- 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
- Veterans at Higher Risk of Overdose/Suicide Death After Stopping Opioid Treatment; Increasing Risk with Duration on Opioids
This study examined the associations between stopping outpatient opioid treatment, length of opioid treatment, and overdose/suicide death among VA patients. Findings showed that Veterans were at a higher risk of overdose/suicide death after stopping opioid treatment, with increasing risk the longer they had been treated before stopping. Even patients treated for up to 30 days had a rise in risk of death after treatment was stopped. Factors independently associated with a higher risk for overdose/suicide death included: receiving prescriptions for long-acting or short-acting opioids compared to tramadol; maximum daily morphine milligram equivalents; number of medical diagnoses; and having a mental health disorder diagnosis or substance use disorder diagnosis. Older age, female gender, and being currently married were independently associated with a lower risk for overdose/suicide death. Risk of death from overdose or suicide was increased for 3 months after starting or stopping treatment with opioids, highlighting these vulnerable risk periods.
Date: March 4, 2020
- All-Cause Deaths and Those Due to Poisoning, Suicide, and Alcoholic Liver Disease Higher among White Veterans Ages 55-64
After years of declining mortality rates across all age groups in the United States, increasing rates in White non-Hispanic Americans ages 45–54 were reported. This study sought to determine whether White non-Hispanic middle-aged male Veterans enrolled in VA primary care experienced similar increases in all-cause and select-cause death rates as was observed in the general population. Findings showed that White non-Hispanic male Veterans ages 55-64 had a significant increase in all-cause death rates from 2003 through 2014, accompanied by increases in deaths due to suicide, poisoning, and alcoholic liver disease. Changes were not evident in the younger (45-54) Veteran age group. For White non-Hispanic males ages 55–64 who were not Veterans, all-cause mortality decreased slightly from 2003-2014. However, there were increases in death rates due to poisoning, alcoholic liver disease, and suicide. For all three race/ethnicity groups in the 55–64 age category, trends in death rates for alcoholic liver disease, poisoning, and suicide did not differ according to rural or urban location. Findings suggest the critical importance of suicide prevention programs, as well as the importance of high-quality integrated healthcare, for both Veteran and non-Veteran white men.
Date: January 31, 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
- 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
- Healthcare Processes Linked to Suicide Risk Following Discharge from VA Residential Substance Abuse
This study examined 39 root-cause analysis (RCA) reports of suicide in Veterans occurring within three months of discharge from a residential drug treatment program that were reported to any one of 140 VA medical centers between 2001 and 2017. RCA is a well-known and robust approach to elucidating the contribution of systems and organizational processes to adverse events such as suicide after hospital discharge. Findings showed that most suicides occurred in close proximity to discharge from a treatment program, with 56% occurring within seven days of discharge and 36% occurring within 48 hours of discharge. The most common method of suicide was overdose (33%), followed by hanging (28%). Categories of root causes ranged from problems with suicide risk assessment to non-engagement in treatment. The largest number of root causes of suicide pertained to problems with risk assessment, breakdowns in communication, and problems with the discharge process. This was followed by problems with treatment of mental health disorders and non-engagement with treatment during the residential stay – and after discharge. Lack of patient engagement was related to willingness to participate in treatments that might mitigate suicide risk – and to involve family or loved ones in discharge planning. Efforts to prevent suicide after discharge from a treatment program should focus on addressing suicide risk factors during admission and helping patients engage more fully in SUD treatment.
