- 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
- 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
- Women Veterans Significantly More Likely than Male Veterans to Use Any Healthcare Up to One Year Post-Discharge
This study examined gender differences among a national sample of Veterans in the use of VA and non-VA health services during the first 15 months of the transition from military to civilian life. Findings showed that women Veterans were twice as likely as men to use any healthcare (VA or non-VA) immediately post-military and 84% more likely than men to do so a year later – but the use of VA care was comparable between men and women. There was no difference at baseline (within 90 days of separation) and only a 22% increase for women relative to men at one year. Use of the Veterans’ Choice Program was uncommon for both genders. While unstable housing was similar across genders (10% for women and 12% for men), women Veterans with unstable housing at military separation were less likely to use healthcare a year later, especially for the subgroup with mental/behavioral health issues. Sleep problems, anxiety, and depression were associated with healthcare use for both men and women following transition. VA housing assistance services could be gender-tailored for the 10% or 12% of Veterans with unstable housing; this could be implemented via outreach in the first 15 months post-separation. Sleep problems, depression, and anxiety remain drivers of healthcare use; whether expert treatment is provided in the community is unknown and should be assessed.
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
- Health is the Main Concern of Newly Separated Veterans
This large study is the first in-depth investigation of U.S. Veterans’ health and well-being as they leave military service. Findings showed that health concerns were the most salient for newly separated Veterans, with many reporting that they had chronic physical (53%) or mental (33%) health conditions – and that they were less satisfied with their health than either their work or social relationships. Chronic pain, sleep problems, anxiety, and depression were most commonly reported by Veterans. Men were more likely to report a hearing condition, high blood pressure, and high cholesterol, while women were more likely to report anxiety and depression at both survey timepoints. Compared with officers, enlisted personnel reported consistently poorer health, vocational, and social outcomes, and deployed Veterans reported poorer health than non-deployed Veterans. Veterans’ work functioning declined in the first year after leaving military service. Findings suggest several important directions for future prevention and early intervention efforts (i.e., health concerns such as chronic pain, sleep, and anxiety), which, if implemented, have the potential to put Veterans on the path to more successful and fulfilling post-military lives.
Date: December 28, 2019
- Social Stressors Strongly Associated with Suicide Ideation and Attempt among Veterans
This study examined documented social stressors in VA’s electronic health record (EHR) and how these stressors were associated with suicidal ideation and suicide attempt. Seven types of social stressors were included: 1) experiences of violence, 2) housing instability, 3) employment or financial problems, 4) legal problems, 5) social or familial problems, 6) lack of access to care or transportation, and 7) non-specific psychological needs. Findings showed that social stressors were strongly associated with suicidal ideation and suicide attempt. For example, compared with Veterans who had no social stressors, those with one social stressor had nearly 2.5 times the odds of suicidal ideation, two social stressors had over four times the odds, three social stressors had nearly five times the odds, and four or more social stressors had over eight times the odds – after adjusting for numerous socio-demographic factors and mental illness diagnoses. Social stressors are as relevant as biological factors (e.g., depression) for suicide prevention and treatment. Systematic assessment of a more complete set of these stressors may improve the ability to identify patients at highest risk of suicide.
Date: November 19, 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
- Weight Management as Effective as Medication Intensification for Glycemic Control among Veterans with Type 2 Diabetes
This randomized clinical trial sought to determine whether adding intensive weight management to group medical visits (WM/GMV) improves glycemia compared with GMV alone, while enhancing weight loss and decreasing medication intensity in patients with uncontrolled type 2 diabetes. Findings showed that for Veterans with diabetes who attended group medical visits, adding intensive weight management using low-carbohydrate nutrition counseling showed comparable glycemic improvement in addition to other clinical advantages (i.e., reduced weight, medication burden, and hypoglycemic events). The largest differences between the GMV vs. the WM/GMV arms occurred at 16 weeks after the intensive initial phase of the WM/GMV 48-week program. The WM/GMV intervention decreased HbA1c levels by 1.7% from baseline, which was 0.7% lower than the GMV arm. The intervention also led to a 5.6 point difference in diabetes distress symptoms (i.e., stress, depression). The estimated intervention cost per patient was $1,513.42 for patients in the WM/GMV arm, and $1,264.49 for patients in the GMV arm. Thus, weight management using a low-carbohydrate diet can be as effective for glycemic improvement as medication intensification, with additional benefits (i.e., weight reduction, fewer hypoglycemic events, less medication use); however, strategies are needed to help patients sustain these improvements.
