- 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
- Use of Clozapine for Veterans with Treatment-Resistant Schizophrenia Could Result in Significant Cost Savings
This cost-benefit analysis sought to simulate potential cost savings for VA that would result from increasing the use of clozapine among Veterans with treatment-resistant schizophrenia. Findings showed that modest increases in clozapine use could result in significant cost savings for VA. Among Veterans with treatment-resistant schizophrenia, VA would save $22,444 per Veteran over the first year of treatment, primarily from 18.6 fewer inpatient hospitalization days per patient. Given this finding, if current clozapine use was doubled from 20% of patients with treatment-resistant schizophrenia to 40%, VA would accrue an estimated cost savings of $80 million over the first year. Moreover, full utilization of clozapine would save VA $320 million over the first year. Findings suggest VA should strongly consider initiatives to substantially increase clozapine use among Veterans with treatment-resistant schizophrenia. Deaths from clozapine-related adverse events are more than balanced out by decreased incidence of suicide attempts, with a net result of slightly fewer deaths with increased use of clozapine.
Date: June 15, 2016
- Barriers and Facilitators to Use of Clozapine for Treatment-Resistant Veterans with Schizophrenia
This study sought to identify facilitators and barriers to clozapine use – and to inform the development of interventions to maximize appropriate use. Findings showed that factors associated with high utilization of clozapine for Veterans with schizophrenia included: providing access to transportation for Veterans; having sufficient capacity to enroll patients; use of multi-disciplinary teams, including non-physician providers; better coordination of care through mental health intensive case management (MHICM) or clozapine clinics; and creation of systems to reduce reliance on too few individuals. Factors associated with low utilization of clozapine included lack of champions to support clozapine processes and limited-capacity care systems. Barriers identified at both high- and low-utilization facilities included time-consuming paperwork, reliance on few individuals to facilitate processes, and issues related to transportation for Veterans living far from VA care facilities.
Date: June 15, 2016
- Antipsychotics Prescribed to Substantial Minority of Veterans with PTSD without Bipolar Disorder or Schizophrenia
Given limited knowledge about the use of antipsychotics in Veterans with PTSD returning from Iraq and Afghanistan, this study examined the rates of antipsychotic use in this patient population. Findings showed that antipsychotics were prescribed to a substantial minority of OEF/OIF/OND Veterans with PTSD who did not also have a diagnosis of bipolar disorder or schizophrenia. Of the Veterans in this study, 20% received no psychiatric medications, 61% received psychiatric mediations other than antipsychotics, and 19% received antipsychotics. Male Veterans and those in the Army, of lower rank, and with active duty status (vs. National Guard/Reserve) were more likely to be prescribed antipsychotics. Comorbid psychiatric conditions, particularly substance use and personality disorders, as well as suicidal ideation also were associated with greater use of antipsychotics compared to other types of psychiatric medications. Antipsychotics were prescribed much later after the date of PTSD diagnosis than other psychiatric medications, suggesting they were not first-line medications. Given limited evidence of the benefit of antipsychotics for PTSD and their potential adverse metabolic side effects, authors suggest that clinicians carefully weigh the risks and benefits of antipsychotic use in Veterans with PTSD.
Date: March 3, 2015
- 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
- Providers’ Endorsement of Stigma Regarding Mental Illness Is Related to Patient Treatment Options
This study examined provider response to two treatment options that might be offered to a male patient with schizophrenia who was seeking help for low back pain due to arthritis: 1) referral for specialist consult, or 2) refilling the patient’s prescription for Naproxen. Findings showed that healthcare providers who endorsed more stigmatizing attitudes about mental illness were likely to be more pessimistic about the patient’s adherence to treatment. Stigmatizing attitudes were greater among those providers who were relatively less comfortable with using mental health services themselves. Greater perceived treatment adherence was positively associated with both health decisions: referrals and prescription refill. Thus, poor perceived adherence was partly a proxy for stigmatizing attitudes providers held about people with mental illness, which in turn led to different treatment decisions in patients with serious mental illness. Providers from mental health backgrounds showed no difference in expectations about treatment response than primary care professionals, suggesting that both primary care and mental health providers should be targets of interventions aimed at decreasing disparities in clinical care.