Date: June 28, 2019
- Over-Prescribing of Medication for Insomnia, Particularly among Women Veterans
Zolpidem, a non-benzodiazepine sedative hypnotic, is extensively prescribed in the U.S. for short-term treatment of insomnia. FDA recommends cutting the dose for women in half because women metabolize the same dose of zolpidem more slowly than men; VA’s national Pharmacy Benefits Management service policy is in line with FDA guidelines. This study examined prescribing patterns among all VA patients who received zolpidem from FY2012-FY2016. Findings showed that there was inappropriate prescribing of zolpidem in terms of both guideline-discordant dosage and co-prescribing with benzodiazepines, with female Veterans affected more than male Veterans. In 2016, among Veterans who were prescribed zolpidem, 30% of female Veterans received an inappropriately high guideline-discordant dosage compared to 0.1% of male Veterans. Further, more women than men had overlapping benzodiazepine and zolpidem prescriptions (19% vs. 14%). For both male and female Veterans, having a substance use disorder was associated with an inappropriate high dose. Further, mental health conditions, including anxiety and PTSD, were associated with co-prescribing of zolpidem with benzodiazepines for both male and female Veterans.
Date: March 1, 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
- Veterans More Likely than Non-Veterans to Receive Both Alcohol Screening and Brief Intervention for Alcohol Misuse
This study sought to describe receipt of alcohol screening and brief intervention across Veteran status in a sample of U.S. residents receiving healthcare. Overall, Veterans were more likely than non-Veterans to be screened for both quantity of alcohol use (69% vs. 64%) and heavy episodic drinking (36% vs. 29%). Male Veterans were less likely than male non-Veterans to endorse heavy episodic drinking (15% vs. 22%) and unhealthy alcohol use (15% vs. 19%), while female Veterans did not differ from female non-Veterans on alcohol consumption measures. Among individuals who endorsed unhealthy alcohol use, Veterans were more likely than non-Veterans to report being offered advice about alcohol’s harms (48% vs. 30%) and being advised to reduce or abstain from alcohol use (25% vs. 18%). Rates of brief intervention were low among females reporting unhealthy alcohol use: only 24% of female non-Veterans and 28% of female Veterans reported receiving advice about alcohol’s harms.
Date: December 1, 2018
- Pharmacotherapy for Opioid Use Disorder Highly Variable across VA Residential Substance Abuse Treatment Programs
Pharmacotherapy, including methadone, buprenorphine, and naltrexone, is both efficacious and cost-effective for treating opioid use disorder (OUD), however it is infrequently prescribed in VA. Investigators in this study sought to describe barriers to and facilitators of pharmacotherapy provided to a national cohort of VA patients with OUD in VA residential substance use disorder (SUD) treatment programs in FY2012. Findings showed that implementation of pharmacotherapy for OUD is highly variable across VA residential SUD treatment programs. Across all 97 treatment programs, the average rate of receipt of pharmacotherapy for OUD in FY2012 was 21% and ranged from 0% to 67%. There were 11 programs where 0% of patients received pharmacotherapy for OUD. Barriers included program or provider philosophy against pharmacotherapy and a lack of care coordination with non-residential treatment settings. Facilitators included education for staff and patients and having a prescriber on staff. Intensive educational programs, such as academic detailing, and policy changes such as mandating buprenorphine waiver training for VA providers, may help improve receipt of pharmacotherapy for OUD.
Date: November 1, 2018
- Medical Records Flag for Suicide Risk Increases VA Healthcare Visits among Veterans with Substance Use Disorder
VA has identified suicide prevention as a top priority and established policies to include high-risk suicide patient record flags (PRFs) in the electronic medical record to alert providers of patient risk and increase healthcare contacts. This study sought to identify predictors of new PRFs and to describe healthcare use before and after PRF initiation among VA patients who had received a substance use disorder (SUD) diagnosis. Findings showed that consistent with VA policy, 62% of Veterans with new suicide risk flags attended the recommended number of visits in months 1 to 3, with an additional 14% meeting recommended targets in month 1 only. Further, outpatient contacts in mental health and substance use disorder clinics increased 2 and 4 times, respectively, over the three-month follow-up period, with mean contacts in these services exceeding the minimum required one contact per week in month one. ED visits decreased by 45% in the three months following initiation of a PRF. Demographic predictors of PRF initiation included being younger than 35, White, and homeless. Clinical predictors were cocaine, opioid and sedative use disorders, PTSD, psychotic, bipolar, and depressive disorders, and suicide-attempt diagnoses. Suicide risk PRFs in an electronic medical record and subsequent follow-up increased service use for those Veterans with flags initiated.