Date: November 4, 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
- Substantial Variation in Opioid Prescribing Rates among ED Providers in the Same VA Healthcare Facility
The study team examined the extent to which variation in individual ED physicians’ opioid prescribing was independently associated with long-term opioid use in Veterans. Using VA data, investigators identified Veterans with an index ED visit at any VA facility in 2012 – and who were opioid naïve (without opioid prescriptions in the prior 6 months). Findings showed that there was a three-fold variation in the rates of opioid prescribing by ED physicians within the same VA facility (21% vs. 6%), regardless of patients’ severity of pain or primary diagnosis. The frequency of long-term opioid use was higher among opioid-naïve Veterans treated by high vs. low-quartile ED prescribers, though above the threshold for statistical significance (1.39% vs. 1.26%). Though the increase in long-term opioid use among Veterans treated by the highest-prescribing ED providers was not significant in the overall sample, it was significant among important patient subgroups, including those with back pain, musculoskeletal pain, or depression. High-intensity prescribers were more likely to prescribe opioids across the spectrum of pain intensity, while low-intensity prescribers were less likely to prescribe opioids across the spectrum.
Date: May 29, 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
- 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
- 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
- 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
- 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
- VA Successfully Implements Interferon-free Treatment for Hepatitis C Virus in Previously Undertreated Patient Populations
This study examined the adoption of interferon-free treatment for hepatitis C virus (HCV) in VA to learn who received this therapy and whether the limitations of interferon-containing treatments have been overcome, including low rates of use among VA healthcare users who are African American or Hispanic, and among those with HCV-HIV co-infection. Findings showed that with the advent of interferon-free regimens, the percentage of VA patients with HCV infection that was treated increased from 2% in 2010 to 18% in 2015, an absolute increase of 16%. There were large treatment gains realized by groups of patients that had been less likely to be treated in 2010. Large absolute increases in the percentage treated were achieved in Veterans with HIV co-infection (19%), alcohol use disorder (12%), and drug use disorder (13%), and in Veterans who were African-American (14%) or Hispanic (14%). Veterans with mental illnesses exacerbated by interferon, depression, PTSD, and bipolar disorder, had absolute increases in treatment that were larger than the overall increase.
Date: March 7, 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
- 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
- Comparing Food Insecurity between Veterans and non-Veterans
This study examined the prevalence of food insecurity in an older male population. Findings showed that there was a significantly lower prevalence of food insecurity among male Veterans compared to non-Veterans (6% vs. 12%, respectively). Nevertheless, several factors predisposed male Veterans to a higher risk for being food insecure. Younger Veterans (aged 50-64) were more likely to be food insecure and had nearly three times the prevalence of food insecurity compared to Veterans aged 65+ (12% vs. 4%, respectively). Overall, having a psychiatric diagnosis, self-reporting symptoms consistent with clinical depression, smoking, and experiencing any difficulty with activities of daily living (ADLs) were all significantly associated with increased odds of being food insecure, even after adjustment for demographics, medical comorbidities, and economic status. As Veterans aged 50-64 are not yet eligible for Social Security benefits, this group in particular should be screened for food insecurity.
Date: March 23, 2017
- 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
- 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
- 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
- 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
- Telemedicine-Based Intervention Improves Outcomes for Veterans with Poorly Controlled Diabetes
Investigators in this pilot trial developed the Advanced Comprehensive Diabetes Care (ACDC) intervention, which bundles four evidence-based telemedicine approaches – telemonitoring, self-management support, medication management, and depression management – and is designed for practical delivery by existing VA Home Telehealth program nurses using standard VA equipment. Findings showed that the ACDC intervention significantly reduced HbA1c by 1.0% versus usual care. Veterans receiving ACDC had significantly better diabetes self-care at six months versus usual care, but depressive symptoms did not differ between groups. Although ACDC did not address hypertension, Veterans in the intervention group had significantly lower systolic and diastolic blood pressure versus usual care. By utilizing Home Telehealth infrastructure that is ubiquitous at VA centers nationwide, ACDC represents a potentially scalable approach to reducing the burden of diabetes within VA.
