%). Many Veterans also received adequate psychopharmacologic treatment following a hospitalization for depression (59%), but relatively few received adequate psychotherapy post-discharge (13%).
    Date: September 1, 2011
  • Study Suggests PTSD Associated with Cognitive Impairment
    This systematic review analyzed data from 21 articles published between 1968 and 2009 that examined memory and cognitive function in subjects with chronic PTSD compared to subjects who had been exposed to trauma but did not have PTSD. Eight of the studies that were analyzed included Veterans. Findings showed that chronic post-traumatic stress disorder is associated with cognitive impairment, particularly in Veterans, when compared to individuals with a history of trauma but no PTSD. The severity of PTSD is positively correlated with cognitive impairment. Strong evidence, especially in studies of Veterans, refugees, and war victims, suggests that individuals with PTSD have a poorer ability to sustain attention compared with individuals who have a history of exposure to trauma.
    Date: September 1, 2011
  • Co-Location of Primary Care in VA Mental Health Clinics Associated with Better Processes of Care for Veterans with Serious Mental Illness
    This study sought to determine the association between the co-location of primary care services and quality of medical care for patients with serious mental illness (SMI) receiving care in VA mental health clinics. Findings showed that the co-location of primary care services within VA mental health clinics was associated with better quality of care for Veterans with serious mental illness, particularly for key processes of care. After adjusting for organizational and patient-level factors, Veterans from co-located clinics were more likely to receive diabetes foot exams and screening for colorectal cancer and alcohol misuse (process measures), and to have satisfactory blood pressure control (outcome measure). Co-location was not associated with better outcomes for hemoglobin A1C levels among Veterans with diabetes. Observed quality of care in this sample exceeded national averages. Overall, integrated medical care may potentially provide an effective medical home model that can improve processes of medical care for Veterans with SMI.
    Date: August 1, 2011
  • Potential Problems with the Use of Antidepressants among Older Veterans Residing in VA Nursing Homes
    This study examined the prevalence and patient/site-level factors associated with potential underuse, overuse, and inappropriate use of antidepressants among Veterans aged 65 years and older that were admitted to any one of 133 VA Community Living Centers (CLC, previously called Nursing Home Care Units). Findings suggest potential problems with the use of antidepressants in older Veterans that reside in VA CLCs. Overall, only 18% of antidepressant use was optimal. Of the 877 Veterans with depression, 25% did not receive an antidepressant, suggesting potential underuse. Among depressed Veterans who received antidepressants, 43% had potential inappropriate use due primarily to problems seen with drug-drug and drug-disease interactions. In addition, of the 2,815 Veterans who did not have depression, 42% were prescribed one or more antidepressants; of these, only 4% had an FDA-approved labeled indication, suggesting potential overuse. Also, the co-prescribing of antipsychotics (in patients without schizophrenia) among those without depression was associated with an increased risk of antidepressant overuse.
    Date: August 1, 2011
  • Veterans with Diabetes and Major Depressive Disorder at Significantly Increased Risk of Myocardial Infarction
    This study sought to determine if major depressive disorder (MDD) complicates the course of type 2 diabetes and is associated with increased risk of myocardial infarction (MI) and mortality. Findings showed that Veterans with comorbid MDD and type 2 diabetes were 82% more likely to experience a MI compared to Veterans without MDD and type 2 diabetes. Veterans with MDD alone were 29% more likely to have a MI, and Veterans with type 2 diabetes alone were at 33% increased risk of MI. The incidence of MI increased in a step-wise fashion, from unaffected Veterans (2.6% incidence of MI) to those with depression only (3.5%) to those with diabetes only (5.9%) to Veterans with both conditions (7.4%). Veterans with PTSD, anxiety, and panic disorder were more likely to have a MI, as were Veterans with hypertension, hyperlipidemia, obesity, and nicotine dependence.
    Date: August 1, 2011
  • Differences in Communication between Providers in VA Mental Health Clinics and General Medical Providers in Treating Veterans with Serious Mental Illness
    Integrated care for co-occurring substance use and general medical disorders is considered essential for improving quality of care for individuals with serious mental illness (SMI), and is one of VA’s priority goals. This study sought to describe the barriers and facilitators of integrated care (from the perspective of mental health providers) for nearly 20,000 Veterans with SMI. Findings show that mental health providers from VA mental health clinics with high versus low quality of care scores differed in their ability to communicate with general medical providers regarding care for Veterans with SMI. Among mental health providers from low-performing sites, lack of communication with primary care providers was a key barrier. Barriers to communication included lack of opportunities to interact on a face-to-face basis and lack of opportunities to have team meetings. In addition, they were concerned that primary care providers did not want to see patients with SMI because of the perception that they were difficult to treat. Stigma was not mentioned as a problem for providers among the high-performing sites, with general medical providers viewed as sensitive to the needs of Veterans with SMI. The authors suggest that these findings indicate that efforts to improve communication between mental health and primary care providers, as well as delineating roles and responsibilities across both types of providers may potentially facilitate integrated medical care for Veterans with serious mental illness.
    Date: July 7, 2011
  • Updated Literature Review Examines Research and Findings on Women Veterans’ Health
    Investigators conducted a systematic review of the scientific literature published from 2004-2008 and summarized major findings, as well as advancements and gaps in comparison to literature from an original synthesis (more research was published in this 5-year review than in the 25-year period of the previous review). High rates of PTSD symptoms and other mental health disorders (e.g., depression) were found among returning OEF/OIF military women. Also, as the number of OIF deployments increases, screening positive for mental health problems appears to increase. Military sexual trauma (MST) combined with combat exposure was associated with doubled rates of new onset PTSD in both women and men, and MST was associated with more readjustment difficulties in civilian life. In addition, the literature suggests the need for repeated PTSD/mental health screening in returning OEF/OIF Veterans. Local organizational culture and quality of leadership support for women’s health were key factors in fostering gender-sensitive VA programs for women Veterans. Within VA healthcare, women Veteran’s satisfaction is positively affected by access to women’s clinics, gynecological services, and overall continuity of care. Women Veterans who do not use VA healthcare lack understanding of VA care and services. Among VA users, women and men had similar outpatient satisfaction ratings; however, women had consistently lower ratings for inpatient care (e.g., physical comfort, courtesy). While successes are evident in the breadth and depth of publications, remaining gaps in the literature include: post-deployment readjustment for women Veterans and their families, and quality of care interventions/outcomes for physical and mental conditions affecting women Veterans.
    Date: July 6, 2011
  • Growing VA Research Agenda for Women Veterans
    This paper reports on the 2010 VA Women’s Health Services Research Conference, as well as the resulting research agenda for moving forward on behalf of women who have served in the military. Recommendations for the future VA women’s health research agenda, resulting from this conference, included, to name a few: Address gaps in women Veterans’ knowledge and use of VA services (e.g., outreach/education, social marketing, telemedicine); Evaluate and improve quality of transitions from military to VA care; Assess gender differences in the presentation and outcomes of chronic diseases; Determine reproductive health needs of women Veterans; Examine the structure and care models that support patient-aligned care teams; Evaluate variations in mental healthcare needs; Assess and reduce the risk of homelessness among women Veterans; Conduct research on post-deployment reintegration and readjustment among women Veterans; and Develop combat exposure measure(s) that reflect women Veterans’ experiences.
    Date: July 6, 2011
  • Women’s Health Issues Journal Focuses on Women Veterans
    This special issue of Women’s Health Issues includes 18 peer-reviewed manuscripts summarizing health services research findings about women Veterans and women in the military, framed in the context of informing evidence-based practice and policy. Highlights include: VA has tailored primary care to women through the use of designated providers or separate women’s clinics. VA’s with these clinics were rated higher on most dimensions of care. These findings are particularly important to VA’s current implementation of patient-aligned care teams (PACTs). More than half of VA facilities now offer one or more mental healthcare services specifically for women Veterans, including services embedded within women’s primary care clinics, designation of women’s healthcare providers within general mental health clinics, and/or separate women’s mental health clinics. Recent data on VA care among men and women Veterans with histories of military sexual trauma (MST) show high satisfaction with care. Authors suggest that VA’s system-wide monitoring of MST-related care may be contributing to these positive results. PTSD among women Veterans is associated with poorer occupational functioning and satisfaction, but not employment status. Symptoms of depression have substantial effects across all components of work-related quality of life, independent of PTSD symptoms. PTSD is the most common psychiatric condition among both women and men with traumatic brain injury (TBI). However, women with TBI are less likely than men to have a PTSD diagnosis, but more likely to have a depression or anxiety disorder diagnosis.
    Date: July 6, 2011
  • Integrated Primary Care Clinic Improves Access to Mental Health and Social Services for OEF/OIF Veterans
    In April 2007, an OEF/OIF Integrated Care (IC) Clinic was established at the San Francisco VAMC, as part of VA primary care system-wide priorities for improving mental health screening and treatment for OEF/OIF Veterans. This study evaluated whether an initial IC clinic visit improved mental health and social services use among OEF/OIF Veterans entering primary care at the San Francisco VAMC, compared to Veterans who received usual care. Findings showed that OEF/OIF Veterans seen in the IC clinic were significantly more likely to have had initial mental health and social work evaluations within 30 days. Moreover, IC clinic patients were significantly more likely than usual care patients to have had at least one follow-up specialty mental health visit within 90 days of initiating primary care. Women Veterans, younger Veterans, and those with positive mental health and TBI screens were significantly more likely to have had mental health and social service evaluations if seen in the IC versus the usual care clinic. While the Integrated Clinic increased initial mental health evaluations, there was no significant increase in longer-term retention in specialty mental health services among Veterans who screened positive for mental health problems.
    Date: June 7, 2011
  • Women as Resilient to Combat-Related Stress as Men in the First Year Following Return from OEF/OIF Deployment
    This study examined gender differences in various dimensions of combat-related stress and associated consequences for post-deployment mental health in a nationally representative sample of male and female OEF/OIF Veterans. Study results suggest that women OEF/OIF service members may be as resilient to combat-related stress as men in the first year following deployment. There were no significant interactions between combat-related stressors and gender in the prediction of post-traumatic stress symptomatology, mental health functioning, or depression. Women reported slightly less exposure than men to most combat-related stressors, but higher exposure to other stressors (i.e., prior life stress, deployment sexual harassment). There were no differences between men and women in reports of perceived threat in the war zone.
    Date: May 30, 2011
  • Telemedicine-Based Collaborative Care Does Not Increase Total Workload for Primary Care or Mental Health Providers
    This study examined patterns of healthcare utilization and cost associated with telemedicine-based collaborative care for depression among Veterans who received care in seven VA community-based outpatient clinics (CBOCs). Findings suggest that telemedicine-based collaborative care does not increase total workload for primary care or mental health providers; therefore, there is no disincentive for mental health providers to offer telemedicine-based care ? or for primary care providers to refer Veterans to telemedicine care. There was no significant difference in the total number or cost of primary care encounters between Veterans in the intervention group and those in the usual care group. Between the two groups, there also were no statistically significant differences in total mental health encounters or cost; however, Veterans in the intervention group did have significantly more cost and encounters in specialty physical health clinics. In addition, Veterans in the intervention group had a significantly greater total outpatient cost compared to Veterans in usual care. These differences were likely due to the high levels of physical and mental health comorbidities in this study population.