Date: June 8, 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
- No Decrease in Drinking among Veterans despite Alcohol-Related Nurse Care Management Intervention in Primary Care
The Choosing Healthier Drinking Options in Primary Care (CHOICE) intervention was designed to improve drinking outcomes by engaging Veterans at high risk for alcohol use disorders (AUDs) in patient-centered, alcohol-related care. Investigators in this study examined whether 12 months of alcohol care management via the CHOICE intervention – compared with usual primary care – improved drinking outcomes (abstinence was not a required goal). Findings showed that the CHOICE intervention did not decrease heavy drinking or alcohol-related problems at 12 months even though more Veterans engaged in alcohol-related care, including a four-fold increase in initiation of medications for alcohol use disorders. Primary outcomes improved at 12 months but did not differ between groups. The mean percentage of heavy drinking days decreased from 61% at baseline to 39% and 35% in the intervention and usual care groups, respectively. The percentage of Veterans with good drinking outcomes was 15% and 20% in the intervention and usual care groups, respectively. Current quality measures for AUDs are based on the assumption that engagement in alcohol-related care emphasizing brief intervention and reduced drinking is sufficient to improve outcomes. This trial’s results, in addition to existing literature, suggest that more intensive measures, such as recommending abstinence (vs. reduction in drinking), engaging most patients in use of naltrexone, and/or offering effective behavioral treatment might be needed for alcohol care programs in primary care to be more effective.
Date: May 1, 2018
- Women Veterans Who Experienced Past-Year Intimate Partner Violence Significantly More Susceptible to Housing Instability
This study used VA clinical screening data to assess the relationship between recent experience of intimate partner violence (IPV) and housing instability among women Veterans. Findings showed that female Veteran patients who screened positive for past-year IPV had up to four times the odds of experiencing housing instability. Women Veterans who screened positive for past-year IPV were significantly more likely to have an indicator of housing instability if they identified as Black or African American, previously screened positive for military sexual trauma, had a mental health diagnosis, or a substance use disorder. Women Veterans receiving compensation for a disability incurred during military service – and those who were married – were significantly less likely to have an indicator of housing instability. IPV interventions should assess for both physical and psychological housing needs, and housing interventions should coordinate with IPV programs to address common barriers to resources.
Date: April 1, 2018
- Then and Now: Medications for Opioid Use Disorder in VA
As the largest provider of substance use disorder treatment in the nation, VA has taken proactive steps to increase access to medications indicated for opioid use disorder (OUD), which is an essential component of evidence-based care. This article examines the history of those medications (methadone, buprenorphine, and injectable naltrexone) within VA, as well as early and ongoing efforts to increase access to and build capacity for the treatment of OUD, which included adding buprenorphine to the VA formulary in 2006, educational and quality improvement initiatives, targeted resources, national policy, and “big data” initiatives. This article also summarizes research on barriers and facilitators to prescribing and medication receipt.
Date: March 29, 2018
- Medical Record Alert Associated with Reduced Opioid and Benzodiazepine Co-prescribing
This implementation project evaluated the effectiveness of an advanced medication alert designed to reduce opioid and benzodiazepine co-prescribing among Veterans with high-risk conditions (substance use disorder, sleep apnea, suicide risk, and age =65) at one VA healthcare system (VA Puget Sound). Findings showed that the proportions of patients with concurrent prescriptions decreased significantly post-alert launch among Veterans with substance use (25%), sleep apnea (39%), and suicide risk (62%), with greater decreases at the alert site relative to the comparison site in sleep apnea and suicide-risk cohorts. Significant decreases in benzodiazepine prescribing were observed at the alert site only.