Date: November 5, 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
- Patient Outcomes for Multi-faceted Intervention for Veterans with Heart Failure Comparable to Usual Care
Investigators in this study developed the Patient-Centered Disease Management (PCDM) intervention for patients with heart failure (HF) that combines multidisciplinary collaborative care by a nurse coordinator, cardiologist, psychiatrist and primary care provider, home tele-monitoring, and depression management. The primary aim of the study was to determine whether or not Veterans enrolled in the intervention experienced better health status (i.e., symptom burden, functional status, and quality of life) compared with Veterans enrolled in usual care. Findings showed that the PCDM intervention did not improve HF health status for Veterans compared with usual care. While there was significant improvement in overall summary scores in both groups after one year (mean increase of 13.5 points in each group), there was no significant difference between Veterans in the intervention group compared to Veterans in the usual care group. Among secondary outcomes, there were significantly fewer deaths at one year among Veterans in the intervention group (8 of 187, or 4%) than in the usual care group (19 of 197, or 10%). Among Veterans who screened positive for depression, there also was greater improvement in depression scores after one year for Veterans in the intervention group compared to Veterans in the usual care group. There was no significant difference in 1-year hospitalization rates between groups (29% vs. 30%).
Date: March 30, 2015
- Sleep Difficulties Associated with Risk Factors for Cardiovascular Disease among Younger Veterans and Active Duty Personnel
This study examined the relationship between sleep difficulties and several cardiovascular (CVD) risk factors (i.e., smoking status, body mass index, self-reported hypertension, hypertension medication use, clinic-based blood pressure readings, symptoms of depression and PTSD, and diagnosis of depression and PTSD) among relatively younger (mean age, 37 years) Veterans and active duty personnel of the Iraq and Afghanistan wars. Findings showed that 8% of the Veterans in this study endorsed only sleep onset difficulties, 9% endorsed only sleep maintenance difficulties, and 41% endorsed both sleep onset and sleep maintenance difficulties. Study participants with both sleep onset and maintenance difficulties had greater odds of being a current smoker, having a diagnosis of PTSD, having clinically significant PTSD symptoms, having a diagnosis of depression, and having clinically significant depression symptoms. The odds for these risk factors did not differ by race or age. Having the combination of sleep onset and maintenance difficulties also was associated with elevated systolic blood pressure readings and increased likelihood of reporting a hypertension diagnosis among younger white Veterans. Overall, study participants with sleep maintenance difficulties were older, while those having both sleep onset and maintenance difficulties were younger and reported more tours of duty. Veterans reporting sleep difficulties of any kind reported more symptoms of depression and PTSD. Authors note that since sleep difficulties are associated with several CVD risk factors, improving sleep in this younger population may reduce the progression of disease and avert the increased incidence of CVD found in older Veterans.
Date: March 27, 2015
- Differences between Men and Women Veterans Undergoing Cardiac Catheterization in VA
This study sought to determine whether there were gender differences in clinical characteristics and comorbidities, coronary anatomy and treatment, and procedural complications and long-term outcomes after diagnostic catheterization. Findings showed that female Veterans were younger (57 vs 63 years), with fewer traditional cardiovascular risk factors, but had more obesity, depression, and PTSD than male Veterans. Compared to male Veterans, female Veterans had lower rates of obstructive coronary artery disease (CAD) (23% vs 53%), similar or lower rates of procedural complications, and lower rates of all-cause rehospitalization. Women Veterans had lower mortality at one year, even when adjusted for age, presence of obstructive disease, and multiple comorbidities. Findings suggest that a significant portion of women Veterans treated in VA catheterization labs have chest pain not related to obstructive CAD. This may represent a complex interplay of psychological stressors and somatic disease, but further research is needed.
Date: March 1, 2015
- OEF/OIF/OND Veterans with PTSD at Greater Risk of Autoimmune Disorders
This study examined whether PTSD, other psychiatric disorders (i.e., depression, anxiety, psychosis, alcohol use disorder, substance use disorder), and military sexual trauma (MST) increase the risk for autoimmune disorders. Findings showed that Veterans diagnosed with PTSD had significantly higher risk for diagnosis of any of the autoimmune disorders – alone or in combination – compared to Veterans with no psychiatric diagnoses. Veterans with PTSD had twice the risk of being diagnosed with an autoimmune disorder compared to those without any psychiatric disorders, and 51% increased risk compared to Veterans with psychiatric disorders other than PTSD. Veterans with a higher number of comorbid psychiatric diagnoses also were more likely to be diagnosed with an autoimmune disorder, but high levels of comorbidity did not entirely account for the effect of PTSD on increased risk. The magnitude of the association between PTSD and autoimmune disorders was similar in women and men. However, overall, women had almost three times higher prevalence of autoimmune disorders. MST was much more common in women than men (13% vs. 0.5%), and was independently associated with increased risk for autoimmune disorders in both women and men. Findings underscore the need to identify and treat PTSD and other psychiatric disorders in Veterans in order to enhance not only mental but also physical health.