    Date: May 26, 2011
  • Book Examines Social and Cultural Factors Contributing to Combat-Related PTSD among OEF/OIF Veterans
    This book follows a group of OEF/OIF Veterans and tells their personal stories of war, trauma, and recovery as they re-enter civilian life while dealing with combat-related PTSD. Written from an anthropologist’s perspective, the author examines the cultural, political, and historical influences that shape individual experiences of PTSD – and how Veterans with PTSD are perceived by the military, medical personnel, and society at large. Despite widespread media coverage and public controversy over the military’s response to wounded and traumatized service members, debate continues about how best to provide treatment and compensation for service-related disabilities. At the same time, new and highly effective treatments are revolutionizing how VA provides trauma care, and redefining the way PTSD is understood. Fields of Combat discusses real-life issues related to living with PTSD, and suggests recommendations to improve PTSD care.
    Date: May 19, 2011
  • Veterans Reporting a History of Military Sexual Trauma are Treated in a Variety of VA Outpatient Mental Health Settings
    This study sought to determine the VA mental health outpatient settings in which patients with military sexual trauma (MST) are most likely to be treated, which might help set priorities for targeted MST-related education and training. Findings showed that more than one-third of female Veterans (36%) and 2% of male Veterans seen in VA outpatient mental healthcare settings during FY08 reported a history of military sexual trauma. Both women and men with MST were more likely to use more than one type of mental health clinic setting, compared to those without MST. A significantly larger proportion of women seen in MST specialty clinics reported MST as compared to all other settings (81% vs. 34%). However, there was a wide range of clinic visit settings for female Veterans with MST, including: MST specialty clinics, PTSD specialty clinics, psychosocial rehabilitation, and substance use disorder clinics. Male Veterans represented a small proportion of patients seen in all clinics, and a larger proportion of men seen in MST specialty clinics reported MST as compared to other settings (56% vs. 2%). These findings indicate that mental health providers who treat women Veterans, even if they work in settings that do not traditionally incorporate interventions focused on traumatic stress, may encounter issues related to MST. Therefore the authors suggest that training in how to respond to sexual trauma disclosure be an important component in all VA mental healthcare settings.
    Date: May 1, 2011
  • Effect of Housing Vouchers on Homeless Veterans with Mental Illness
    This study examined how homeless Veterans with mental illness obtain housing without a voucher, and whether greater employment earnings or better clinical outcomes were associated with such housing success. Findings showed that Veterans who obtained independent housing without a voucher worked more days and had higher employment income than those with a voucher, but they were less satisfied with their housing. Veterans who used vouchers lived in housing with the highest rent, but paid less of their own income toward rent because of their vouchers. They also reported the highest quality of life with respect to their living situation, higher satisfaction with their housing, and higher safety scores. About one-third of Veterans who obtained independent housing without a voucher lived with others, most often with a family member, and reported lower total rent costs, but paid the greatest share of the rent themselves. Approximately 80% of participants were diagnosed with alcohol or drug dependency. There were no differences in psychiatric, substance abuse, or legal outcomes between groups at three months; however, data over all three years shows that Veterans who were not housed had higher psychiatric, substance abuse, and work problems over time than all other groups.
    Date: May 1, 2011
  • Less than One-Quarter of Veterans who Complete Suicide Access VA Healthcare in Year Prior to Death
    This study sought to determine the number of Veterans who completed suicide and who had accessed VA healthcare in the Pacific Northwest Region in the year prior to death. Findings show that of the 968 Veterans in this study who completed suicide, less than one-quarter (22%) accessed VA healthcare in the year prior to death, and a minority of those Veterans visited mental health providers. These numbers are consistent with current estimates of the number of Veterans accessing care at VA hospitals and clinics, and suggest that Veterans who go on to complete suicide may access VA healthcare at similar rates as Veterans who do not commit suicide. Of those Veterans who completed suicide, 57% did not have a mental health diagnosis, and 58% had not seen a mental health professional, suggesting that it is perhaps equally important to understand patients with general medical conditions who also may be likely to complete suicide. Of those who completed suicide, 55 were hospitalized during the year prior to death. Of these, 39% with a psychiatric hospitalization and 22% with a medical/surgical hospitalization completed suicide within 30 days. A large number of Veterans (73% of men; 36% of women) completed suicide by use of a firearm, supporting concerns from earlier studies over firearm access as a key risk factor in Veteran suicide.
    Date: April 4, 2011
  • Initial Implementation of VA Primary Care Mental Health Not Associated with Differences in Specialty Mental Health Clinic Use by Veterans
    This study sought to determine whether the implementation of primary care mental health services is associated with differences in specialty mental health clinic use within the VA healthcare system. Findings show that the initial implementation of primary care mental health within VA is not associated with substantial differences in mental health clinic use – or diagnoses received in specialty mental health clinics by primary care patients. Facilities with primary care mental health – compared to those without – had similar rates of primary care patients initiating specialty mental health treatment (5.6% vs. 5.8%), and their primary care patients averaged similar total specialty mental health clinic visits (7.0 vs. 6.3). After adjusting for facility characteristics and multiple comparisons, there were no statistically significant differences with regard to diagnoses for Veterans who initiated specialty mental health clinic treatment at primary care mental health facilities. The authors note that primary care mental health may impact mental health clinic use over longer periods of time as these programs mature.
    Date: April 1, 2011
  • Successful Translation of Behavioral Intervention for Caregivers of Veterans with Dementia
    This study assessed the translation of the NIA/NINR Resources for Enhancing Alzheimer’s Caregivers Health (REACH II) intervention into REACH VA – a behavioral intervention for caregivers of Veterans with dementia that ran from 9/07 through 8/09. Findings show that the REACH VA intervention provided clinically significant benefits for caregivers of Veterans with progressive dementia. Caregivers reported significantly decreased burden, depression, impact of depression on daily life, frustrations associated with caregiving, and number of troubling dementia-related behaviors. Also, a decrease of two hours per day “on duty” trended toward significance. Of the caregivers who participated in the REACH VA intervention, 96% believed that the program should be provided by VA to caregivers.
    Date: February 28, 2011
  • Using Administrative Data to Measure Treatment for Veterans with PTSD May Overestimate Delivery of Psychotherapy
    This study sought to determine whether using administrative data to determine the number of psychotherapy sessions Veterans receive is equivalent to manual record review. Manually-classified notes were used to develop an automated coding protocol using the Automated Retrieval Console (ARC), a VA-developed natural language processing program. ARC was then used to independently code the notes, and the performance of the automated coding program was compared to manual coding. Findings showed that, of the notes that were administratively coded as individual psychotherapy for PTSD, 57% were coded as individual psychotherapy after manual review of records. Thus, nearly half of the encounters that would have been counted as the provision of psychotherapy in large administrative studies appeared to be records of services other than psychotherapy (e.g., intakes, psychological testing). Findings suggest that using counts of administrative codes over-estimates the amount of psychotherapy delivered to Veterans with PTSD. This suggests a potential limitation in current studies of the quality of care for PTSD in VA. The ARC program replicated the performance of the manual coders in classifying psychotherapy notes very well. This suggests that ARC may help bridge the gap between the accuracy of manual coding and the scope of administrative coding.
    Date: February 14, 2011
  • Study Evaluates Workshop to Assist OEF/OIF Veterans with Reintegration and Resiliency
    Few programs to promote healthy reintegration exist that are evidence-based and designed for individuals who are not receiving formal mental health care. In response to this need, a two-hour workshop, Life Guard, was developed for the Arkansas National Guard. This pilot study evaluated the effectiveness of the Life Guard workshop for OEF/OIF National Guard Veterans. Findings show that Veterans who participated in the workshop reported significant declines in symptoms of depression, anxiety, and PTSD, in addition to increased satisfaction with relationships. Results also show high levels of exposure to traumatic events, physical injury, and symptoms of psychosocial distress. The authors suggest that these findings support the continued evaluation of Life Guard as a valuable tool to help service members with reintegration and resiliency.
    Date: February 1, 2011
  • Rates of PTSD and Depression Highly Prevalent among OEF/OIF Veterans with Alcohol and/or Drug Use Disorders
    This study sought to determine the prevalence and independent correlates of alcohol use disorders (AUD) and drug use disorders (DUD) among OEF/OIF Veterans who were first-time users of VA healthcare. Findings show that, overall, 11% of the OEF/OIF Veterans in this study received diagnoses of AUD, DUD, or both; 10% received AUD diagnoses and 5% received DUD diagnoses. Post-deployment AUD and DUD diagnoses were more prevalent in particular sub-groups of OEF/OIF Veterans and were highly comorbid with PTSD and depression. Among Veterans diagnosed with AUD, DUD, or both, 55% to 75% also received a diagnosis of PTSD or depression. AUD, DUD, or both diagnoses were 3 to 4.5 times more likely among Veterans with PTSD and depression. AUD and DUD diagnoses were more prevalent among Veterans younger than age 25, men, and Veterans who were more likely to have had greater exposure to combat, e.g., Veterans who were enlisted versus officers, and those who served in the Army and Marines.
    Date: January 28, 2011
  • Suicide Risk Factors for OIF Veterans
    This study examined combat and mental health as risk factors for suicidal ideation among OIF Veterans. Findings show that, overall, 2.8% of the OIF Veterans in the study reported suicidal thinking, the desire for self-harm, or both. Post-deployment depression symptoms were associated with suicidal thoughts, while post-deployment PTSD symptoms were associated with current desire for self-harm. Post-deployment depression and PTSD symptoms mediated the association between killing in combat and suicidal thinking, while post-deployment PTSD symptoms mediated the association between killing in combat and the desire for self-harm. These results provide preliminary evidence that suicidal thinking and the desire for self-harm are associated with different mental health predictors, and that the impact of killing on suicidal ideation may be important to consider in the evaluation and care of our newly returning Veterans.
    Date: January 22, 2011
  • Telephone-based Care Coordination Intervention Complements Care for Veterans with Dementia and Supports their Caregivers
    This article provides a detailed description of a telephone-based care coordination intervention – Partners in Dementia Care (PDC) – developed for Veterans with dementia and their family caregivers across all stages of the disease. Findings show that, overall, the PDC intervention addresses the diverse needs of Veterans with dementia and their caregivers, including non-medical care issues such as understanding VA benefits, accessing community resources, and addressing caregiver strain. The authors also note that the PDC intervention incorporates several unique features that distinguish it from most other services and programs for dementia caregiving, such as the delivery of the intervention through formal partnerships between VAMCs and local Alzheimer’s Association Chapters, the inclusion of family caregivers, and the breadth of issues addressed for both Veterans and their caregivers. The consumer-directed philosophy of the program enabled Care Coordinators to serve a large number of families in a cost-efficient way, since Veterans and families were taking action on their own with support and guidance from both VA and Alzheimer’s Association care coordinators.
    Date: January 17, 2011
  • Collaborative Care Intervention Improves Depression in Veterans with HIV
    The goal of this study was to adapt an evidence-based primary care model of depression collaborative care for HIV clinic settings (HIV Translating Initiatives for Depression into Effective Solutions [HITIDES])) – and to evaluate its effectiveness. Findings show that the HITIDES intervention was successfully implemented in HIV settings and improved both depression and HIV symptom outcomes. Veterans who participated in the intervention were more likely to report treatment response and remission compared to Veterans in usual care at 6-month follow-up but not at 12-month follow-up. Improved depression response and remission outcomes at 6 but not 12 months suggest that depression symptoms improved more rapidly in the intervention group compared to usual care. Intervention participants also reported more depression-free days over 12 months. Compared to usual care, significant intervention effects also were observed for lowered HIV symptom severity at 6 and 12 months. The authors suggest that the HITIDES intervention may serve as a model for collaborative care interventions in other specialty physical healthcare settings.
