Spotlight: Improving Mental Healthcare for Veterans

October 2014

October 5 - 11, 2014 is Mental Health Awareness Week. Mental illnesses rank first among the illnesses that cause disability in the U.S., and today 37% of Veterans returning from service in Iraq and Afghanistan and entering VA healthcare have received a mental health diagnosis.¹

VA/HSR&D's Mental Health Quality Enhancement Research Initiative (MH-QUERI) works to improve the quality of care, outcomes, and health-related quality of life for Veterans with mental health conditions. MH-QUERI research focuses on the following areas:

• Physical health and treatment outcomes of Veterans with serious mental illness,
• Recovery,
• Primary Care-Mental Health,
• Post-traumatic stress disorder (PTSD),
• Suicide prevention, and
• Disparities for special or vulnerable populations, such as women, Veterans living in rural settings, and the homeless.

MH-QUERI also prioritizes developing and sustaining partnerships with a diverse collection of stakeholders from VA's Office of Mental Health Operations, Mental Health Services, the Primary Care-Mental Health Integration (PC-MHI) program, as well as other clinical leaders. For example, in August 2012, the VA Primary Care Office charged an interdisciplinary group of 11 VA subject matter experts nationwide to participate in a workgroup to identify PC-MHI goals and objectives given the reorganization of VA primary care into PACTs (Patient Aligned Care Teams), and to make recommendations for integrating mental health into PACT. The IMHIP (Integrating Mental Health into PACT) Workgroup, which includes many MH-QUERI investigators, focused on clarifying a vision and goals for PC-MHI that was built on the past, but also looks to the future. The charge also asked for expert assessment of the progress of the current PC-MHI initiative, achievements, and gaps in care. Thus, the IMHIP report will help inform strategic planning.

Another example of productive partnerships is MH-QUERI's Stakeholder Council - an innovative strategy for engaging stakeholders in research. Membership currently includes Veterans of multiple eras, family members of Veterans, VA clinical providers and clinical managers, VA operations, faith-based leaders and clergy, community and state service providers, and Veteran advocates. The Stakeholder Council provides consultation to MH-QUERI investigators and leadership on the development and implementation of evidence-based programs and practices for Veterans using or needing mental health services. For more information, see the archived cyberseminar presentation "Developing a Stakeholder Council to Improve Research Impact," which was held on September 23, 2014.

For general information about Mental Health-QUERI, please contactBridgette Larkin, M.B.A., MH-QUERI Administrative Coordinator, at Bridgette.Larkin@va.gov .

HSR&D and QUERI Research on Mental Illness

Following are descriptions of just a few select studies that HSR&D and QUERI investigators conduct on issues related to improving the quality of health and care for Veterans with mental illnesses.

Traumatic Brain Injury during Most Recent Deployment Strongest Predictor of Post-Deployment PTSD

According to prior reports, approximately 10% to 20% of OEF/OIF/OND service members report mild traumatic brain injury (TBI) or concussion, and nearly 60% of those report exposure to more than one blast (i.e., IEDs, rocket-propelled grenades, land mines). Using data from the Marine Resiliency Study - a prospective, longitudinal study of infantry Marines - investigators in this QUERI study examined whether deployment-related TBI predicts post-traumatic stress disorder (PTSD) symptom severity when accounting for combat intensity and pre-deployment characteristics. Specifically, investigators analyzed data from 1,648 active-duty Marine and Navy service members who completed pre-deployment and post-deployment assessments between July 14, 2008 and May 24, 2012. Other measures included: pre-deployment TBI and psychiatric symptoms, combat intensity, general cognitive ability, and demographics. Results show:

• Even when accounting for pre-deployment psychiatric symptoms, prior TBI, and combat intensity, TBI sustained during the most recent deployment was the strongest predictor of post-deployment PTSD symptoms. Deployment-related TBI nearly doubled the likelihood of post-deployment PTSD for service members who reported minimal to no PTSD symptoms before deployment.
• The probability of post-deployment PTSD was greatest for service members with severe pre-deployment symptoms, high combat intensity, and deployment-related TBI.
• At the pre-deployment assessment, 57% of service members reported prior TBI; at post-deployment assessment, 20% reported deployment-related TBI.