Date: February 15, 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
- Telemedicine-based Collaborative Care Intervention Improves PTSD Outcomes among Veterans Residing in Rural Settings
This trial sought to test a collaborative care model designed to improve access to and engagement in evidence-based psychotherapy and pharmacotherapy for Veterans with PTSD living in rural settings. Findings showed that telemedicine-based collaborative care successfully engaged Veterans who lived in rural settings in evidence-based psychotherapy to improve PTSD outcomes. During the 12-month study period, 55% of Veterans randomized to the Telemedicine Outreach for PTSD (TOP) intervention received Cognitive Processing Therapy (CPT) compared to 12% of Veterans who were randomized to usual care. Veterans randomized to TOP had 18 times higher odds of initiating CPT and 8 times higher odds of completing >8 sessions (considered the minimally therapeutic dosage). Veterans in the TOP group had significantly larger decreases in PTSD symptoms compared to Veterans in the usual care group – a 5.31 decrease in symptom severity on the Posttraumatic Diagnostic Scale at six months, on average, compared to 1.07 for Veterans in usual care (a 5-point decrease in the Scale represents a decrease in frequency from 2 to 4 times a week to once a week for 5 symptoms of PTSD). The TOP group had significantly greater reductions in depression symptom severity compared to usual care at both six and twelve months.
Date: November 19, 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
- 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
- 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
- Penetrating Traumatic Brain Injury Strongly Associated with Risk of Epilepsy among OEF/OIF Veterans
This study examined the association between epilepsy and TBI, including penetrating TBI (pTBI), in OEF/OIF Veterans. Findings showed that epilepsy was associated with previous TBI diagnosis. The estimated risk of epilepsy among Veterans with pTBI was nearly 18 times greater than among those without TBI, even after controlling for other factors. When examined separately, risk for epilepsy was also elevated among Veterans with severe, moderate, and mild TBI. Even among this relatively young group of Veterans, stroke was one of the strongest risk factors for epilepsy. Veterans with epilepsy also were more likely to be younger than 50 years and white, and were more likely to have previously diagnosed substance use disorder, depression, anxiety, bipolar disorder, schizophrenia, and PTSD than those without epilepsy. Headache, cardiac conditions, cerebrovascular disease, and cognitive impairment/dementia were also epilepsy risk factors. An increasing burden of epilepsy in this Veteran population is likely. These Veterans should be followed closely, and systems of care, such as VA Epilepsy Centers of Excellence, should be prepared to provide epilepsy specialty care.
Date: April 1, 2014
- Combat Deployments Associated with New-Onset Coronary Heart Disease among Young U.S. Service Members and Veterans
This study sought to determine whether specific deployment experiences and PTSD symptoms are associated with newly reported coronary heart disease (CHD) among a young cohort (mean age = 34 years at baseline) of U.S. military personnel (active duty) from all service branches. Findings showed that combat deployments were associated with new-onset CHD among young U.S. service members and Veterans. Service members who reported combat experiences had nearly twice the odds of having a diagnosis code for new-onset CHD than service members without combat exposure. This suggests that experiences of intense stress may increase the risk for CHD over a relatively short period among young adults. Screening positive for PTSD symptoms was associated with self-reported CHD prior to – but not after adjusting for depression and anxiety, and was not associated with a new diagnosis of CHD.
Date: March 11, 2014
- Veterans with Multiple Chronic Conditions Account for Disproportionate Share of VA Healthcare Costs
This study examined the association between number of chronic conditions and costs of care for non-elderly (<65 years) and elderly Veterans (=65 years) within the VA healthcare system – and estimated VA expenditures for the most prevalent and costly combinations of three conditions (triads). Findings showed that Veterans with multiple chronic conditions account for a disproportionate share of VA healthcare costs. Almost one-third of non-elderly and slightly more than one-third of elderly VA patients had >3 conditions, but they accounted for 65% and 67% of total VA healthcare costs, respectively. The most common triad of chronic conditions for both non-elderly and elderly Veterans was diabetes, hyperlipidemia, and hypertension (24% and 29%, respectively). Conditions present in the most costly triads included: spinal cord injury, heart failure, renal failure, ischemic heart disease, peripheral vascular disease, stroke, and depression. While patients with the most costly triads had average costs that were three times higher than average costs of patients in other triads, the prevalence of these costly triads was extremely low (0.1 to 0.4%). These findings highlight the need for interventions that target the sickest patients who have high resource use to provide more cost-effective care.