    Date: January 10, 2011
  • Peer-Support Interventions May Reduce Symptoms of Depression Better than Usual Care
    Investigators in this study conducted a meta-analysis of published randomized clinical trials (RCTs) to determine whether peer-support interventions resulted in a greater reduction of depression symptoms compared to either usual care or psychotherapy (group cognitive behavioral therapy only). Seven RCTs comparing peer support vs. usual care for depression showed a significantly greater reduction in mean depression scores with peer support. Seven RCTs comparing a peer-support intervention to group cognitive behavioral therapy (CBT) showed no statistically significant difference between group CBT and peer interventions. These findings suggest that peer-support interventions have the potential to be effective components of depression care.
    Date: January 1, 2011
  • Veterans who Commit Suicide May Not Show Apparent Emotional Distress During Last Healthcare Contact
    This retrospective study examined VA healthcare contacts (by phone or in person) by Veterans in the year prior to their deaths by suicide. The majority of Veterans in this study were seen for routine VA medical care in the year prior to committing suicide, and did not show apparent signs of emotional distress at their last healthcare visit. In the year prior to death, nearly 50% of the Veterans had one or more mental health contacts, and 63% had one or more primary care contacts. Just over half of the Veterans received care in the 30 days prior to death, with 20% receiving mental health care and 15% receiving primary care. Forty percent of these Veterans were assessed for suicidal ideation during the year prior to death, and 16% were assessed during their last contact. Nearly three-quarters of those who were specifically asked about thoughts of suicide in the year prior to death denied having such thoughts. The median number of days between final VA healthcare contact and date of death was 42. Of the 26 Veterans whose final contacts were with mental health, 87% were assessed for depression, substance use disorder, or PTSD, and 54% were assessed for suicidal ideation. Of the 22 Veterans whose final contacts were with primary care, 55% were assessed for depression, substance use disorder, or PTSD, and 9% were assessed for suicidal ideation.
    Date: December 1, 2010
  • Pregnancy and Mental Health Conditions among Female OEF/OIF Veterans Using VA Healthcare
    This study sought to determine the prevalence of mental health problems among 43,078 OEF/OIF women Veterans who received a pregnancy diagnosis in the VA healthcare system over a five-year study period (2003-2008). Although a relatively small proportion of OEF/OIF women Veterans received VA healthcare related to pregnancy (7%), a substantial proportion of these women (32%) received one or more mental health diagnoses compared with 21% of women without a pregnancy-related condition. Compared with all women Veterans enrolled in VA healthcare, Veterans with a pregnancy were twice as likely to have a diagnosis of depression, anxiety, PTSD, bipolar disorder, or schizophrenia than those without a pregnancy. The most common mental health diagnoses among Veterans with a pregnancy were anxiety (43%), depression (36%), and PTSD (21%), followed by bipolar disorder (3%), and alcohol abuse/dependence (3%). [Sum is greater than 100% due to comorbidity.] Veterans with a pregnancy were significantly more likely to have a service-connected disability than those without a pregnancy. 71% of Veterans with a pregnancy were either never married or no longer married. On average, women Veterans experienced their index pregnancy nearly two years after returning from their last deployment.
    Date: December 1, 2010
  • Differences in Mental Health Diagnoses among OEF/OIF Soldiers Transitioning from DoD to VA Care
    This study assessed the transition of healthcare from DoD to VA for service members traumatically injured in OEF/OIF, and their subsequent psychiatric care. Findings show that although none of the 994 DoD inpatients received a diagnosis of PTSD, 21% (209) had other mental health diagnoses, primarily drug abuse (12%). Of the 216 service members who transitioned to VA care, 71% (153) subsequently had at least one psychiatric diagnosis, with PTSD (52%) and depression (40%) the most common. OEF/OIF service members who were discharged from DoD care in FY06 were more likely to transition into VA care (31%) than were patients discharged in earlier years. Of service members who sought VA care, 38% did so within six months of DoD discharge, and 75% within one year of discharge. Nearly 88% of those service members who transitioned to VA healthcare were still using VA care in the final year of the study, FY09. Treatment retention was significantly greater for those receiving psychiatric care: 98% vs. 62% for those not receiving psychiatric care.
    Date: November 2, 2010
  • Providing Free Care for Veterans with Military Sexual Trauma Does Not Result in Major Income Loss to VA
    Since 2002 there have been no co-payments for VA healthcare related to military sexual trauma (MST), defined by VA as sexual assault or harassment that took place during military service. However, eliminating co-payments reduces income for the VA healthcare system. This retrospective study estimated the loss in outpatient co-payment revenue for VA due to the mandate for free care related to MST. Findings show that about 95% of Veterans who received outpatient care for military sexual trauma would have had no co-payment, even in the absence of a free-care mandate. The estimated co-payment revenue foregone by the free-care mandate for MST was modest, totaling about $418,000 in FY06, $517,000 in FY07, and $455,000 in FY08. These totals represented only .04-.05% of first-party co-payment revenues for outpatient care. These results suggest that VA can continue to provide free care for patients who have experienced military sexual trauma without major income loss.
    Date: November 1, 2010
  • Link between Psychiatric Diagnosis and Higher Risk of Suicide among Veterans
    As part of VA’s ongoing evaluation of suicide risk among Veterans being treated in VA facilities, this study examined the impact of different psychiatric diagnoses on the risk of suicide. Findings show that a clinical diagnosis of a psychiatric disorder increased the risk of subsequent suicide by 160%. Psychiatric diagnoses were an especially strong risk factor for suicide among women, increasing their risk of suicide more than 5-fold. Bipolar disorder was the least common diagnosis (only 3% of all Veterans studied), but was diagnosed in approximately 9% of all Veterans who died by suicide. A diagnosis of bipolar disorder increased the risk of suicide nearly 3-fold in men and 6-fold in women. Authors suggest this makes bipolar disorder particularly appropriate for targeted interventions (e.g., improving medication adherence). Overall, suicides were more than three times as common in men than in women and were 37% to 77% more common in Veterans ages 30 and older than among those ages 18 to 29.
    Date: November 1, 2010
  • Substantial Gaps in Processes of Care for Veterans with Bipolar Disorder
    This study applied a comprehensive set of process of care measures that reflect the integration of psychosocial, patient preference, and continuum of care approaches to mental health – and evaluated whether Veterans with bipolar disorder received care concordant with these practices. Findings show substantial gaps in care for Veterans with bipolar disorder, especially for patient-centered processes such as symptom assessment and treatment experience. Only half of the patients received care in accordance with clinical practice guidelines. Moreover, only 17% had documented assessment of psychiatric symptoms, 28% had documented patient treatment preferences, 56% had documented assessment of substance abuse and psychiatric comorbidity, and 62% had documented assessment of cardiometabolics. Monitoring of weight gain was noted in 54% of the patient charts, and no-show visits were followed up only 20% of the time. However, 72% of the patients received appropriate anti-manic medication, and all patients were assessed for suicidal ideation. Overall, results suggest that in order to present a more patient-centered view of quality, processes of care for bipolar disorder cannot be distilled into a single measure; but rather, a series of patient-centered composite indicators.
    Date: November 1, 2010
  • Gender Differences in Mental Health Diagnoses among OEF/OIF Veterans
    This study examined differences in socio-demographic, military service, and mental health characteristics between female and male OEF/OIF Veterans. Findings show that female OEF/OIF Veterans who were new users of VA healthcare were younger, more often African-American, and more frequently diagnosed with depression. In addition, older age was associated with a higher prevalence of PTSD and depression diagnoses among female Veterans. Male OEF/OIF Veterans who were new users of VA healthcare were more frequently diagnosed with PTSD and alcohol use disorder. Among male Veterans, younger age indicated greater risk for PTSD. Both female and male OEF/OIF Veterans with higher combat exposure were more likely to receive a diagnosis of PTSD.
    Date: October 21, 2010
  • PTSD Associated with Poorer Couple Adjustment and Increased Parenting Challenges among Male OIF National Guard Troops
    This study examined associations among combat-related PTSD symptoms, parenting behaviors, and couple adjustment among male National Guard troops who had served in Iraq (OIF). Findings show that increases in PTSD symptoms were associated with poorer couple adjustment and greater perceived parenting challenges one year post-deployment. Further, PTSD symptoms predicted parenting challenges independently of their impact on couple adjustment. PTSD was associated with higher levels of alcohol use, but alcohol use was not significantly associated with couple adjustment or parenting. Deployment injury also was independently associated with increased PTSD symptoms. Findings suggest that symptoms of PTSD may exert their influence at multiple levels within the family, making transitions from combat to home life even more complicated. This highlights the importance of investigating and intervening to support parenting and couple-adjustment among combat-affected National Guard families, who often lack the support available to active duty families via the military base community.
    Date: October 1, 2010
  • Increasing Access to VA Primary Care via Community Clinics May Alter Veterans’ Use of Healthcare
    This study examined trends in primary care, specialty care, and mental health services use in VA and Medicare among Medicare-eligible Veterans who obtained community-based primary care or hospital-based primary care. Findings show that VA primary care patients who were eligible for Medicare used significant primary care and specialty care outside of VA, but not mental health care. Community-based VA patients used less VA care and more Medicare services, suggesting possible unintended fragmentation of care. Hospital-based VA patients were more likely than community-based patients to obtain primary care and specialty care only at VA. Dual use of VA and Medicare specialty care was the most common care pattern and the most fragmented among both community and hospital-based patients. Mental healthcare services were not fragmented, as most patients used VA only for these services. Use of Medicare only for outpatient primary and specialty care increased over the 4-year study, while use of VA only for these services decreased.
    Date: October 1, 2010
  • Threshold for Glycemic Control among Veterans with Diabetes
    In 2009, the National Committee for Quality Assurance (NCQA) – Healthcare Employer Information Data Set (HEDIS) measure for good (<7% A1c) glycemic control for individuals with diabetes was revised to apply only to persons younger than 65 years without cardiovascular disease, end-stage diabetes complications, or dementia. However, multiple guidelines recommend that glycemic control targets be individualized, especially in the presence of comorbid medical and mental health conditions. This retrospective study used the NCQA <7% measure to compare overall VA facility rankings with a subset of Veterans receiving complex glycemic treatment regimens (CGR). Findings show that the assessment of the quality of good glycemic control among VA facilities differs using the NCQA-HEDIS measure for the overall study population compared to a subset of patients receiving CGR. For example, the overall top 10% performing facilities achieved a rate of 57% at the <7% A1c threshold compared to 34% for Veterans on CGR using the same measure. Therefore, the authors suggest that reliance upon a <7% A1c threshold measure as the “quality standard” for public reporting or pay-for-performance could have the unintended consequence of adversely impacting patient safety. Moreover, they propose that rather than assessing “good glycemic control” by an all-or-none threshold, developers of measures should provide credit for an A1c result within an acceptable range (e.g. incremental credit for improvement between 7.9% and <7%) in order to balance the trade-offs of benefits, harms, and patient preferences.