Date: December 28, 2017
- Higher Risk of Suicidal Ideation and Suicidal Self-Directed Violence following Discontinuation of Long-term Opioid Therapy
The primary objective of this study was to identify predictors of suicidal ideation (SI) and non-fatal suicidal self-directed violence (SSV) following clinician-initiated discontinuation of long-term opioid therapy. Findings showed that a substantial proportion of Veterans with substance use disorder diagnoses and similar matched patients experienced suicidal ideation or suicidal self-directed violence following discontinuation of long-term opioid therapy by their opioid-prescribing clinicians, most of whom represent new onset cases. Approximately 12% of patients in this sample had SSV and/or SI documented in the medical record in the 12 months following discontinuation of opioid therapy: 47 patients had SI only, while 12 had SSV. Half of patients with SSV attempted suicide by overdose, most commonly with benzodiazepines. Mental health diagnoses associated with having SI/SSV included PTSD and psychotic disorders. The majority of patients (75%) were discontinued from opioid therapy due to aberrant behaviors. Healthcare providers should pay special attention to safety when patients are discontinued from long-term opioid therapy, particularly patients with PTSD or psychotic disorders.
Date: July 1, 2017
- Discontinuation of Long-Term Opioid Therapy among Veterans is Overwhelmingly Initiated by VA Clinicians
The aim of this study was to compare reasons for discontinuation of long-term opioid therapy (LTOT) between Veterans with and without substance use disorder (SUD) receiving care within the VA healthcare system in the years following release of 2009 and 2010 clinical practice guidelines. Findings showed that the majority of Veterans (85%) discontinued opioid use because their clinician stopped prescribing, rather than the patients deciding to stop. For patients whose clinicians initiated discontinuation, 75% were discontinued due to opioid-related aberrant behaviors (i.e., suspected substance abuse, aberrant urine drug test). Veterans with SUD diagnoses were more likely to discontinue LTOT due to aberrant behaviors, particularly abuse of alcohol or other substances, compared to Veterans without SUD. High proportions of patients received diagnoses for mental health disorders in the year prior to discontinuation of LTOT, including PTSD, anxiety disorders other than PTSD, and depressive disorders (25%). Increasing rates of opioid discontinuation are likely to occur due to policies and programs that encourage close monitoring of Veterans on LTOT for opioid misuse behaviors. Integrating non-opioid pain therapies and SUD treatment into multiple settings such as primary care and specialty SUD care is one possible approach to enhance their care.
Date: March 1, 2017
- Safety Risk for Veterans Receiving Overlapping Buprenorphine, Opioid, and Benzodiazepine Prescriptions from VA and Medicare Part D
Ensuring safe buprenorphine prescribing is especially challenging for VA, which treats a substantial number of Veterans with chronic pain and opioid use disorder, as well as an increasing number of patients who receive concurrent care in the private sector (i.e., Medicare Part D). This study identified Veterans dually enrolled in VA and Medicare Part D who filled a buprenorphine prescription in 2012 from either healthcare system and identified the proportion of Veterans with overlapping prescriptions from either system. Findings showed that more than one in four Veterans who received a VA prescription for buprenorphine – and one in five Veterans who received a Medicare prescription for buprenorphine – also received overlapping prescriptions for opioids from a different healthcare system. Among Veterans receiving buprenorphine from VA, 1% received an overlapping benzodiazepine prescription from Medicare, while among those receiving buprenorphine from Medicare, 16% received an overlapping benzodiazepine prescription from VA. Among VA and Part D buprenorphine recipients who had cross-system opioid overlap, 25% and 35%, respectively, had >90 days of overlap. Findings indicate a previously undocumented safety risk for Veterans dually enrolled in VA and Medicare who are receiving prescriptions for buprenorphine and overlapping prescriptions for opioids and/or benzodiazepines.