Date: March 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
- 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
- Gaps in Quality of Supportive VA Cancer Care for Veterans
This study evaluated non-hospice supportive VA cancer care in a nationally representative sample of Veterans with stage IV metastatic lung, colorectal, and prostate cancers who were diagnosed in 2008. Quality of care was measured using the Cancer Quality-Assessing Symptoms and Side Effects of Supportive Treatment (ASSIST) quality indicators. Findings showed that, overall, Veterans received only about half (49%) of recommended care as measured by ASSIST quality indicators. Gaps in quality of cancer care included: inpatient pain screening was common (96%) but lacking for outpatients (58%); few Veterans had timely dyspnea evaluation (16%) or treatment (11%); only 4% of Veterans had a new diagnosis of depression identified; of patients at high risk for diarrhea from chemotherapy, 24% were offered antidiarrheals; only 18% of Veterans had their goals of care addressed in the month after a diagnosis of advanced cancer; and 64% of patients had timely discussion of goals ICU admission. Most Veterans who died (86%) were referred to palliative care or hospice before death and 72% had an advanced directive or surrogate decision maker documented in the medical record.
Date: December 9, 2013
- Electronic Patient Portals and their Effect on Health Outcomes
Investigators conducted a systematic review of the relevant literature evaluating peer-reviewed articles on patient portals tied to existing electronic medical record systems, specifically looking at whether or not these systems improve health outcomes, patient satisfaction, healthcare utilization and efficiency, and adherence. Findings showed that the evidence is insufficient as to the effects of patient portals on health outcomes. A limited number of studies and variations in study design, portal functionalities, and implementation processes make it difficult to draw strong conclusions or generalizations about this relatively new technology. Examples were identified in which portal use was associated with improved outcomes for patients with chronic diseases (i.e., diabetes, hypertension, depression), but these were generally studies that used the portal in conjunction with case management. Evidence was mixed about the effect of portals on healthcare utilization and efficiency. Some findings included more acceptance of portals by patients who were younger and had more computer literacy or trust in the Internet, and more enthusiasm for portals among patients than physicians. Administrative and human factors in the interface were cited as barriers to use. Thus, the jury is still out on whether patient portals such as MyHealtheVet improve health outcomes or increase healthcare efficiency, although patients seem to value the ability to access their own medical records. While patients’ attitudes on portals are generally positive, more widespread use may require efforts to overcome racial, ethnic, and literacy barriers.
Date: November 19, 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 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
- 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
- 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
- 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
- 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
- Opioid Prescribing for Veterans with Chronic Non-Cancer Pain
This study sought to describe patterns of prescription opioid initiation, identify correlates of opioid initiation, and examine correlates of receipt of chronic opioid therapy (COT) among Veterans with persistent non-cancer pain. Findings showed that the initiation of opioid drug therapy is common among Veterans with persistent pain, but most Veterans are not prescribed opioids long-term. During the study year, 35% of Veterans in the sample received an opioid prescription: 30% were prescribed opioids on a short-term basis (<90 days), and 5% received chronic opioid therapy (>90 days). Clinical factors associated with initiating COT include increased pain intensity, nicotine dependence, substance use disorders, and major depression diagnoses. Nearly one-quarter of Veterans prescribed COT also received prescriptions for benzodiazepine medications, which is a concern given that overdose deaths have been linked to the use of multiple sedating medications. Two-thirds of opioid prescriptions resulting in COT were initiated by primary care clinicians. The authors suggest that this supports the development of guidelines geared toward primary care practice. It also supports the provision of interventions and structures in primary care that facilitate proactive planning around opioid use and its monitoring.
Date: February 1, 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
- 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
- Post-deployment Health Outcomes Associated with Multiple Deployment-Related Factors
This study examined the unique contributions of various deployment-related exposures and injuries to current post-deployment physical, psychological, and general health outcomes in National Guard members. Findings showed that various deployment-related experiences increased the risk for post-deployment adverse mental and physical health outcomes, individually and in combination. Most adverse outcomes had associations with multiple deployment-related factors. Deployment-related mild traumatic brain injury (TBI) was associated with post-deployment depression, anxiety, PTSD, and post-concussive symptoms such as headaches and dizziness. Combat exposures with and without physical injury were associated not only with PTSD, but also with numerous post-concussive and non-post-concussive symptoms (e.g., chest pain, indigestion). Associations between blast exposure and abdominal pain, pain on deep breathing, shortness of breath, hearing loss, and tinnitus suggested residual barotrauma. The experience of seeing others wounded or killed, or experiencing the death of a buddy or leader, was associated with indigestion and headaches, but not with depression, anxiety, or PTSD. Findings indicate that an integrated interdisciplinary healthcare approach would be beneficial for Veterans with multiple deployment-related health issues. Such a system of care is currently being used within the VA Polytrauma programs.