Yurgil K, Barkauskas D, Vasterling J, et al., for the Marine Resiliency Study Team. Association between traumatic brain injury and risk of post-traumatic stress disorder in active-duty Marines. JAMA Psychiatry. February 2014;71(2):149-157.

Ethnic Differences in Receipt of Depression Care

This QUERI study sought to characterize differences in treatment for multiple racial/ethnic groups of Veterans with ongoing depression. Using VA data, investigators identified Veterans with chronic depression who had a VA outpatient visit for depression in FY09 and/or FY10. Three outcome measures were examined: 1) receipt of adequate antidepressant therapy; 2) receipt of adequate psychotherapy; and 3) receipt of guideline-concordant depression treatment (either adequate antidepressant therapy or adequate psychotherapy during the 6 months after the depression visit). Investigators also assessed patient socio-demographics, comorbidities and health behavior (e.g., current drinking), healthcare access and utilization, as well as race and ethnicity. Of the 62,095 Veterans in this study, 72% were white, 16% black, 4% Hispanic, 2% Asian, 2% AI/AN (American Indian/Alaska Native), and 4% were categorized as unknown race. Results show:

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.

• Receiving 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.

Quiñones A, Thielke S, Beaver K, et al. Racial and ethnic differences in the receipt of antidepressants and psychotherapy among Veterans with depression. Psychiatric Services. February 2014;65(2):193-200.

Only Small Percentage of Veterans with Mental Illness Access VA Employment Services

Individuals with mental illness face unemployment rates higher than the general population, and Veterans with mental illness who receive VA healthcare are less likely than other VA patients to be employed. VA provides vocational rehabilitative services through the Therapeutic and Supported Employment Services (TSES) program to assist Veterans with psychiatric diagnoses in obtaining employment and experiencing the therapeutic effects of work. This study assessed the reach of TSES services over one year (FY10) 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). The study also sought to identify clinical and demographic characteristics (e.g., homelessness status) associated with accessing at least one visit of TSES. Using VA administrative data, investigators identified VA patients with a psychiatric diagnosis (n=52,542) from a random sample of all VA patients. Among these patients, 8% had a primary diagnosis of schizophrenia, 4% bipolar disorder, 41% depression, 40% PTSD, and 8% another anxiety disorder. Results show:

• Only a small percentage of Veterans with psychiatric diagnoses that used the VA healthcare system (4%) accessed even one VA employment service in FY10.
• Among Veterans who accessed at least one visit for employment services (n = 2,178), 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.

Study investigators are pursuing additional research aimed at: 1) understanding the employment-related needs of Veterans with anxiety and depression, and 2) assessing the extent to which specific VA TSES services are associated with Veterans achieving competitive employment.

Abraham K, Ganoczy D, Yosef M, et al. Receipt of employment services among Veterans Health Administration users with psychiatric diagnoses. Journal of Rehabilitation Research & Development. 2014;51(3):401-414.

PTSD Treatment via Video-Teleconferencing as Effective as In-Person Treatment for Veterans Living in Rural Settings

One efficacious treatment for post-traumatic stress disorder (PTSD) is Cognitive Processing Therapy (CPT) - a trauma-focused psychotherapy that can be delivered in individual or group formats. CPT targets the cognitive symptoms of PTSD, and CPT-cognitive only (CPT-C) therapy is a variant of this therapy. This study is the first randomized controlled trial to compare the efficacy of delivering CPT-C via video-teleconferencing (VTC) to in-person delivery among a sample of rural Veterans. Investigators recruited 125 male Veterans from four VA healthcare facilities across the Hawaiian Islands; of these patients, 64 received in-person treatment and 61 received treatment via VTC. Veterans' PTSD symptoms were assessed at baseline, mid-treatment, immediately post-treatment, and 3 and 6 months post-treatment. Treatment process measures included attrition, treatment adherence, patient satisfaction, treatment expectancy, and group therapeutic alliance. Findings show:

• The use of clinical video-conferencing services to provide CPT-C therapy to Veterans with PTSD who lived in rural settings was found to be as effective as face-to-face treatment. Statistically significant and clinically meaningful 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. For example, at post-treatment, Veterans reported high levels of satisfaction with both in-person and VTC therapies, rating 11 of 14 items on the satisfaction scale as "very good" or "excellent."

