Spotlight on Mental Health
The concept of “mental health” can be traced as far back as ancient Greece, but the modern use of the term in a clinical setting dates roughly from 1946. Today, the National Institute of Mental Health and other health agencies define mental health as “that which includes our emotional, psychological, and social well-being.” Today, there are also new tools in genetics and neuroimaging that can help healthcare providers understand the underlying biology of mental disorders. Both biological factors (i.e., genetics, brain chemistry), and life experiences (i.e., history of trauma or abuse) can play a role mental health—and for some individuals, these factors may predispose them to developing a mental health concern or condition.
For many Veterans, exposure to combat conditions—or other experiences during active duty service—can greatly impact their mental health, putting them at high risk for developing such conditions as post-traumatic stress disorder (PTSD), anxiety, or substance use disorders. Investigators in VA’s Health Services Research and Development Service (HSR&D) conduct a variety of research studies that help to further the understanding of why Veterans may develop certain mental health conditions; focus on improving treatment and delivery of mental health services; and assess efficacy and cost of services.
In this paper, published in JAMA Network Open in October 2020, VA HSR&D investigators described the impact of integrating primary care and mental health (PC-MHI) on access to care among men and women Veterans. Key findings showed that enabling mental healthcare (MH) through PC-MHI has differing impacts on men and women Veterans, as well as differing health system impacts. Differences in healthcare use by gender highlight the importance of anticipating potential differences in policy effects and tailoring services for health system patients in the numerical minority.
Beginning in 2007, VA invested to improve access to mental healthcare through the national PC-MHI initiative. Through PC-MHI care models, primary care providers, mental health specialists, and/or care managers jointly manage mild-to-moderate psychiatric conditions directly in primary care settings. This paper described a retrospective cohort study that set out to answer the following question: Did VA’s national PC-MHI initiative improve access to care equally among men and women Veterans? This is important given that depression and anxiety are nearly twice as prevalent among women than men – and disproportionately affect women Veterans compared to male Veterans in the United States. Investigators identified 5.4 million Veterans (including 448,455 women), who received care at one of 396 VA primary care clinics between FY2013 and FY2016, and estimated VA healthcare use (mental health, primary care, other specialty care, telephone, hospitalizations) and total costs for men and women. In addition, they adjusted their findings for year, clinic, patient characteristics, and interactions between patient-reported gender and clinic PC-MHI penetration.
Specific findings included:
- Mental health integration in primary care 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.
VA HSR&D investigators Lucinda Leung, MD, PhD, MPH; Lisa Rubenstein, MD, MSPH; Edward Post, MD, PhD; Ranak Trivedi, PhD; Alison Hamilton, PhD, MPH; Jean Yoon, PhD; and Elizabeth Yano, PhD, MSPH authored this publication.
When compared to the general population, Veterans have higher rates of mental illnesses, social isolation, and other social risk factors—all of which increase their risk for negative mental health impacts (i.e., social isolation, increased depression, increased substance use) associated with the COVID-19 pandemic. Peer support is a promising, but largely untapped, resource that could increase the VA’s mental healthcare system capacity. In VA mental healthcare settings, peers are Veterans with a history of mental illness or substance use disorder who receive specialized training to use their recovery experiences to instill hope, engage patients, and support their recovery.
Given the healthcare delivery changes and challenges created by COVID-19, investigators in this study are working to develop a better understanding of how peer support programs have reconfigured or shifted services to maintain and potentially expand delivery of services—such as Veterans' outreach and engagement—that traditionally require in-person contact. It is expected that study data will also show how better to respond to new and potentially increasing mental health needs of Veterans.
About the Study
Using interviews with mental health peers and peer supervisors, investigators will describe COVID-19-induced changes in peer programs' structure, and in peers' roles and activities. The study will also seek to characterize pandemic-induced programmatic adaptations made to maintain and/or enhance mental healthcare services delivery to Veterans. In addition, investigators will examine programs that are succeeding in enhancing peer support capacity during the COVID-19 pandemic to identify implementation strategies and processes that are helping to meet Veterans’ existing and future mental healthcare needs.
Johanne Eliacin, PhD, is an investigator with the Center for Health Information and Communication, in Indianapolis, IN.
At least two thirds of Veterans with serious mental illness (SMI) use a smart phone, and data generated by these devices can be used to characterize sociability, activity, and sleep behaviors. Changes in these behaviors are warning signs for worsening and relapse of mental illness. In this project, investigators developed and are using an app that monitors passively generated mobile phone data. These data are analyzed to predict mental health status. Evidence from the project will be used to produce a mobile platform that: A) monitors the mental health status of patients, B) feeds self-tracking data back to patients; C) identifies risk for relapse; and D) supports early intervention by clinicians. If successful, VA will have a mobile analytics platform that supports passive self-monitoring of behaviors and symptoms of patients with serious mental illness.
About the Study
Effectively managing patients with SMI requires ongoing monitoring and adjustments in treatment. Stress, substance abuse, or reduced medication adherence can cause rapid worsening of symptoms, with consequences that may include job loss, homelessness, suicide, incarceration, and hospitalization. Tools that can quickly detect “red flags” — or behaviors that signal impending relapse — could contribute greatly to maintaining improved health outcomes among Veterans with SMI.
Passive mobile sensing is a novel approach to illness self-tracking and monitoring. There has been too little research on passive self-tracking in SMI, with limited analytics development in this area. Investigators in this project are studying passive mobile sensing with Veterans in treatment for SMI. During the project, investigators will:
- Conduct user-centered design of passive mobile self-tracking.
- Study the feasibility, acceptability, and safety of passive self-tracking of mental health that includes feedback of mental health status to the Veteran.
- Use mobile phone data to develop valid estimates of sociability, activities, and sleep as measured by weekly interviews.
- Study the predictive value of using data on sociability, activities, and sleep to identify exacerbations of psychiatric symptoms.
Alexander S. Young, MD, MSHS, is an investigator with the Center for the Study of Healthcare Innovation, Implementation and Policy, in Los Angeles, CA.
Several VA HSR&D investigators contributed articles and editorial guidance to a February 2021 special supplement to the journal Medical Care. Sponsored by HSR&D and the VA Women's Health Research Network, the special supplement seeks to expand the knowledge base on women Veterans and suicide, as well as increase national awareness of suicide among women Veterans—which may further increase the resources available to address this growing concern.
VA HRS&D guest editors for this supplement were investigators Lauren Denneson, PhD; Claire Hoffmire, PhD; and Elizabeth Yano, PhD, and articles contributed by HSR&D investigators included:
- Blosnich and colleagues found that transgender patients are more likely to use poisoning or firearms to die by suicide than their non-transgender peers.
- Chen and colleagues’ findings – that gender may be associated with self-directed violence classifications by providers – raise awareness of the potential for gender disparities in systems designed to identify and treat Veterans at risk for suicide.
- Denneson and colleagues discuss women’s needs in recovering from a nonfatal suicide attempt, increasing a sense of self-worth and developing stronger relationships with others.
- Gibson and colleagues’ study on women Veterans over age 50 found that menopausal hormone therapy at baseline was associated with a two-fold increase in the risk of suicide at follow-up.
- Hoffmire and colleagues discuss challenges associated with studying gender in suicide prevention and outline several key future directions for the field.
- Monteith and colleagues describe circumstances associated with women Veterans’ willingness to seek care for mental health concerns and suicidal thoughts; for example, their findings suggest that military sexual trauma is associated with a lower willingness to seek care for suicidal ideation.