Date: November 1, 2012
- Association between Several Common Antiepileptic Drugs and Suicide-Related Behavior in Older Veterans
This retrospective study examined the relationship between antiepileptic drugs (AEDs) and suicide-related behaviors among Veterans aged 65 years and older who received VA healthcare. Findings showed that, within the study sample of 2 million older Veterans, there were 332 cases of suicide-related behavior (SRB). Exposure to antiepileptic drugs was significantly associated with suicide-related behavior, even after controlling for psychiatric comorbidity and prior SRB. Individuals who received AEDs were significantly more likely to have prior diagnoses of suicide-related behavior, depression, anxiety, bipolar disorder, PTSD, schizophrenia, substance abuse/dependence, conditions associated with chronic pain, and dementia. Veterans who received prescriptions for several specific AEDs – valproate, gabapentin, lamotrigine, levetiracetam, phenytoin, and topiramate – were at greater risk of diagnosed suicide-related behavior than Veterans with no AED exposure. Findings indicated that suicide-related behavior may occur as early as one week following AED use.
Date: October 30, 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
- Rape and Sex Partnership Adversely Associated with Lower Physical Functioning in Women Veterans
This study sought to determine whether current physical health status in women Veterans is associated with rape in military (RIM) and same-sex partnering. Findings showed that women Veterans who reported a history of rape (during childhood or adolescence, in-military or post-military) and those with same-sex sexual partners at some point in their lives had significantly lower current physical health status compared to women without such histories. Of the participants in the study, 11% reported having women as sex partners (WSW). Women with same-sex partners reported significantly higher lifetime substance use disorder (SUD) and higher rates of rape, both lifetime and in separate time periods, compared to women who reported having sex with men exclusively. Three-quarters (74%) of WSW reported lifetime rape and one-third (35%) reported RIM compared to 48% and 23% in women with men as partners only. Physical health status was lowest for women with a history of chronic pain. Other factors significantly associated with lower physical health status were depression, PTSD, and not having a current SUD.
Date: October 15, 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
- 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
- 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
- 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
- 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
- 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
- Veterans that Use Cigarette Smoking to Cope with Chronic Pain Experience Worse Pain-Related Outcomes
Veterans who reported smoking as a coping strategy for chronic pain scored significantly worse compared to Veterans who did not smoke and those who denied using cigarettes to cope with pain on the majority of measures of pain-related outcomes. After controlling for demographics and clinical factors, smoking as a coping strategy for pain was significantly and positively associated with pain intensity, pain interference, and fear of pain. There were no significant differences between the three groups on current symptoms of depression or anxiety, indicating that comorbid psychopathology likely did not contribute to poorer pain-related outcomes in the group who used cigarettes to cope with pain. The two smoking groups did not differ with respect to the frequency or severity of nicotine dependence, use of opioid medications, or on other clinical factors, suggesting that impairment in pain-related variables may be due to reliance on cigarettes as a coping strategy for chronic pain.
Date: March 1, 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
- 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
- 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
- Prevalence and Risk Factors for Non-Fatal Injuries among Veterans with TBI – Post-Discharge from VA Polytrauma Care
This study examined the prevalence of, and potential risk factors for, non-fatal injuries among Veterans with TBI after discharge from VA inpatient polytrauma rehabilitation programs. Caregivers reported that nearly one-third (32%) of Veterans discharged from VA Polytrauma Rehabilitation Centers had incurred subsequent, medically treated injuries; most were associated with falls (49%) and motor vehicles (37%). Factors associated with Veterans’ increased odds of subsequent injury included poor or fair general health and requiring assistance with activities of daily living or instrumental activities of daily living. A number of caregiver-reported ongoing symptoms/health problems among Veterans (e.g., depression, vision loss, hearing loss) were also associated with greater injury odds. Moreover, the odds of subsequent injury increased as the number of reported symptoms/comorbid health problems increased. Compared to male Veterans, the small proportion of female Veterans (n=23) had approximately four and a half times the odds of sustaining subsequent injury. Caregivers who reported their own health as poor or fair were more likely to report subsequent injuries for Veterans compared to caregivers who reported their own health as excellent, very good, or good. Caregivers with higher than average or average depressive or anxiety symptoms, or lower than average physical functioning scores, also were more likely to report injuries among Veterans compared to caregivers without these symptoms.