    Date: October 1, 2010
  • Greater Burden of Medical Illness among OEF/OIF Veterans with PTSD
    This study sought to determine whether the burden of medical illness is higher in OEF/OIF Veterans with PTSD who used VA outpatient care compared to OEF/OIF Veterans with no mental health conditions. Findings show that among women and men OEF/OIF Veterans who used VA outpatient care between FY06 and FY07, the burden of medical illness (measured as a count of diagnosed conditions) was greater for those with PTSD than for those with no mental health conditions. The median number of medical conditions for women Veterans was 7.0 for those with PTSD versus 4.5 for those with no mental health conditions; for men, the rates were 5.0 versus 4.0. For Veterans with PTSD, the most frequent conditions among women were lumbosacral spine disorders, headache, and lower extremity joint disorders; among men, the most frequent were lumbosacral spine disorders, lower extremity joint disorders, and hearing problems. These high-frequency conditions were more common in those with PTSD than in those with no mental health conditions.
    Date: September 18, 2010
  • Measuring the Quality of Mental Healthcare: Barriers and Strategies
    This article discusses the barriers to mental health quality measurement – and identifies strategies to enhance the development and use of quality measures in order to improve outcomes for people with mental health disorders. The authors suggest that key reasons for the lag in mental health performance measurement include: lack of sufficient evidence regarding appropriate mental health care, poorly defined quality measures, limited descriptions of mental health services from existing clinical data, and lack of linked electronic health information. The refinement of quality measures and, ultimately, enhanced outcomes in mental health will require investment in information technology, additional studies to support the evidence base, and the development of a culture of measurement-based care. Sustaining efforts to improve mental health performance measurement will require rethinking how quality measurement is used to promote the uptake of evidence-based mental healthcare across systems of care. In addition, measurement systems should cut across mental health disorders, physical disorders, and substance use disorders, which often co-occur.
    Date: September 1, 2010
  • Dementia More Prevalent among Older Veterans with PTSD
    This study sought to determine the association between PTSD and dementia in older Veterans. Findings show that older Veterans with PTSD had twice the incidence and prevalence of dementia diagnoses, even after accounting for confounding illnesses, combat-related trauma (measured by receipt of a Purple Heart), and number of primary care visits. Rates of TBI were highest in the group with PTSD and a Purple Heart, while rates of stroke were slightly higher among all groups with PTSD (regardless of Purple Heart receipt). The prevalence of drug dependence and abuse and the rates of alcohol dependence and abuse were highest in the group with PTSD, but without a Purple Heart. The mechanism for the observed increased incidence and prevalence of dementia among Veterans with PTSD is unknown. Possibilities include a common risk factor underlying PTSD and dementia, or PTSD being a risk factor for dementia. Regardless, the authors suggest that veterans over 65 years of age with PTSD be considered for dementia screening.
    Date: September 1, 2010
  • Minor Depression Highly Prevalent among Women Veterans with Complex Chronic Illness
    This study compared the rates of major and minor depression among women Veterans with chronic conditions (diabetes, heart disease, or hypertension) who received VA care in FY02. Of 13,430 women Veterans with depression, 60% were diagnosed with minor depression and 40% with major depressive disorders. Compared to major depression, minor depression was significantly more likely among women Veterans who were older, and those without any other psychiatric condition or substance use disorders. Results also show that compared to the hypertension only group, women Veterans with diabetes only or diabetes plus hypertension had higher rates of major depression. Moreover, all types of psychiatric conditions and substance use were associated with higher rates of major depression, and 22% of the study population had a substance use disorder. The authors suggest that the generally high rates of depressive disorders among women Veterans with chronic physical illnesses indicate the need for a continuum of care that encompasses both physical and mental illness domains.
    Date: August 1, 2010
  • Most VA Patients with Substance Use Disorders Who Die from Suicide Use Violent Means
    Most VA patients with substance use disorders (SUDs) who died from suicide used violent means (70%, n=600), and the majority were carried out with firearms. No specific SUD was associated with increased risks of violent suicide, but several SUD diagnoses (e.g., cocaine use and opiate use) were associated with a higher risk of non-violent suicide. Alcohol use was associated with a lower likelihood of non-violent suicide. While many psychiatric disorders (e.g., major depression, PTSD, schizophrenia) were associated with increased risk of both violent and non-violent suicide, the strength of the association between the disorder and type of suicide was greater for non-violent than violent suicide. The authors suggest that by linking data on risk factors to information about the specific methods used, future interventions designed to decrease access to lethal means could be tailored to focus on those at greatest risk of dying by specific means.
    Date: July 1, 2010
  • Medication Management for Veterans with Schizophrenia
    This study examined medication management for a random sample of Veterans who received drug therapy for schizophrenia at any one of three VA mental health clinics in Southern California between 2002 and 2003. Overall, 67% of Veterans had inappropriate management at baseline: 32% had inappropriate management of psychotic symptoms, 45% had inappropriate management of weight, and 8% had inappropriate management of tardive dyskinesia (TD). Further, 11% had depression that was moderately severe or worse. At one year, the appropriateness of management for psychotic and depressive symptoms had not changed. The appropriateness of management of TD also did not change over time, but the management of elevated weight improved modestly. There were no significant differences between the three clinics in the prevalence of symptoms or side effects, or in the appropriateness of medication management. However, psychiatrists with more than 12 patients were significantly more likely to improve their patients’ care over time.
    Date: July 1, 2010
  • Military Sexual Trauma: Important Mental Health Issue for OEF/OIF Veterans
    Of the 125,729 OEF/OIF Veterans who received VA primary care or mental health services between 10/01 and 9/07, 15% of women and 0.7% of men reported military sexual trauma (MST) based on results of universal screening that asks about sexual assault or harassment. Women and men who reported a history of MST were significantly more likely than those who did not to be diagnosed with mental health conditions, including PTSD, other anxiety disorders, depression, and substance use disorders. This finding remained consistent after adjusting for demographics, healthcare use, and military service characteristics. The relationship of MST to PTSD was stronger among women compared to men, suggesting that MST may be a particularly relevant issue for women Veterans seeking care for PTSD. There were high rates of post-deployment mental health conditions among all OEF/OIF patients.
    Date: June 17, 2010
  • Majority of National Guard Soldiers Recently Returned from Combat in Iraq Did Not Meet Criteria for Mental Health Disorder
    This study provides the first known report of rates of mental health disorders and comorbidities diagnosed by structured clinical interviews, as opposed to self-report, in a sample of 348 National Guard troops who returned from Iraq. Findings show that a majority (62%) did not meet criteria for a mental health disorder. However, the soldiers had slightly higher rates than community and non-deployed military samples across all mental health diagnoses, with the exception of drug use disorders. Depressive disorders were the most common, followed by non-PTSD anxiety disorders. Mental health diagnoses were associated with poorer functioning and quality of life, with PTSD having the strongest negative relationship with social functioning and quality of life. Results also show that more than 85% of soldiers with a diagnosis of PTSD had at least one additional mental health diagnosis, with depressive disorders being the most common. In addition, female soldiers were significantly more likely to have a mental health diagnosis than male soldiers. Specifically, women were diagnosed with PTSD, depressive disorders, and non-PTSD anxiety disorders at twice the rate of men.
    Date: June 9, 2010
  • Aggression May Be Linked to Psychosis in Elderly Persons with Dementia
    This literature review examined the evidence on whether delusions or hallucinations contribute to the development of agitation or aggression in persons aged 65 and older with dementia. Most studies showed a statistically significant association between psychosis and aggression. Findings also showed that the use of antipsychotic medications in the setting of agitation/aggression and psychosis among patients with dementia is not uniformly supported. Authors note that given the multifactorial etiology of psychosis and aggression with other comorbid symptoms in dementia, it is important to understand the various contributing factors to facilitate more effective treatment interventions with least possible risk.
    Date: June 1, 2010
  • Veterans Living in Rural Settings Less Likely to Receive Psychotherapy than Veterans Living in Urban Settings
    Analyzing VA data collected in FY 2004, the use of specialty mental health care was significantly and substantially lower for Veterans living in rural settings. Veterans living in urban settings were significantly more likely than rural Veterans to receive a specialty mental health visit, any form of psychotherapy, individual psychotherapy, or group psychotherapy in the 12 months following their initial diagnosis of depression, anxiety, or PTSD. Urban Veterans were about twice as likely as rural Veterans to receive four or more and eight or more psychotherapy sessions, even after controlling for travel distance and other demographic and clinical characteristics. This suggests that distance alone is insufficient to account for the differences observed. Length of time between an initial diagnosis of depression, anxiety, or PTSD and receipt of psychotherapy services was longer for rural Veterans compared to urban Veterans, but the difference was not clinically meaningful. The authors suggest that focused efforts are needed to increase access to psychotherapy services provided to rural Veterans with mental health disorders. It may be useful to examine recent VA data to assess whether VA’s emphasis on health care for rural Veterans is associated with improved measures of access and quality.
    Date: May 11, 2010
  • All Antipsychotics May Not Increase Short-Term Risk for Mortality among Veterans with Dementia
    Commonly prescribed doses of haloperidol, olanzapine, and risperidone, but not quetiapine, were associated with short-term increases in mortality. During the first 30 days, there was a significant increase in mortality in subgroups prescribed a daily low dose of haloperidol, olanzapine, or risperidone, after adjusting for demographics, comorbidities, and medication history. However, increased mortality was not seen when quetiapine was prescribed. No antipsychotic was associated with increased mortality after the first 30 days. Therefore, the authors suggest that all antipsychotics might not pose the same degree of risk in all patient groups as implied by the general warnings that have been issued.
    Date: May 7, 2010
  • History of Depression Remains a Risk Factor for Heart Disease after Accounting for Other Contributing Factors among Twin Veterans
    A history of depression remained a risk factor for incident heart disease even after adjusting for numerous covariates including: sociodemographics, co-occurring psychopathology, smoking, obesity, diabetes, hypertension, and social isolation. Moreover, twins with both high genetic and phenotypic expression of depression were at greatest risk of ischemic heart disease (IHD). Results also show that twins with hypertension and twins with diabetes were more likely to have IHD, as were twins who reported no social support. Age, race, education, and marital status were not associated with IHD status.
    Date: May 1, 2010
  • Communication Regarding Health-Related Quality of Life between Cancer Patients and Providers
    Health-related quality of life (HRQOL) discussions between oncologists and patients were common, but the emphasis was often on treatment (e.g., side effects) and symptoms (e.g., pain), even in patients with advanced disease. All provider/patient encounters included some talk of HRQOL, ranging from 3% to 75% of the total conversation, with the average HRQOL discussion taking up 25% of the conversation. An analysis of topics showed that 56% concerned treatment, 14% concerned disease, and 3% concerned testing. Talk of emotions, mental health, and psychological HRQOL was introduced into the conversations more frequently by patients than providers and occurred in only 9% of the audio segments studied. Spiritual HRQOL also was introduced into the conversations more frequently by patients than providers, and was discussed in only 1% of all audio segments. The authors suggest that given the often intense emotional experience of patients with advanced cancer, oncologists may need to pay more attention to psychological, social, and spiritual HRQOL concerns.
    Date: May 1, 2010
  • Predictors of Veterans’ Use of Mental Health Services
    Findings show that being older, female, having greater clinical need, lack of enabling resources (e.g., employment, stable housing, social support), and fewer problems with access to treatment significantly predicted increased mental health services use over the three-month follow-up period. Results also show that fewer outpatient mental health visits did not adversely affect clinical outcomes. Findings support VA’s ongoing commitment to provide special programs and initiatives focused on easing access to mental health services, vocational rehabilitation, and housing assistance.
