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SDP 10-047 – HSR&D Study

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SDP 10-047
Linking National Guard Veterans with Need to Mental Health Care
Marcia T. Valenstein MD AB
VA Ann Arbor Healthcare System, Ann Arbor, MI
Ann Arbor, MI
Funding Period: September 2010 - February 2014

BACKGROUND/RATIONALE:
National Guard (NG) Soldiers have high levels of mental health symptoms, and many report interpersonal difficulties following deployments. Social support may be important in mitigating symptoms, and treatment may be needed when symptoms persist. Peer outreach is one strategy for increasing support, reducing stigma, and facilitating appropriate connections to resources. The Michigan Army National Guard (MIARNG) and its University and VA partners developed an innovative peer outreach program, the BuddytoBuddy (B2B) program, implemented in January 2009. The program was designed with two tiers; the first consists of Soldiers within the unit, Buddy Ones (B1s) while the second tier consists of community Volunteer Veterans, Buddy Twos (B2s), who visit NG units in-person during drill weekends and are available by telephone at other times. Both tiers are trained in communication techniques and identify and assist Soldiers who need assistance in a variety of areas (financial, mental health, employment, legal, family). B1s receive guidance from NG staff while B2s receive guidance from University staff.

OBJECTIVE(S):
Our objectives were to: 1) conduct a formative and summative evaluation of the implementation of the B2B program to inform program modifications and facilitate dissemination efforts; and 2) conduct a preliminary assessment of whether the B2B program is associated with mental health and substance use treatment initiation and Soldier outcomes.

METHODS:
We used a mixed methods design. Data were collected through surveys of Soldiers and qualitative interviews of Soldiers, NG leadership, and B2B staff.

Surveys were fielded to Soldiers in all 32 NG units that deployed between August 2010-July 2013, at 6 and 12 months following deployment and to an additional 4 units at 12 months post-deployment. Soldiers were recruited in person during drill weekends and by mail. Surveys assessed B2B awareness/use, mental health symptoms, well-being, and functioning. A total of 2922 surveys were returned (53% response rate), 1474 at 6 months and 1448 at 12 months.

During the formative evaluation, research staff met monthly to quarterly with NG command and B2B program staff to discuss interim survey and interview results and make program adjustments.

Descriptive statistics were completed and multivariable logistic regressions used to evaluate the relationships between: B2B use and Soldier and unit characteristics; MH services use and B2B use, and other covariates; and MH symptoms and treatment, B2B use, and other covariates.

Semi-structured interviews were completed with 78 Soldiers and 5 B2s purposively drawn from 3 NG units with substantial and 3 units with lower levels of B2B implementation. Three interviews were conducted with NG leadership and 7 with B2B staff. For the final report, research staff analyzed13 interviews from two lower implementation units and 26 interviews from two higher implementation units using a team-based rapid assessment process.

Administrative data from the B2B program, including attendance at B2B guidance calls and B2 interactions logs with Soldiers were considered in the formative and summative evaluations

FINDINGS/RESULTS:
Interim survey results and rapid assessments of early interviews were presented at regular meetings with NG command, B1 NG program staff, and B2 University staff. Program adjustments and modifications were made based on findings including changes in B1 trainings to increase dissemination and new strategies for promoting awareness and training of B2s.

Survey findings indicated high rates of MH symptoms. At 6 months, 18.5% reported significant depressive symptoms; 15.0% reported PTSD symptoms, and 48.6% reported hazardous drinking. Similar rates were reported at 12 months. Approximately 57% of Soldiers with MH need reported using MH services in the past year; 70% of Soldiers with PTSD symptoms reported services use.

At 6 months, 25% of the 32 surveyed units had completed B1 training and 59% of units had had a B2 placed for at least 4 months. At 12 months, 28% of 36 surveyed units had B1 training and 72% had a B2 for at least 4 months. At 12 months, B2 implementation was rated as "high" in 6 units of 36 surveyed units, "moderate" in 15 units, "low" in 5 units. Ten units did not have a volunteer. Approximately 80.7% of Soldiers reported awareness of B2B program at 6 months and 85.7% at 12 months. At 6 and 12 months, approximately 25.0% and 23.1% of Soldiers had interacted with a B1 and 15.2% and 18.2% had interacted with a B2.