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
- 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
- Complementary and Alternative Medicine Options for Veterans with Chronic Pain
As part of the “Study of the Effectiveness of a Collaborative Approach to Pain,” investigators surveyed Veterans with chronic (non-cancer) pain about their prior use of, and their willingness to try four complementary/alternative medicine (CAM) treatments: massage, chiropractic care, herbal medicines, and acupuncture. Investigators also examined whether demographic characteristics, VA treatment satisfaction, common pain-related characteristics (i.e., pain intensity, disability, depression), or overall disease burden distinguished CAM users from non-users. Findings showed that 82% of Veterans reported previously trying CAM therapy, and nearly all were willing to try one or more of the four CAM treatment options in the study survey. Chiropractic care was the least preferred CAM therapy, whereas massage was the most preferred option. Compared to Veterans who did not use CAM therapy, CAM users were less likely to have service-connected disabilities, and reported having spent a larger percentage of their lives in pain. Investigators detected few differences between Veterans who had tried CAM therapy and those who had not, suggesting CAM may have broad appeal among Veterans with chronic pain. Moreover, study results did not show differences in treatment satisfaction or pain treatment effectiveness ratings between the two groups. This suggests that Veteran patients with chronic pain may use CAM as an additional tool in pain management, rather than as a reaction to perceived inadequacies of conventional care.
Date: December 1, 2011
- Chronic Conditions among Veterans and Related VA Healthcare Spending Trends: 2000-2008
This study estimated the change in prevalence and total VA spending for 16 chronic conditions (e.g., hypertension, diabetes, heart conditions, depression, PTSD, renal failure, cancer) between 2000 and 2008. Findings showed that most of the total VA spending increases during the study period were driven by the increase in VA’s patient population – from 3.3 million in 2000 to 4.9 million in 2008. In addition, the prevalence of many chronic conditions among VA patients increased as the VA population got older. Spending on renal failure increased the most, by more than $1.5 billion, with 66% of this increase related to greater prevalence of the disease. Spending increases for other conditions, such as hepatitis C, stroke, hypertension, diabetes, PTSD, and depression were also driven in large part by higher prevalence among VA patients. Higher treatment costs did not contribute much to higher spending; instead, lower costs per patient for several conditions may have helped to slow spending. During this time period, VA continued to expand its outpatient care system with community-based outpatient clinics; better access to outpatient care may have shifted costs away from more expensive inpatient care.
Date: December 1, 2011
- Caregivers of Veterans with Chronic Illness
This study sought to identify predictors of caregiver strain and satisfaction associated with caring for Veterans with chronic illness. Findings showed that although 76% of caregivers reported feeling very self-confident in their caregiving role, more than one-third (37%) reported high strain. Overall, the mean caregiving satisfaction score indicated a moderate level of satisfaction. Caregiver characteristics that predicted strain included having less support, having depressive symptoms, and using paid help. Veteran characteristics that predicted caregiver strain included greater need for caregiving assistance in IADL (instrumental activities of daily living), and greater levels of depression. Predictors of lower caregiver satisfaction included less social support, older age, depression, and poor Veteran health status. Predictors of higher caregiver satisfaction included helping the Veteran with medical equipment and the coping style of “taking medication.” Both caregivers and Veterans reported similar levels of assistance provided, which were relatively low for ADL (activities of daily living) and IADL. However, caregivers reported providing a mean of 43 hours per week in assistance. Investigators suggest this may be due to the higher percentage of spouse caregivers in this sample, who are available for caregiving around the clock. A majority of caregivers expressed a need to know more about the Veteran’s medication.
Date: November 22, 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
- 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
- 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
- Cognitive Processing Therapy Improves PTSD Symptoms More than Usual Care among Veterans in Residential Rehabilitation Program
This study examined one VA PTSD Residential Rehabilitation Program and compared clinical outcomes for two cohorts of male Veterans with PTSD that were treated with either cognitive processing therapy (CPT) or trauma-focused group treatment as usual (TAU). Findings showed that Veterans treated with CPT experienced more improvement of PTSD and depression symptoms, psychological quality of life, coping, and psychological distress than Veterans who received TAU. In the CPT cohort, more Veterans reported PTSD symptoms that were classified as recovered or improved, compared to the TAU cohort.
Date: October 1, 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
- 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
- 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
- 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
- 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
- Veterans with Spinal Cord Injury and Pressure Ulcers have More Hospitalizations and Higher Costs of Care
This study compared the annual healthcare utilization and costs of Veterans with spinal cord injury/disorder (SCI/D), with and without pressure ulcers, who used the VA healthcare system. Findings show that among Veterans with SCI/D, pressure ulcers were associated with greater rates of hospitalization and higher healthcare costs. After adjusting for patient demographics, comorbidities, and other characteristics, total annual healthcare costs per patient were $73,021 higher for Veterans with pressure ulcers and annual hospitalizations were nearly 52 days longer. This represents more than $89 million in total additional costs to the VA healthcare system. Higher total costs were due primarily to higher total inpatient costs for Veterans with pressure ulcers compared to Veterans without pressure ulcers. Factors associated with more total inpatient days included: older age, hospitalization within the 12-month period prior to the index date, and a history of depression.