    Date: April 1, 2010
  • Rates of Depression Rise among VA Nursing Home Residents
    Prevalence rates for dementia and schizophrenia fluctuated moderately from 1990 to 2006, but rates for depression were substantially higher in 2006 than in 1998. Results also show that PTSD was more prevalent, while the prevalence of alcohol use disorders declined. The prevalence of serious mental illness (e.g., schizophrenia, bipolar and manic disorders) was relatively stable over this time period, except for increases among the oldest residents. Understanding recent changes in the prevalence of mental health disorders among VA nursing home residents can contribute to optimal planning to meet their treatment needs.
    Date: April 1, 2010
  • Rural-Dwelling VA Patients have Worse Physical Health but Better Mental Health than Urban-Dwelling Counterparts
    Rural Veterans reported worse physical health but better mental health when compared to their urban counterparts, and these differences persisted across the four survey years. The differences were substantial and statistically significant and persisted after correcting for age, gender, marital and employment status, educational level, and local income level.
    Date: March 1, 2010
  • Characteristics and Needs of Veteran Cancer Survivors
    Findings show that 11% of the Veterans treated within the VA healthcare system in FY07 were cancer survivors. The most common cancer types were prostate, skin (non-melanoma), and colorectal. Compared to the general population, Veteran cancer survivors are older (84% are older than 60) and predominantly male (97%). Cancer site prevalence statistics vary between the VA and general U.S. cancer patient populations due to differences in age, gender, and risk factors. Overall, the four common symptom concerns reported by cancer survivors are sexual dysfunction, fatigue, anxiety, and depression. The authors suggest that Veteran-specific research is needed on topics such as cancer survival among older Veterans, and the role of military exposures (physical, emotional, and psychological) in causing cancer and impacting recovery. The authors also suggest that four models of care may be relevant to improving care for Veterans who have survived cancer: 1) cancer survivorship clinics, 2) cancer care transition plans, 3) rehabilitation, and 4) chronic disease management. These models of care may help integrate the physical and mental health needs of cancer survivors.
    Date: March 1, 2010
  • Aggression is Common among Veterans with Dementia
    Findings showed that 41% of Veterans with newly diagnosed dementia became aggressive within 24 months, corroborating the findings of previous studies that aggression is common in persons with dementia. The use of antipsychotic medications increased significantly in Veterans after they became aggressive, and this group also had a ten-fold greater occurrence of injuries. In addition, almost twice as many aggressive Veterans were admitted to nursing homes. There were no differences in rates of restraint use or in- and outpatient visits between Veterans who became aggressive and those who did not.
    Date: March 1, 2010
  • Interactive Communication between Primary Care and Specialty Care Improves Patient Outcomes
    This meta-analysis showed that interactive communications between collaborating PCPs and specialists were associated with improved patient outcomes. Interactive communication methods included: initial joint patient consultations, regular specialist attendance at primary care team meetings, telepsychiatry with primary care physicians, scheduled phone discussions, and shared electronic progress notes. The studies in this review all involved collaborations with psychiatrists for management of depression and other mental health disorders and with endocrinologists for management of diabetes; however, the consistency of the effects across different primary care-specialty collaborations, healthcare conditions, and study designs suggests the potential for improvement across other specialties and conditions. Effectiveness was enhanced by interventions to improve the quality of information exchange (e.g., needs assessment, joint care planning).
    Date: February 16, 2010
  • Male OEF/OIF Veterans with PTSD More Likely to Perpetrate and Experience Aggressive Behavior toward/from Female Partners
    This study examined the nature and frequency of self-reported partner aggression among three male cohorts recruited from one large VAMC outpatient PTSD clinic: OEF/OIF Veterans with PTSD, OEF/OIF Veterans without PTSD, and Vietnam Veterans with PTSD. Findings show that OEF/OIF Veterans with PTSD were significantly more likely to report psychologically abusing their partners than OEF/OIF Veterans without PTSD. Although other comparisons did not reach significance, results suggested that OEF/OIF Veterans with PTSD were about two to three times more likely than the other two groups to report perpetrating or sustaining violence. OEF/OIF Veterans with PTSD also were six times more likely to report sustaining injury from their female partners than OEF/OIF Veterans without PTSD. Significant correlations among reports of violence perpetrated and sustained suggest many men may have been in mutually violent relationships. In terms of family functioning, 63% of OEF/OIF Veterans with PTSD reported having children in the home. These results emphasize the importance of assessing partner aggression in VA clinical settings in order to provide a more complete psychological picture of Veterans and their families’ potential treatment considerations.
    Date: February 2, 2010
  • Mental Health Treatment Seeking among OIF National Guard Soldiers
    This study sought to determine the rate of reported mental health treatment-seeking in 424 returning OIF National Guard soldiers – and to examine potential barriers to and facilitators of treatment-seeking. Findings show that approximately one-third of the soldiers in this study reported post-deployment mental health treatment through military, VA, or other sources; however, 51% of soldiers who screened positive for PTSD and 40% who screened positive for depression did not report involvement in mental health treatment. Of the 34.7% who reported receiving mental health services, 22.9% had received psychotherapy only, 4.5% received psychiatric medications only, and 7.3% had received both. Reported treatment-seeking was more common among soldiers who screened positive for either PTSD or depression. Injury in-theater, illness-based need (e.g. presence and severity of mental illness), and mental health treatment in-theater were significantly associated with both self-reported psychotherapy and medication treatment-seeking. More positive attitudes regarding mental health treatment were associated with greater reported utilization of both psychotherapy and medication. Findings also indicate that while concerns about stigma were present, they were not associated with reported treatment-seeking behavior.
    Date: February 1, 2010
  • Veterans Diagnosed with Traumatic Brain Injury Significantly More Likely to Experience Mental Illness
    In April 2007, VA implemented national screening for symptomatic TBI resulting from combat exposure. Using VA data for 13,201 OEF/OIF Veterans who were screened for TBI in VISN 23, investigators examined rates of psychiatric disorders in relation to both TBI screening results and post-screening confirmation of TBI status. Findings show that among 836 Veterans with confirmed TBI, 85% had at least one psychiatric diagnosis, and 64% had two or more distinct diagnoses. Compared to Veterans with negative TBI screens, those with positive screens but without confirmed TBI were three times more likely to have PTSD – and were two times more likely to have depression and substance-related diagnoses. Veterans with clinically confirmed TBI were more likely than those with positive screens but no confirmed TBI to have diagnoses of PTSD, anxiety, and adjustment disorders. Nearly half of all OEF/OIF Veterans screened for TBI in VISN 23 had at least one psychiatric disorder, with PTSD (25.9%) and depression (25.6%) being the most common.
    Date: February 1, 2010
  • Taking a Life in War Associated with Higher Rates of PTSD and Behavioral/Adjustment Problems in OIF Soldiers
    This study examined the relationship between killing and mental health among 2,797 soldiers returning from Operation Iraqi Freedom (OIF). Overall, 40% of the soldiers in this study reported direct killing or being responsible for killing during their deployment. Taking another life in war was an independent predictor of multiple mental health symptoms. Even after controlling for combat exposure, killing was a significant predictor of PTSD symptoms, alcohol abuse, anger, and relationship problems. In addition, 22% of soldiers met threshold screening criteria for PTSD, 32% for depression, and 25% for alcohol abuse. The authors suggest a comprehensive evaluation of Veterans returning from combat should include an assessment of direct and indirect killing and reactions to killing. This information could be part of a treatment plan, including specific interventions targeted at the impact of taking a life.
    Date: February 1, 2010
  • Minority of OEF/OIF Veterans Receive Recommended Treatment for PTSD
    This study examined OEF/OIF Veterans use of VA mental health services within the first year of receiving new mental health diagnoses. Only a minority of OEF/OIF Veterans with newly diagnosed PTSD received a recommended number and intensity of VA mental health treatment sessions within the first year of diagnosis. Of the 49,425 OEF/OIF Veterans with newly diagnosed PTSD, only 9.5% attended >9 VA mental health treatment sessions in 15 weeks or less in the first year of diagnosis. Overall, two-thirds of OEF/OIF Veterans who received new mental health diagnoses from any VA outpatient clinic had at least one follow-up VA mental health visit in the first year of diagnosis, including 80% of OEF/OIF Veterans with a new PTSD diagnosis and nearly 50% with mental health diagnoses other than PTSD. Among the 35,547 OEF/OIF Veterans with new mental health diagnoses other than PTSD, 42.3% were diagnosed with a depressive disorder and 34.1% with an adjustment disorder. Overall, 60.3% received two or more new mental health diagnoses.
    Date: February 1, 2010
  • Checklist Successfully Identifies VA Environmental Hazards for Inpatient Suicide
    This is the first study to examine the implementation and effectiveness of the Mental Health Environment of Care Checklist to improve patient safety. Findings show that between 2007 and 2008, 7,642 environmental suicide hazards had been identified and 5,834 (76.3%) had been abated. Approximately 2% of these suicide hazards were identified as critical, and another 27% were rated as serious. The most common hazard was anchor points for hanging (44%); anchor points also presented the greatest risk level, followed by suffocation and poison. High-risk locations included bedrooms and bathrooms.
    Date: February 1, 2010
  • Predictors Associated with Homelessness among Women Veterans
    Among women Veterans, being unemployed, disabled, or unmarried were the strongest predictors of homelessness. Homeless women Veterans also were significantly more likely than housed women Veterans to have low incomes, to have experienced military sexual assault (53%), to be in fair to poor health, to have diagnosed medical conditions, and to screen positive for anxiety disorder and/or PTSD. Homeless women Veterans were significantly less likely than housed women Veterans to be college graduates or to have health insurance, but were more likely to have used mental health services, VA health care, or been hospitalized in the prior 12 months. Homeless Veterans had an average of four entries into and exits out of homelessness, and the median length of time they spent being homeless (over lifetime) was 2.1 years. Of the homeless women Veterans, 16% had children under the age of 18 living with them in the prior 12 months.
    Date: February 1, 2010
  • Prior Violence Associated with Greater Risk of Suicidal Thoughts and Attempts in Patients Seeking SUD Treatment
    Even after accounting for other known risk factors, such as symptoms of depression or childhood victimization, a history of violent behavior was consistently associated with a higher likelihood of lifetime suicidal thoughts and behaviors. Suicidal thoughts and attempts are common in those with substance use disorders (SUD): more than 43% of the participants in this study reported either prior suicide attempts or suicidal ideation at some point in their lives. A history of either suicidal ideation or suicide attempt(s) was more common among substance users who were female and those with a history of depression or childhood abuse.
    Date: February 1, 2010
  • Therapy via Video-Teleconference as Effective as In-Person Treatment in Reducing Anger Problems in Veterans with PTSD
    Cognitive behavioral therapy (CBT) anger management conducted via video-teleconference was as effective as in-person delivery of the same treatment in reducing anger problems among Veterans with PTSD who live in rural settings. Moreover, mean improvements in the video-teleconferencing group were actually slightly larger than in the in-person treatment group. Veterans in both treatment groups benefited from anger management therapy (AMT), making this one of the few large randomized controlled trials to show meaningful benefits for reducing anger problems in Veterans with PTSD. Veterans in both treatment groups reported high rates of treatment credibility, satisfaction with care, homework adherence, and high alliance with the therapist.