In regression analyses, non-commissioned officers (NCOs) were more likely to interact with B1s and B2s than junior enlisted Soldiers. Positive views of leadership were associated with more B1 interactions. Reported use of B1s or B2s was not associated with MH services use. Higher levels of B1 use were associated with higher levels of PTSD symptoms at 12 months. B2 use was not associated with MH symptom levels.

Preliminary qualitative analyses suggested that more positive evaluations of leadership in a unit, higher levels of leadership support, and regular B2 attendance was key for B2B uptake. There was a high degree of commitment to continuation of the program.

IMPACT:
The formative and summative evaluations suggest the importance of unit leadership in implementing a peer program in military settings. Regular re-trainings are needed for peers. Community volunteer peers must make continued efforts to stay visible within units, and regular in-person drill attendance is key to Soldiers' willingness to engage. Awareness and participation in B2B was moderate to high in half or more of the units studied and there is substantial commitment to continuing the program.

Preliminary data do not point to a clear association between reported B1/B2 interactions and treatment receipt or symptoms, potentially due to the high level of MH treatment receipt or the general focus of the B2B program which assists Soldiers with a variety of needs, not only MH needs. Symptom burden among NG Soldiers remains high, with continued efforts needed to reduce this burden. New research is underway involving B2s in a brief intervention to reduce hazardous drinking among Soldiers.

PUBLICATIONS:

Journal Articles

  1. Kim HM, Levine DS, Pfeiffer PN, Blow AJ, Marchiondo C, Walters H, Valenstein M. Postdeployment Suicide Risk Increases Over a 6-month Period: Predictors of Increased Risk among Midwestern Army National Guard Soldiers. Suicide & Life-Threatening Behavior. 2017 Aug 1; 47(4):421-435.
  2. Gorman LA, Sripada RK, Ganoczy D, Walters HM, Bohnert KM, Dalack GW, Valenstein M. Determinants of National Guard Mental Health Service Utilization in VA versus Non-VA Settings. Health services research. 2016 Oct 1; 51(5):1814-37.
  3. Zivin K, Yosef M, Levine DS, Abraham KM, Miller EM, Henry J, Nelson CB, Pfeiffer PN, Sripada RK, Harrod M, Valenstein M. Employment status, employment functioning, and barriers to employment among VA primary care patients. Journal of affective disorders. 2016 Mar 15; 193:194-202.
  4. Nelson CB, Zivin K, Walters H, Ganoczy D, MacDermid Wadsworth S, Valenstein M. Factors Associated With Civilian Employment, Work Satisfaction, and Performance Among National Guard Members. Psychiatric services (Washington, D.C.). 2015 Dec 1; 66(12):1318-25.
  5. Sripada RK, Bohnert AS, Teo AR, Levine DS, Pfeiffer PN, Bowersox NW, Mizruchi MS, Chermack ST, Ganoczy D, Walters H, Valenstein M. Social networks, mental health problems, and mental health service utilization in OEF/OIF National Guard veterans. Social psychiatry and psychiatric epidemiology. 2015 Sep 1; 50(9):1367-78.
  6. Sripada RK, Richards SK, Rauch SA, Walters HM, Ganoczy D, Bohnert KM, Gorman LA, Kees M, Blow AJ, Valenstein M. Socioeconomic Status and Mental Health Service Use Among National Guard Soldiers. Psychiatric services (Washington, D.C.). 2015 Sep 1; 66(9):992-5.
  7. Bonar EE, Bohnert KM, Walters HM, Ganoczy D, Valenstein M. Student and Nonstudent National Guard Service Members/Veterans and Their Use of Services for Mental Health Symptoms. Journal of American College Health : J of Ach. 2015 Jan 1; 63(7):437-46.
  8. Valenstein M, Gorman L, Blow AJ, Ganoczy D, Walters H, Kees M, Pfeiffer PN, Kim HM, Lagrou R, Wadsworth SM, Rauch SA, Dalack GW. Reported barriers to mental health care in three samples of U.S. Army National Guard soldiers at three time points. Journal of traumatic stress. 2014 Aug 1; 27(4):406-14.


DRA: Military and Environmental Exposures, Mental, Cognitive and Behavioral Disorders
DRE: Treatment - Observational, Prevention
Keywords: Deployment Related, Mental Health Care, Prevention, QUERI Implementation
MeSH Terms: none