Date: December 7, 2016
- OEF/OIF/OND Veterans that Currently Smoke More Likely to Receive Opioid Prescription than Non-Smokers
This study sought to determine if smoking status is associated with the receipt of opioids among OEF/OIF/OND Veterans – and to examine important covariates of smoking (i.e., current pain intensity, gender, and mental health diagnoses) and receipt of opioids. Findings showed that compared to non-smokers, OEF/OIF/OND Veterans who were current smokers were more likely to receive an opioid prescription, even after controlling for covariates including: pain intensity, age, gender, service-connection, substance use disorder, mood disorders, and anxiety disorders. Veterans who reported a higher current pain intensity and those with pain diagnoses also were more likely to receive an opioid prescription. Among this young cohort of Veterans (mean age=30 years), more than one-third (34%) reported moderate to severe current pain intensity within +/-30 days of smoking status, with approximately 8% receiving at least one opioid prescription.
Date: September 21, 2016
- Racial and Ethnic Differences in Primary Care Experiences for Veterans with Mental Health and Substance Use Disorders
This study examined racial and ethnic differences in positive and negative experiences in VA Patient-Centered Medical Home (PCMH) settings among Veterans with mental health or substance use disorders (MHSUDs) who completed VA’s 2013 PCMH Survey of Healthcare Experiences of Patients. Findings showed that positive experiences were reported least often for access. Negative experiences were reported most often for self-management support and comprehensiveness, defined as provider attention to MHSUD concerns. One or more racial/ethnic minority groups reported more negative and/or fewer positive experiences than Whites in the following 4 domains: access, communication, office staff helpfulness/courtesy, and comprehensiveness. Solutions are needed to improve access to care for all Veterans with MHSUDs, with additional attention on improving access for Black, Hispanic, and AI/AN Veterans.
Date: June 20, 2016
- Military Sexual Trauma is Independent Risk Factor for Homelessness among Veterans, Particularly Male Veterans
This study examined the relationship between military sexual trauma (MST) and post-deployment homelessness among a large cohort of OEF/OIF Veterans, including whether the relationship varied by sex, and whether MST was a predictor of homelessness independent of other risk factors (i.e., mental health and/or substance use disorders). Findings showed that a positive MST screen was independently related to post-deployment homelessness. In unadjusted models, Veterans with a positive screen had odds for homelessness that were approximately double those who screened negative. Moreover, findings in the 30-day and 1-year follow-up cohorts suggested a greater risk for homelessness among men with a history of MST than among women. After adjusting for mental health and substance use diagnoses, MST screening status remained a significant predictor of homelessness, with Veterans who had a positive MST screen having approximately 1.5 times greater odds for homelessness than those who screened negative. Findings of greater risk among men also remained. Among Veterans with a positive MST screen, the incidence of homelessness was 2% within 30 days, 4% within one year, and 10% within five years. The stronger risk conferred by MST for homelessness among men suggests that men with a positive MST screen are a particularly vulnerable group.
Date: June 1, 2016
- The Gerontologist Supplement Highlights VA Research on Health Issues Affecting Older Women Veterans
This Supplement includes 13 articles that highlight findings on a range of topics related to women Veterans and aging, such as, menopause, diabetes, cardiovascular disease, chronic pain, and substance use.
Date: February 1, 2016
- Veterans Exiting Prison Have Extensive Treatment Needs, Particularly for Mental Health and Substance Use Issues
This study determined incarcerated Veterans’ contact with VA healthcare in the year after a Health Care for Reentry Veterans (HCRV) visit (prior to release from prison), the prevalence of mental health and substance use disorder (SUD) diagnoses, and rates of mental health or SUD treatment entry and engagement in the first month after diagnosis. Findings showed that of the Veterans with an HCRV outreach visit, 56% had contact with VA healthcare within one year, including primary care, mental health or SUD treatment, or other VA services. Among Veterans with an HCRV outreach visit who had contact with VA healthcare, 69% were diagnosed with at least one mental health or substance use disorder, and 35% were diagnosed with co-occurring mental health and substance use disorders. The three most common disorders were depressive disorders, alcohol use disorder, and PTSD. Of Veterans diagnosed with a mental health disorder, 77% entered mental health treatment in the first month after diagnosis and 28% engaged in treatment. At one year after diagnosis, 93% of Veterans had entered and 52% had engaged in mental health treatment. Of those Veterans diagnosed with a SUD, 37% entered and 24% engaged in SUD treatment in the first month, while 57% had entered and 39% engaged in treatment at one year following diagnosis.