    Date: January 26, 2010
  • Affective Disorders Strongest Predictor of Suicidal Behavior in Elderly Veterans Receiving Anti-Epileptic Medication
    In January 2008, the FDA issued an alert indicating that anti-epileptic drug (AED) treatment is associated with increased risk for suicidal ideation, attempt, and completion. This study sought to assess variation in suicide-related behaviors in a population not well-represented by the data used for the FDA analysis – individuals 66 years and older with new exposure to AEDs. Findings show that in older Veterans who were started on AED monotherapy, the strongest reliable predictor of suicide-related behaviors was the diagnosis of an affective disorder prior to AED treatment. Increased suicide-related behaviors were not associated with individual AEDs. However, while most Veterans in this study received AED prescriptions for gabapentin (76.8%), a trend for increased suicide-related behaviors was found among those prescribed levetiracetam or lamotrigine, but interpretation was difficult since few Veterans received either drug (0.6%). The associations between suicide-related behaviors and chronic pain or chronic disease burden were not statistically significant, but dementia was significantly associated with suicide-related behaviors (42.2% with dementia vs. 25.8% without).
    Date: January 11, 2010
  • Cost/Benefit of Collaborative Care Intervention for Veterans with Chronic Pain and Depression
    This study reports on the incremental benefit (pain disability-free days – PDFDs) and incremental health services costs of the Study of the Effectiveness of a Collaborative Approach to Pain (SEACAP) intervention from a VA healthcare perspective. Findings show that the collaborative care intervention resulted in more pain-free days for Veterans with chronic pain and depression, but was more expensive than usual care. Veterans in the intervention group experienced an average of 16 additional PDFDs over the 12 month follow-up period compared to Veterans in the treatment as usual group, with a cost per PDFD of $364 (overall, about $2300 per patient during the study year). Study results also show that important predictors of costs were baseline medical comorbidities, depression severity, and prior year treatment costs.
    Date: January 1, 2010
  • Validity of Mental Health Diagnosis Using VA Administrative Data
    This study estimated the validity of eight ICD9-based algorithms for the identification of mental health disorders in administrative data among 124,716 Veterans with diabetes who used the VA healthcare system in 1998, and also participated in the 1999 Large Health Survey of Veteran Enrollees, which included questions about history of mental health diagnoses. Findings show that many Veterans with a diagnosed mental health disorder can be identified through VA administrative data; however, the choice of algorithm influenced conclusions. Since the limitations of administrative data cannot be fully eliminated with any algorithm, the authors suggest that investigators and quality improvement programs also consider conducting sensitivity analyses in which they vary the algorithm, in order to indicate how different assumptions affect conclusions.
    Date: January 1, 2010
  • Lower Quality of Care for Cardiometabolic Disease among Veterans with Mental Disorders, Regardless of Rural or Urban Dwelling
    Mental disorders (MD) were associated with a decreased likelihood of obtaining quality cardiometabolic care. When compared to those without MD, Veterans with MD were less likely to receive diabetes sensory foot exams, retinal exams, and renal tests. Rural residence was not associated with differences in quality measures. Primary care visit volume was associated with a greater likelihood of obtaining diabetic retinal exam and renal testing, but did not explain disparities among patients with MD.
    Date: January 1, 2010
  • Veteran Minorities Equally Likely to Receive PTSD Treatment
    This study sought to determine the rates of mental health use in the six months after Veterans received a PTSD diagnosis – and to examine whether service use varied by race or ethnicity. Findings show that minority Veterans were similar to Whites in the likelihood of receiving VA mental health treatment in the six months following a diagnosis of PTSD. Of the 20,284 Veterans with PTSD in this study, 50% received psychotropics, 39% received counseling, and 64% received at least one of these forms of treatment. However, only 24% who received any counseling had at least eight sessions, and most had only one session. These findings indicate that possible treatment preferences exist. The authors suggest that incorporating preferences into treatment planning may facilitate treatment retention and help to maximize treatment outcomes for all Veterans with PTSD.
    Date: December 1, 2009
  • Effectiveness of Residential Substance Use Disorder Programs in Treating Veterans with SUDs and Mental Illness
    This study compared processes and outcomes for alcohol-dependent Veterans with and without comorbid psychiatric illness at one and five years following treatment in 15 residential substance use disorder (SUD) treatment programs affiliated with VA. Findings show that dually-diagnosed (DD) Veterans did not perceive SUD programs as positively as Veterans with SUD alone, and DD Veterans had worse proximal outcomes at discharge from treatment. For example, DD patients saw fewer benefits to quitting and had less self-efficacy in regard to staying abstinent. Results also showed that dually-diagnosed Veterans did as well as SUD patients on 1-year and 5-year substance use outcomes but had worse psychiatric outcomes. Veterans from both groups who perceived treatment more positively and had better outcomes at discharge had better longer-term outcomes; however, DD patients perceived the programs to be less supportive and clear, and were less satisfied with treatment. The authors suggest that SUD programs either need to add resources directed toward treating psychiatric problems, or that DD Veterans need to be treated in sequential or integrated programs. They note, however, that standard SUD programs may offer more components of integrated treatment than standard psychiatric programs do.
    Date: December 1, 2009
  • Older Elderly Patients Experience Poorer Outcomes Following Collaborative Depression Care
    This study examined the differences between young-old (age 60 to 74) and old-old (age 75 and older) patients who received collaborative depression care as part of the IMPACT (Improving Mood: Promoting Access to Collaborative Treatment) study, which include both VA and non-VA patients. Findings show that young-old and old-old patients who receive collaborative depression care have a similar initial clinical response, but old-old patients may have a lower rate of long-term treatment response and complete remission. For example, young-old and old-old patients randomized to the IMPACT intervention responded similarly to initial treatment at 3 months, but the old-old were less likely to respond to treatment at later follow-up intervals. Treatment response and remission rates peaked for both age groups at 6 months, although treatment response rates for the young-old were significantly higher than those for the old-old group (51% vs. 44%). Study findings also show that the process of care did not differ between young-old and old-old patients who received the IMPACT intervention.
    Date: December 1, 2009
  • Substance Abuse is Strongest Predictor of Suicide among Veterans with Depression
    This study was an analysis designed to derive an empirically-based set of interactions related to rates of suicide in a national sample of VA patients diagnosed with depression. Findings show that among Veterans with depression those at highest risk for suicide have the combined risk factors of a substance use disorder (SUD), non-African American race, and a psychiatric inpatient stay in the past 12 months. Substance use disorder was also identified as the strongest single risk factor for suicide. Among Veterans without a substance use disorder, gender was the strongest predictor of suicide risk – rates were significantly higher for men than for women. Ethnicity also was related to suicide risk in this group. African American Veterans without an SUD were less likely to die by suicide compared to non-African American Veterans. The authors suggest that providers treating patients with these characteristics should be aware of these risks and consider target strategies to screen for current suicidal ideation.
    Date: November 1, 2009
  • Veterans with Psychosis More Likely to Die from Heart Disease
    This study assessed whether Veterans with mental disorders receiving care in the VA healthcare system were more likely to die from heart disease than Veterans without these disorders, and whether modifiable factors may explain mortality risks. Findings show that compared to Veterans without a mental health diagnosis, Veterans with psychosis (schizophrenia or other psychotic disorder diagnoses) were more likely to die from heart disease. Smoking and physical inactivity were the behavioral factors most strongly associated with mortality related to heart disease. Veterans with schizophrenia were the most likely to be current smokers, and those with bipolar disorder were the least likely to report adequate physical activity. Controlling for behavioral factors (e.g., smoking and physical inactivity) diminished but did not eliminate the impact of psychosis on mortality. The authors suggest that to reduce mortality related to heart disease, early interventions that promote smoking cessation and physical activity among Veterans with psychotic disorders are warranted.
    Date: November 1, 2009
  • Mental Illness and Substance Use Disorders Highly Prevalent Among Veterans with Spinal Cord Injury
    Using VA and Medicare data, this study sought to estimate the prevalence of mental illness and substance use disorders (SUDs) among 8,338 Veterans with spinal cord injury (SCI) who used outpatient or hospital care in VA or Medicare facilities between FY00 and FY01. Findings show that mental illness and SUDs are highly prevalent among Veterans with SCI. Overall, 47% of the Veterans in this study had either a mental illness or SUD. The most common mental illness was depression (27%), followed by anxiety (10%) and PTSD (6%). Tobacco use also was prevalent (19%), followed by alcohol (9%) and illicit drugs (8%). Moreover, mood and anxiety disorders were highly prevalent among those with chronic physical conditions such as diabetes, hypertension, and COPD. Results also showed that women Veterans had higher rates of mental illness and lower rates of SUD, and were significantly more likely to have mental illness only. In addition, as the duration of SCI increased, the likelihood of mental illness or SUD alone or in combination decreased.
    Date: November 1, 2009
  • Barriers to Dementia Diagnosis
    The goals of this study were to ascertain what is known about the prevalence of missed and delayed diagnosis of dementia in primary care, and to identify factors contributing to problems in diagnosis. While the findings did not definitively determine the prevalence of missed or delayed dementia diagnoses, estimates suggest that the number is substantial. Major barriers to diagnosing dementia included patient/provider communication (e.g., poor provider communication skills, language barriers), education deficits (e.g., belief that little or nothing can be done to treat dementia), and system resource constraints (e.g., time constraints for office visits). Attitude problems also were found; for example, among providers, a major barrier often noted was the attitude that diagnosis, particularly in the early stages of dementia, was more harmful than helpful, while patients often feared and/or denied cognitive problems.
    Date: October 1, 2009
  • Use of Medicare and VA Healthcare among Veterans with Dementia
    This study sought to characterize healthcare use among Veterans with dementia over a four-year period (1998-2001), and to determine predictors of whether a Veteran will be a VA-only, dual, or Medicare-only user. Findings show that during the four-year study period, Medicare-only use increased while VA-only use decreased. Results also show that an increased likelihood of some Medicare use was associated with being older, white, married, and having higher education, private insurance or Medicaid, and low VA priority level. Further, the number of functional limitations was associated with an increased likelihood of Medicare-only use and a decreased likelihood of VA-only use, while higher comorbidities were associated with a higher likelihood of dual use as opposed to any single system use. The authors suggest that these results imply that different aspects of Veterans’ needs have differential effects on where Veterans seek care. Efforts to coordinate care between VA and Medicare providers are necessary to ensure patients receive high quality care, particularly among those with multiple comorbidities.
    Date: October 1, 2009
  • Determinants of Veteran Treatment-Seeking for PTSD
    This study explored determinants of PTSD treatment initiation among 21 treatment-seeking and 23 non-treatment-seeking Veterans who had served in Vietnam, or the current conflicts in Afghanistan and Iraq (14 of the 44 participants were women Veterans). Findings show that both Veterans who were and were not in treatment for PTSD described similar factors that hindered their help-seeking, including their own values and priorities (e.g., pride in self reliance), treatment-discouraging beliefs (e.g., providers would not believe them, or would treat them as if they were “crazy”), and trauma-related avoidance (e.g., avoiding discussion of the traumatic event). They also cited an invalidating post-trauma environment as a detriment to seeking treatment; for example, some women cited a military culture that silenced the reporting of sexual assault. But for some participants, facilitators located within the healthcare system and Veterans’ social networks led to help-seeking despite individual-level barriers. In some cases, it was a trusting relationship with the primary care provider that led the Veteran to follow the provider’s recommendation to seek mental health care. This suggests that factors outside the individual can promote mental health service use for PTSD, even when the Veteran is reluctant.