Date: April 15, 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
- 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
- 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
- Concussion/mild TBI During Deployment Does Not Result in Significant Post-Deployment Health Effects Separate from PTSD
This study assessed the longitudinal associations between concussion/mild TBI (mTBI) and PTSD symptoms reported in-theater and longer-term psychosocial outcomes in 953 combat-deployed National Guard soldiers. Findings show that the rate of self-reported concussion/mTBI was 9% at Time 1 (one month before returning home from Iraq) and 22% at Time 2 (one year later). Differences may be explained by recall bias and/or poor reliability of the TBI screening instrument. Prevalence of probable PTSD at Times 1 and 2 was 8% and 14%, respectively; and for probable depression was 9% and 18%, respectively. At Time 2, 42% screened positive for problematic drinking and 29% endorsed clinically-significant non-specific somatic complaints. Self-reported post-concussive symptoms at Time 2 were common. For example, among those who reported neither mTBI nor PTSD, 23% reported balance problems, 57% reported tinnitus, 60% reported memory problems, and 64% reported concentration problems and irritability. Post-concussive symptom prevalences were even higher among those who reported mTBI and/or PTSD. The increased post-concussive symptoms reported by soldiers who also reported concussion/mTBI were no longer statistically significant after adjusting for post-deployment PTSD symptoms, suggesting that post-concussion symptoms may be largely explained by PTSD. Findings suggest that early identification and evidence-based treatment of PTSD may be important to the management of post-concussive symptoms following deployment.
Date: January 1, 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
- 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
- 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
- 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
- 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
- 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
- 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
- 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
- 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
- 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
- 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
- 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
- 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
- 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
- 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
- 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
- Predictors Associated with Use of Complementary/Alternative Medicine in Men with HIV
This study sought to describe the types, frequency, and intensity of complementary/alternative medicine (CAM) use among men living with HIV infection in southern California and northern Florida/southern Georgia, and to identify predictors of CAM use and intensity. Findings show that the majority of men with HIV infection in this study (69%) reported some CAM use. The most frequently cited types of CAM use were drug or dietary supplements (71%) and spiritual therapies (66%). CAM use was almost three times higher in California compared to Florida/Georgia, and was also greater in men who reported depression or more health-promoting behaviors. The odds of CAM use intensity increased with greater symptom frequency and more health-promoting behaviors. In addition, vitamins, dietary supplements, and herbs were used by the majority of men in this study. The authors suggest that high levels of CAM use among men with HIV infection should alert healthcare providers to assess CAM use and to incorporate CAM-related patient education into their clinical practices.
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
- 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
- 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
- High Rates of Violence among Substance Abusers
This study examined violence related to SUD, as well as potential violence prevention treatment needs for men and women patients (non-Veterans) in SUD treatment settings. Investigators looked specifically at violence resulting in injury toward partners and non-partners, as well as against individuals in treatment. Findings show that rates of injury across relationship types were substantial, with more than 54.8% reporting injuring another person, and 55.4% reporting being injured. Further, there was a strong association between injuring others and being injured. Overall, those reporting injuring others had significant psychosocial challenges in terms of low rates of employment, low household income, relatively few prior SUD treatment visits on average, and most participants did not have prior “anger-management/domestic violence” treatment. Moreover, those injuring or reporting injury by others had higher rates of problems (e.g., binge drinking, opiate use, depression) than those in the non-injury groups.
Date: July 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
- Outpatient Healthcare Use for American Indian and Alaska Native Women Veterans
American Indian and Alaska Native (AIAN) women are among the growing number of female Veterans who now seek VA healthcare. In 2003, VA and the Indian Health Service (IHS) executed a Memorandum of Understanding (MOU) to improve access and health outcomes for AIAN Veterans by encouraging cooperation and resource sharing. In order to inform inter-agency planning and coordination, this study reports on the demographic characteristics and healthcare utilization patterns of AIAN women Veterans at the outset of the MOU agreement. Findings show that regardless of group, the medical needs of female AIAN Veterans were similar to other Veterans, including other female Veterans. On average, Veteran dual-users received two-thirds of their healthcare at VA facilities, while non-Veteran dual-users received most of their healthcare at IHS facilities. The lowest outpatient utilization rate was for IHS-only users. Results also show that three of the most frequent diagnoses were hypertension, diabetes, and depression.
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
- 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
- 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
- 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
- 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
- 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