Date: December 21, 2015
- 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
- Data from Electronic Health Records Can Predict and Possibly Prevent Missed Patient Appointments
This study sought to develop a model that identifies patients at high risk for missing scheduled appointments (no-shows and cancellations), and to project the impact of predictive over-booking in a gastrointestinal (GI) endoscopy clinic – a resource-intensive environment with a high no-show rate. Findings showed that information from electronic health records can accurately predict whether patients will no-show. The model used in this study was able to correctly classify 711 out of 888 attended appointments, and 317 out of 538 missed appointments. The strongest predictor of no-show was a patient’s cancellation history – the proportion of all outpatient appointments missed. Veterans with histories of mood or substance use disorder, and those with a greater overall disease burden also were less likely to keep appointments. Predictors of being more likely to keep appointments included: being married, having a history of diverticular disease, attending a colonoscopy education class, and having care partly funded by VA. Urgency of appointment, race, ethnicity, and day of the week of appointment were not significant predictors of appointment no-shows. Compared to a strategy that employs a fixed level of overbooking, predictive over-booking was much less likely to lead to days where the clinic was substantially over- or under-booked.
Date: December 1, 2015
- Factors Contributing to Insensitive Clinical Alcohol Screening in VA Primary Care
This study sought to understand factors that might contribute to low sensitivity of alcohol screening. Findings showed that most observed screening was done verbally; lesser used methods included paper-based or laminate-based screening. During verbal screening, questions were often not asked verbatim and were otherwise adapted. Other verbal screening practices that might contribute to low sensitivity of clinical screening included making inferences, assumptions, and/or suggestions to input responses. Clinical staff introduced and adapted screening questions to enhance the comfort of Veterans. For example, using introductory statements such as, “I have several questions to ask you that we ask of all Veterans every year – so we are not just singling you out.” Non-verbal approaches to screening – or patient self-administration – might enhance validity and standardization of screening, while also addressing limitations of the clinical reminder and issues related to perceived discomfort.
Date: August 1, 2015
- Individual and Facility-Level Factors Associated with Higher Risk of Suicide Attempt among Veterans Receiving Opioid Therapy
This study examined the associations between the receipt of guideline-recommended care for opioid therapy and risk of suicide-related events, assessing associations between individual-level and facility-level delivery of recommended care, and individual-level suicide-related events. Findings showed that within 180 days following opioid prescription, 1.6% of the study population on chronic short-acting opioids and 2.1% of the study population on long-acting opioids experienced suicide-related events. At the individual level, Veterans who received opioid therapy and had medical frailty, drug, alcohol, or mood disorder, and/or traumatic brain injury had a higher risk of suicide-related events. Patients on opioid therapy within VA facilities that ordered more drug screens were associated with a decreased risk of suicide-related events. Patients on long-acting opioid therapy within facilities that provided more follow-up after new prescriptions also were associated with decreased risk of suicide-related events. Patients on long-acting opioid therapy within facilities having higher sedative co-prescription rates had an increased risk of suicide -related events. Among the sub-population of patients with a substance use disorder and a short-acting opioid prescription, the facility rate use of specialty substance use disorder treatment was associated with lower risk of suicide-related events. Encouraging facilities to make more consistent use of drug screening, providing follow-up within four weeks for patients initiating new opioid prescriptions, avoiding sedative co-prescription in combination with long-acting opioids, and engaging patients with substance use disorders in specialty substance use treatment, may help prevent suicide-related events.