Study results provide evidence that delivering a psychological intervention for PTSD via video-teleconferencing may be a viable solution to the long-standing access to care disparity that exists for rural and ethnically diverse populations.

Morland L, Mackintosh M, Greene C, et al. Cognitive processing therapy for post-traumatic stress disorder delivered to rural Veterans via telemental health: A randomized non-inferiority clinical trial. Journal of Clinical Psychiatry. May 2014;75(5):470-76.

Decreasing Obesity among Veterans with Serious Mental Illness

Obesity has reached epidemic proportions and has serious adverse health consequences. VA has deployed the "MOVE!" weight management program nationally in the general patient population and MOVE! has also been adapted for use among Veterans with serious mental illness (SMI), creating "MOVE! SMI." This ongoing QUERI study:

• Developed a comprehensive web-based system that delivers MOVE! using design features that meet the needs of Veterans with mental illness;
• Examines the effectiveness of the web-based MOVE! system compared with in-person MOVE! and a control group, and;
• Assesses patients' perspectives of web-based MOVE! to inform implementation of the system.

This prospective, randomized controlled trial includes 276 Veterans with SMI who are obese and receive treatment with medications that have weight gain as a common side-effect.

Thus far, the computerized system for MOVE! SMI is fully functional and has been delivering personalized diet and activity education to Veterans by kiosk or Internet access. Veterans work through a computerized curriculum, which includes audio and video content, progress charts, quizzes, homework, meal plans, and tailored handouts. The system also is integrated with pedometers. Each Veteran is assigned a Peer Coach, who has been trained to use motivational techniques and to support use of the system for weight loss. The full curriculum has been completed by more than half of the Veterans in the WebMove! Group, but, as yet, by no Veterans in the in-person MOVE! SMI group. The system has been well received by patients, and feedback regarding the peer support component of the web system has been particularly positive.

No publications at this time.

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 enable patients to mitigate suicidal thoughts. One such tool, which a patient creates and customizes with clinician guidance, 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, investigators from VA and the National Center for Telehealth and Technology collaborated to develop a Virtual Hope Box (VHB) for service members and Veterans that expands the reach of the hope box modality to a smartphone app. This feasibility study compared the VHB with a Conventional Hope Box (CHB) integrated into VA behavioral health treatment. Participants included 18 Veterans enrolled in a Dialectical Behavior Therapy program, who were identified as being at high risk of self-harm, and their clinicians (six clinical social workers and one clinical psychologist). Veterans were interviewed and completed questionnaires during pre-testing, testing, and post-testing.

Findings show:

• Compared with a Conventional Hope Box, 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 a usable therapeutic tool.

Results from this study were used to modify the app's functionality and user interface. Investigators are currently conducting a randomized trial to test the effect of Virtual Hope Box use, as compared to enhanced usual care, on Veterans coping skills, mental health symptoms, and suicidal ideation.

Bush N, Dobscha S, Crumpton R, et al. A virtual hope box smartphone app as an accessory to therapy: Proof-of-concept in a clinical sample of Veterans. Suicide and Life Threatening Behavior. May 2014; Epub ahead of print.

References:

1. Mental Health-QUERI Fact Sheet. VA/HSR&D. July 2014.

Additional Resources:

VA Mental Health and Get Help Now.

The National Alliance on Mental Illness.

Substance Abuse & Mental Health Services Administration (SAMHSA).

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Any health information on this website is strictly for informational purposes and is not intended as medical advice. It should not be used to diagnose or treat any condition.