Date: August 15, 2014
- 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
- 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
- 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
- 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
- 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
- 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
- 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
- Most VA Patients with Substance Use Disorders Who Die from Suicide Use Violent Means
Most VA patients with substance use disorders (SUDs) who died from suicide used violent means (70%, n=600), and the majority were carried out with firearms. No specific SUD was associated with increased risks of violent suicide, but several SUD diagnoses (e.g., cocaine use and opiate use) were associated with a higher risk of non-violent suicide. Alcohol use was associated with a lower likelihood of non-violent suicide. While many psychiatric disorders (e.g., major depression, PTSD, schizophrenia) were associated with increased risk of both violent and non-violent suicide, the strength of the association between the disorder and type of suicide was greater for non-violent than violent suicide. The authors suggest that by linking data on risk factors to information about the specific methods used, future interventions designed to decrease access to lethal means could be tailored to focus on those at greatest risk of dying by specific means.
Date: July 1, 2010
- Medication Management for Veterans with Schizophrenia
This study examined medication management for a random sample of Veterans who received drug therapy for schizophrenia at any one of three VA mental health clinics in Southern California between 2002 and 2003. Overall, 67% of Veterans had inappropriate management at baseline: 32% had inappropriate management of psychotic symptoms, 45% had inappropriate management of weight, and 8% had inappropriate management of tardive dyskinesia (TD). Further, 11% had depression that was moderately severe or worse. At one year, the appropriateness of management for psychotic and depressive symptoms had not changed. The appropriateness of management of TD also did not change over time, but the management of elevated weight improved modestly. There were no significant differences between the three clinics in the prevalence of symptoms or side effects, or in the appropriateness of medication management. However, psychiatrists with more than 12 patients were significantly more likely to improve their patients’ care over time.
Date: July 1, 2010
- 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
- Veterans with Psychosis More Likely to Die from Heart Disease
This study assessed whether Veterans with mental disorders receiving care in the VA healthcare system were more likely to die from heart disease than Veterans without these disorders, and whether modifiable factors may explain mortality risks. Findings show that compared to Veterans without a mental health diagnosis, Veterans with psychosis (schizophrenia or other psychotic disorder diagnoses) were more likely to die from heart disease. Smoking and physical inactivity were the behavioral factors most strongly associated with mortality related to heart disease. Veterans with schizophrenia were the most likely to be current smokers, and those with bipolar disorder were the least likely to report adequate physical activity. Controlling for behavioral factors (e.g., smoking and physical inactivity) diminished but did not eliminate the impact of psychosis on mortality. The authors suggest that to reduce mortality related to heart disease, early interventions that promote smoking cessation and physical activity among Veterans with psychotic disorders are warranted.
Date: November 1, 2009
- Regular Primary Care Associated with Better Survival Rates for Veterans with Schizophrenia and Diabetes
Medical comorbidity among aging people with schizophrenia is common and many patients with schizophrenia have difficulty managing their medical healthcare needs, which may result in delayed treatment and poor outcomes. This retrospective cohort study assessed whether patterns of VA primary care use among Veterans with diabetes, schizophrenia , or both were a significant predictor of mortality over the study period (FY02-FY05). Findings show that regular primary care and high levels of primary care were associated with better survival for patients with chronic illness, whether psychiatric or medical. For example, increasing use of primary care was least common among Veterans with schizophrenia only (4%) compared with Veterans with diabetes only (7%), or those with both conditions (8%), – and was associated with improved survival. This suggests that innovations in treatment retention targeting at-risk groups can offer significant promise of improving outcomes.
Date: July 26, 2009
- Treatments for Co-Occurring Schizophrenia and Substance Use Disorders
While studies to date suggest better outcomes with second-generation antipsychotics (SGAs), for example, olanzapine and risperidone, the available evidence does not clearly demonstrate an advantage for any particular SGA; thus investigators recommend that clinicians select the medication that balances efficacy and side effects for each individual patient.
Date: October 1, 2008