    Date: October 1, 2009
  • Veterans Using VA Pharmacy Services are More Ill than their Counterparts
    This study compared users and non-users of VA pharmacy services separately by age group – Veterans ages 18-64 (non-elderly) vs. age 65 and older (elderly). Findings suggest that Veterans who use VA pharmacy services appear to be more ill than their counterparts who do not use the VA pharmacy benefit. Among younger Veterans, users of the VA pharmacy were more than twice as likely to report fair or poor general health status and more than three times as likely to report fair or poor mental health status. Moreover, both non-elderly and elderly users of VA pharmacy services reported more medical conditions and were more disabled. Overall results show a higher proportion of Veterans who use VA pharmacy services are African American and have no alternative insurance. Compared to non-users, VA pharmacy users also were more likely to be unemployed or out of the labor force, and living in a poor or low income family.
    Date: October 1, 2009
  • Aggressive Behavior Prevalent in Veterans with Dementia
    This study examined aggressive behavior in 400 community-dwelling Veterans, 60 years or older and newly diagnosed with dementia at one VAMC, who were non-aggressive at the beginning of the study. Findings show that 40.9% of initially non-aggressive Veterans with dementia became aggressive within the 24-month study period, and most aggression was verbal. Verbal aggression was associated with the highest levels of disruptiveness, with 69.3% of verbally aggressive behaviors considered moderately or extremely disruptive, while 39.8% of physically aggressive behaviors and 12.5% of sexually aggressive behaviors were considered moderately or extremely disruptive. Results also show that most caregivers were women (94%), and there were no significant differences found in aggressive vs. non-aggressive Veterans with dementia in terms of demographics.
    Date: October 1, 2009
  • OEF/OIF Veterans with Mental Health Diagnoses, Particularly PTSD, Use More Non-Mental Health VA Services
    Using national data from all returning OEF/OIF Veterans (N=249,440) who used VA healthcare between 10/01 and 3/07, this study sought to examine the association of PTSD and other mental disorders with non-mental health outpatient, inpatient, and emergency services utilization. Findings show that OEF/OIF Veterans diagnosed with mental health disorders had significantly greater utilization of all types of non-mental health care services than OEF/OIF Veterans with no mental health diagnoses. In adjusted analyses, compared with OEF/OIF Veterans without mental disorders, those with mental disorders other than PTSD had 55% greater utilization of all non-mental health outpatient services; Veterans with PTSD had 91% higher utilization. Results also showed that female gender and lower rank were independently associated with greater utilization. The authors suggest that as more Veterans return home, many with mental and physical injuries, evaluating the capacity of VA and other healthcare systems to meet their needs will be increasingly important.
    Date: September 29, 2009
  • Ethnic Disparities in the Treatment of Veterans with Dementia
    This study sought to determine if there were ethnic disparities in the evaluation and treatment of dementia among 410 Veterans treated at one VAMC between 4/05 and 6/05. Findings show that while laboratory and imaging workup (i.e., CT, MRI) did not differ between ethnic groups, there were significant differences in the treatment of dementia. For example, African American Veterans with dementia were 40% less likely than all other patients to receive acetylcholinesterase inhibitors. This treatment disparity did not appear to be due to differences in the evaluation of dementia, which was similar across groups, although significantly more Caucasian Veterans (43.8%) underwent neuropsychological testing compared to African American (24.8%) or Hispanic Veterans (32.4%).
    Date: September 1, 2009
  • Emerging Issues Related to PTSD for OEF/OIF Women Veterans
    The goal of this review was to highlight emerging issues relevant to the development of PTSD among women deployed to Iraq and Afghanistan. Investigators reviewed the literature on topics including: gender differences in combat experiences and in PTSD following combat exposure; sexual assault, sexual harassment, and other interpersonal stressors experienced during deployment; women Veterans’ experiences of pre-military trauma exposure; and unique stressors faced by women Veterans during the homecoming readjustment period. Findings show that combat deployments are not associated with a higher risk of mental health problems for women compared to men. However, women are more likely than men to meet criteria for PTSD following a range of traumatic experiences. In addition, studies published between 2002 and 2007 suggest that more than half of women Veterans experienced pre-military physical or sexual abuse, and there is some evidence that pre-military trauma increases women Veterans’ risk of developing PTSD following combat exposure. Further, concerns about family/relationship disruptions are more strongly associated with post-deployment mental health for female than male service members.
    Date: August 24, 2009
  • Mental Health Diagnoses Associated with Cardiovascular Risk Factors among OEF/OIF Veterans
    Studies of Veterans from prior wars found that those with PTSD are at increased risk of developing and dying from cardiovascular disease, but this risk had not yet been evaluated in OEF/OIF Veterans. This article discusses findings from a study on the association between mental health disorders, including PTSD, and cardiovascular risk factors. Findings show that OEF/OIF Veterans (male and female) with mental health diagnoses had a significantly higher prevalence of cardiovascular risk factors (e.g., hypertension, obesity, diabetes, tobacco use). The association between mental health diagnoses and cardiovascular risk factors remained after adjusting for demographics and military factors. The most common mental health diagnosis was PTSD (24%). The majority of Veterans with PTSD had comorbid mental health diagnoses: depression (53%), anxiety disorder (29%), adjustment disorder (26%), alcohol use disorder (22%), substance use disorder (10%), as well as other psychiatric diagnoses (33%).
    Date: August 5, 2009
  • Regular Primary Care Associated with Better Survival Rates for Veterans with Schizophrenia and Diabetes
    Medical comorbidity among aging people with schizophrenia is common and many patients with schizophrenia have difficulty managing their medical healthcare needs, which may result in delayed treatment and poor outcomes. This retrospective cohort study assessed whether patterns of VA primary care use among Veterans with diabetes, schizophrenia , or both were a significant predictor of mortality over the study period (FY02-FY05). Findings show that regular primary care and high levels of primary care were associated with better survival for patients with chronic illness, whether psychiatric or medical. For example, increasing use of primary care was least common among Veterans with schizophrenia only (4%) compared with Veterans with diabetes only (7%), or those with both conditions (8%), – and was associated with improved survival. This suggests that innovations in treatment retention targeting at-risk groups can offer significant promise of improving outcomes.
    Date: July 26, 2009
  • Mental Health Diagnoses among OEF/OIF Veterans Increased Rapidly Following Invasion of Iraq
    This study sought to investigate longitudinal trends and risk factors for mental health diagnoses among OEF/OIF Veterans. Findings show that the prevalence of new mental health diagnoses among OEF/OIF Veterans using VA healthcare increased rapidly following the Iraq invasion. Among the 289,328 Veterans in this study, new mental health diagnoses increased 6-fold from 6.4% in April 2002 to 36.9% by March 2008. 21.8% of Veterans were diagnosed with post-traumatic stress disorder (PTSD), and 17.4% with depression. Two-year prevalence rates of PTSD increased 4-7 times after the invasion of Iraq. The youngest active duty OEF/OIF Veterans (< 25 years) were at nearly twice the risk for PTSD, more than twice the risk for alcohol use disorders, and at a nearly 5-fold risk for drug use disorders than older active duty Veterans (> 40 years). Among National Guard/Reserve Veterans, those older than age 40 were at greater risk for PTSD and depression. Women Veterans from both service components (active duty and Guard/Reserve) were at higher risk for depression, while male Veterans were at greater risk for drug use disorders. Authors suggest that early targeted interventions may prevent chronic mental illness.
    Date: July 16, 2009
  • Smoking Cessation Services for Veterans in VA Psychiatric Facility
    This study had two goals: 1) determine staff characteristics that are associated with attitudes about providing smoking cessation services to Veterans who are psychiatric patients, and 2) seek suggestions from staff about what would be important to include in a tobacco cessation program. Findings show that nearly 75% of staff in this study thought that VA should do more to assist Veterans to quit smoking, yet only about 25% said that they personally provide cessation services. However, more than 50% felt moderately, very, or extremely confident in providing cessation services. Interestingly, nurses were less likely than other staff to feel that it was important to provide cessation services, which could be because of competing job demands. The most common reasons given by all respondents for not providing services were not enough time and lack of training. When asked how VA could best assist smokers to quit, most responses focused on educating Veterans about tobacco use and how they can quit, as well as providing tobacco cessation medications.
    Date: June 1, 2009
  • High Rate of Suicidal Ideation among Veterans with Bipolar Disorder
    Some suicidal ideation within the past two weeks was reported in 49% of Veterans with bipolar disorder in this study. Approximately 32% of the Veterans reported suicidal ideation for several days, 9% reported suicidal ideation more than half of the days, and 8% reported experiencing it nearly every day. Elevated rates of suicidal ideation were found in Veterans who reported drug use, poorer mental health status, and poorer general functioning. After accounting for current mood state and other risk factors, even minimal increases in the extent to which Veterans perceived their therapeutic relationship as collaborative were associated with a reduction in the risk of suicidal ideation.
    Date: May 1, 2009
  • Strong Association between Homelessness and Incarceration among Veterans with Bipolar Disorder
    This study assessed the association between homelessness and incarceration in 435 Veterans with bipolar disorder who received inpatient or outpatient care at one large, urban VAMC from 7/04 to 7/06. Findings show that homelessness and incarceration are common among Veterans with bipolar disorder, and share many risk factors. Among Veterans with bipolar disorder, 12% reported having been homeless in the previous four weeks, and 55% reported ever having been homeless or incarcerated. Results also show that lifetime experience of homelessness was associated with 4-fold increased odds of lifetime experience of incarceration. Moreover, recent homelessness was strongly related to recent incarceration. Programs that better coordinate psychiatric and drug treatment with housing programs may reduce the cycle of incarceration, homelessness, and treatment disruption among this vulnerable patient population.
    Date: May 1, 2009
  • Suicide Risk Significantly Higher for VHA Patients Compared to the General Population
    Suicide rates among the Veterans enrolled in the VA healthcare system during FY00 and FY01 were found to be significantly higher than those in the general population. However, the differentials between suicide rates for VA patients and the general population were less than what might be expected given previous comparisons. Overall, for men and women combined, suicide risks among Veterans were 66% higher than those observed in the general population. Among male Veterans, suicide rates were highest for those aged 30-49 years and lowest among Veterans aged 18-29 and 60-69. Among women Veterans, suicide rates were highest among those aged 50-59 years. It is important to emphasize that this study compares a general population to users of a health care system where the prevalence of all conditions would be expected to be higher. Also, the study population precedes current conflicts in Iraq and Afghanistan.
    Date: April 15, 2009
  • Access to Healthcare among Veterans with Bipolar Disorder
    Findings from this study show that despite the fact that all Veterans were currently receiving VA treatment for bipolar disorder, 15%-20% experienced trouble obtaining different aspects of healthcare when needed. Compared with accessing psychiatric care, Veterans with bipolar disorder reported greater difficulty accessing general medical services. Veterans experiencing current bipolar symptoms more frequently avoided psychiatric care due to cost, and perceived greater problems accessing medical specialists. As with mental healthcare services, the dominant influences predicting limitations in obtaining needed general medical care included living alone, an inpatient stay, homelessness, and current bipolar symptoms. The authors suggest that current VA efforts to expand mental healthcare access should be coupled with efforts to ensure adequate access to medical services for Veterans with chronic mental illness.
    Date: April 1, 2009
  • Primary Care-Based Collaborative Care for Chronic Pain May Be More Effective than Usual Care
    A primary care-based collaborative care intervention for chronic pain was significantly more effective than usual care across a variety of outcome measures, including pain disability and intensity. However, these improvements were generally modest. Depression severity and pain disability and intensity improved among Veterans in the intervention group who reported both chronic pain and depression. Greater use of adjunctive pain medications and long-term opioids among the intervention group suggested that the intervention contributed to the delivery of guideline-concordant care.
    Date: March 25, 2009
  • Areas for Mental Health Intervention for Patients with Hepatitis C
    In addition to the physiological side effects of treatment for the hepatitis C virus (HCV), there also can be significant neuropsychiatric effects such as depression, anxiety, psychosis, and suicidality. Moreover, numerous studies have documented the high prevalence of pre-existing psychiatric disorders among patients with HCV. This article reviews the psychological and psychosocial issues that are relevant to patients with HCV and provides mental health treatment recommendations. Some of these issues include stigma (i.e., more than half diagnosed with HCV have experienced discrimination) and social support. The authors also identify areas in which clinicians can intervene, including adjustment to having a chronic medical illness, management of side effects, and implementing healthy lifestyle recommendations.
    Date: March 1, 2009
  • Assessing Healthcare Utilization among Veterans with Depression
    Nearly half of VA primary care patients with significant depressive symptoms also used non-VA care. Among dual users, 94.9% used both VA and non-VA care for physical health problems, but only 20.3% used both for emotional health problems. Lower levels of alcohol use and the presence of PTSD were associated with the use of non-VA outpatient care for emotional health services. Authors suggest that care management strategies for Veterans with depression should include communication and coordination with non-VA providers.
    Date: March 1, 2009
  • Costs Associated with Providing Depression Care in the Primary Care Setting
    This study reports on organizational costs associated with depression care quality improvement, specifically introducing an evidence-based depression model – Translating Initiatives in Depression into Effective Solutions (TIDES) Project – into VA primary care settings. Findings show that organizational costs for the TIDES project (in the locations studied) were significant, and should be accounted for in planning the implementation of evidence-based depression care.
    Date: February 1, 2009
  • Hybrid Quality Improvement Approach May Be Best
    There is a growing consensus that a hybrid of two common approaches to quality improvement (QI) – local participatory QI and central expert QI – might be the best method for achieving quality care across a variety of conditions. This study examined preferences of frontline staff and managers participating in HSR&D’s Translating Initiatives for Depression into Effective Solutions (TIDES) project regarding how to engage in QI dialogue and provide practical suggestions for implementation. Many study participants believed that a hybrid of participatory and expert QI models might provide the best formula for improving the quality of care.
    Date: February 1, 2009
  • Sexual Harassment has Negative Effects on Men and Women Marines’ Mental Health
    This study is the first to examine the role of post-traumatic stress symptoms (PSS) in the relationship between sexual harassment in the military and perceived physical health. Findings show that both men and women who experienced sexual harassment had increased PSS. For men, higher levels of sexual harassment were associated with worse perceived physical health; whereas for women, lower levels of sexual harassment were associated with worse perceived health.
    Date: February 1, 2009
  • Investigators Develop Diagnostic Guidelines for Post-Traumatic Stress Disorder
    Diagnosing mental disorders is often challenging, but may be especially difficult in post-traumatic stress disorder (PTSD) due to the high rates of comorbidity between PTSD and other psychiatric disorders. As a result of this study, investigators offer guidelines for the differential diagnosis of Veterans with PTSD. Clinicians should be aware that those suffering from PTSD might present with symptoms that initially point to other diagnoses, and that mistaken diagnoses can have detrimental effects. Investigators believe that the guidelines they offer can lead to greater reliability in the diagnosis of PTSD and related comorbid conditions.
    Date: February 1, 2009
  • Successful Strategy that Engages Veterans and Families in Psychoeducation to Improve Treatment for Mental Illness
    Recently, VA funded 19 initiatives to implement family psychoeducation, an evidence-based practice in the treatment of psychotic disorders that results in reduced risk of relapse, remission of residual psychotic symptoms, and enhanced social and family functioning, but the implementation of such programs requires engaging mental health clinicians, consumers, and families. This paper discusses the engagement strategies used in the Reaching out to Educate and Assist Caring, Healthy Families (REACH) program, a 9-month family psychoeducation program for Veterans with serious mental illness or post-traumatic stress disorder (PTSD). Findings show that REACH has had notable success in engaging Veterans and their families, with participation rates that are comparable to those for programs requiring a much shorter commitment than 9 months, and suggest that the REACH engagement strategy may be a promising tool in recruiting Veterans and their families into family psychoeducation.
    Date: February 1, 2009
  • Study Suggests Additional Interventions for Veterans with SUD and History of Abuse
    Men with a history of physical or sexual abuse had more severe drug problems at intake, but by six months there were no group differences in drug use. However, veterans with a history of sexual abuse had more severe psychiatric problems at all time points and were more likely to report significant suicidality at intake and 6 month follow-up. This suggests that additional interventions may be warranted for veterans with SUD and a history of sexual abuse. Also, routine screening for suicidality in SUD treatment programs may be warranted given the prevalence of lifetime sexual abuse among SUD patients and the relationship between sexual abuse and attempted suicide.
    Date: December 1, 2008
  • Using VA Medical Data Alone May Underestimate Post-Stroke Depression and Geographic Variation in this Condition
    When VA medical data alone were used, investigators found no significant geographic variation in the detection of post-stroke depression (PSD). But when VA medical data were used along with Medicare and VA pharmacy data, significant geographic variation (nearly double – 39.1% vs. 20.0%) was observed. This suggests that to gain a comprehensive view of PSD detection in VA patients, investigators must evaluate non-VA data sources because 70% of VA stroke patients were multiple health program users.
    Date: December 1, 2008
  • Consumer-Providers Improve Care for Veterans with Serious Mental Illness
    In 2005, VA began funding a number of positions for consumer-providers (CPs) – veterans with personal experience of serious mental illness who provide support services to other veterans suffering from the same condition. Findings from this study suggest that hiring and employing CPs within VA has been feasible, beneficial, and acceptable to a majority of clinical teammates. However, CPs reported experiencing some role confusion and resistance and fears among professional staff about how CPs would fit in.
    Date: November 1, 2008
  • Program Improves Access to Mental Health Care for Veterans
    This article discusses the implementation and outcomes for the first four years of the “Primary Mental Health Care Clinic” (PMHC) program, an innovative program developed at one VA medical center that shifted specialized staffing into an existing mental health clinic in primary care and added advanced clinical access in primary care. Waiting time for new appointments was shortened from a mean of 33 days to 19 minutes. Clinician productivity and evaluations of new referrals more than doubled. In addition, the program has reduced the number of veterans referred into the specialized mental health clinic, thus conserving resources.
    Date: November 1, 2008
  • Quality Indicators to Help Treat Veterans with HIV and Depression
    Quality indicators were developed based on a review of the existing clinical guidelines for depression, particularly depression related to HIV, in addition to a review of the literature. Authors suggest that quality indicators identified in this study provide a useful tool for measuring and informing the quality of HIV depression care.
    Date: October 1, 2008
  • Treatments for Co-Occurring Schizophrenia and Substance Use Disorders
    While studies to date suggest better outcomes with second-generation antipsychotics (SGAs), for example, olanzapine and risperidone, the available evidence does not clearly demonstrate an advantage for any particular SGA; thus investigators recommend that clinicians select the medication that balances efficacy and side effects for each individual patient.
    Date: October 1, 2008
  • Reducing Cardiovascular Risk for Veterans with Diabetes and Depression
    The Cardiovascular Risk Reduction Clinic (CRRC) is an ongoing clinical, multi-disciplinary, disease management program at the Providence VAMC. Veterans with and without a depression diagnosis had a significant improvement in cardiovascular risk reduction after participation in the CRRC program. Veterans with a diagnosis of depression had significantly higher cardiovascular risk than those with no mental health condition, but they had greater improvement after participating in the program.
    Date: October 1, 2008
  • Continuity of Care Improves Abstinence among Veterans with Substance Use Disorder
    The use of outpatient mental health services in the year prior to treatment and the staff's continuity of care practices were the most important factors for increasing abstinence rates, while engagement in continuing care was a key post-treatment factor. Veterans also were more likely to be abstinent when staff provided continuing care appointments prior to discharge, developed discharge plans that called for patients to attend continuing care at least once a week, and arranged drug-free and sober living arrangements.
    Date: September 1, 2008
  • Psychotherapy Administered via Telephone Reduces Depression
    Findings show a significant reduction in depressive symptoms for patients enrolled in telephone-administered psychotherapy as compared to those in control conditions (e.g. treatment as usual). Moreover, attrition rates were considerably lower than rates reported in face-to-face psychotherapy.
    Date: September 1, 2008
  • Advances in Couple Therapy for Returning Soldiers and their Spouses
    The authors of this article present a case study about a service member who suffers from PTSD and his wife, who are treated with an adaptation of integrative behavioral couple therapy (IBCT). At the end of the 13 weeks of treatment, this couple reported that their relationship was considerably stronger.
    Date: August 1, 2008
  • Improving the Environment of Care to Reduce Inpatient Suicide and Suicide Attempts in VA Facilities
    Authors provide 5 recommendations for reducing environmental hazards for suicide on inpatient psychiatric units.
    Date: August 1, 2008
  • Panic Control Treatment Proves Effective in Veterans with Panic Disorder and PTSD
    Panic control treatment appeared to be superior in reducing the frequency, severity, and distress associated with panic disorder and suggests that brief cognitive-behavioral therapy for panic is effective for veterans with PTSD.
    Date: August 1, 2008
  • Mental Illness and Substance Use Costs among Veteran Clinic Users with Diabetes
    Alcohol and drug use among veterans with diabetes increased healthcare costs due to greater use of inpatient services, regardless of the presence or severity of mental illness.
    Date: July 1, 2008
  • Veterans with Spinal Cord Injury Report Frequent Physical and Mental Health Concerns
    Overall, veterans with spinal cord injury (SCI) were much more likely to experience frequent physically and mentally unhealthy days, and frequent days with depression than what has been reported for the general population. In addition, both chronic illnesses and smoking had a substantial effect on health-related quality of life for persons with SCI.
    Date: July 1, 2008
  • Appreciation of Research Information in Patients with Bipolar Disorder
    Patients with bipolar disorder were able to weigh risk levels associated with various studies, and to appreciate that their participation was voluntary. However, patients demonstrated two misconceptions: their appreciation of research goals was flawed (a substantial proportion had difficulty distinguishing clinical research from clinical care), and they incorrectly applied concepts of 'double-blind' and 'randomization.' In addition, more than half believed that their primary mental health provider could convince them to participate in a study even if they did not want to.
    Date: July 1, 2008

What is included in Publication Briefs?

HSR requires notification by HSR-funded investigators about all articles accepted for publication. These journal articles are reviewed by HSR and publication briefs or summaries are written for a select number of articles that are then forwarded to VHA Central Office leadership to keep them informed about important findings or information. Articles to be summarized are selected by HSR based on timeliness of the findings, interest of leadership, or potential impact on the organization. Publication briefs are written for only a small number of HSR published articles. Visit the HSR citations database for a complete listing of HSR articles and presentations.

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