Date: July 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
- Prevalence of Alcohol Misuse among Women Veterans High Regardless of Care Setting
This study sought to estimate the prevalence and correlates of alcohol misuse in women Veterans – and to assess the associations between alcohol misuse and mental health use in a group comprising both VA healthcare system users and non-users. Findings showed that women Veterans who did not use VA healthcare had a higher prevalence of alcohol misuse (32%) compared to women Veterans who did use VA healthcare (27%). The prevalence of binge drinking was similar for VA non-users (26%) and VA users (24%). The prevalence of past-year mental healthcare among women Veterans with alcohol misuse was higher for VA users than for non-users: 26% versus 5% for mild alcohol misuse, and 43% versus 17% for moderate-to-severe alcohol misuse. Among VA non-users, 46% of women Veterans with PTSD and 66% of those with sexual assault in the military screened positive for alcohol misuse. Among VA healthcare users, the prevalence of alcohol misuse was notably high among younger women (ages 18-44, 43%), those who served in OEF/OIF (51%), and those with combat exposure (41%).
Date: May 1, 2015
- NEJM Perspective Discusses Withholding of CMS Data Related to Substance Use Disorder and Its Impact on Research
In November 2013, the Centers for Medicare and Medicaid Services (CMS) began to withhold from research data sets any Medicare or Medicaid claim with a substance use disorder (SUD) diagnosis or related procedure code. This move — the result of privacy-protection regulations overseen by the Substance Abuse and Mental Health Services Administration — affects about 4.5% of inpatient Medicare claims [recent research suggests this figure is closer to 7%] and about 8% of inpatient Medicaid claims from key research files, impeding a wide range of research evaluating policies and practices intended to improve care for patients with substance use disorders. As a consequence, VA researchers cannot see the full utilization of Veterans who also use Medicare- or Medicaid-financed healthcare. This Perspective summarizes the problem, quantifies it, describes how it arose, and argues that research access to such data should be restored.
Date: April 15, 2015
- VA Maintains Access to Care as Need for Substance Use Treatment Grows
VA has enhanced funding of mental health programs and substance use disorder (SUD)-specific treatment and also has directed approximately $152 million toward hiring additional SUD staff. This study examined the relationship between dedicated SUD funding and SUD performance measures from 2005 and 2010 for VA medical centers. Findings showed that, overall, access and quality of care kept pace with the demand for SUD services in the VA healthcare system. There was a statistically significant and generally positive correlation between additional, dedicated SUD resources and access and treatment intensity. The number of VA patients with an SUD diagnosis grew from about 310,000 in 2005 to 439,000 in 2010 – an increase of 42%. Average dedicated SUD funding per facility grew from $65,870 in 2005 to $324,416 in 2007, falling to $147,151 in 2009 and 2010. However, not all VAMCs received funding in each year.
Date: March 12, 2015
- 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
- No Significant Association between Public Support Income, VA Disability Compensation, and Money Spent on Alcohol and Drugs among Homeless Veterans
This study describes the amount of money homeless Veterans report spending on alcohol and drugs, and examines the association between public support dollars received – and VA disability compensation in particular – and dollars spent on alcohol and drugs. Findings showed that about one-third of homeless Veterans reported spending money on alcohol and about one-fifth reported spending money on drugs in the past month. However, no positive association was found between public support income and money spent on alcohol or drugs, and there was no association found between VA disability compensation and substance use. This suggests that the amount of income homeless Veterans received from disability and other public support sources did not influence their amount of substance use. Employment income was positively associated with days of alcohol use and money spent on alcohol, as well as with money spent on drugs. Other sources of income (e.g., family and friends, panhandling) were also positively associated with alcohol use and money spent on alcohol along with drug use and money spent on drugs. In contrast, public support income was negatively associated with alcohol use and money spent on alcohol.
Date: March 1, 2015
- Veterans Receiving Brief Alcohol Misuse Intervention Rate VA Providers and Care Higher than Veterans without Intervention
This study assessed the relationship between receipt of brief alcohol intervention and patient-reported indicators of care quality. Findings showed that among Veterans who screened positive for unhealthy alcohol use, a higher proportion who reported receipt of a brief alcohol intervention, compared to those who did not, rated their provider (87% vs. 82%) and VA healthcare (83% vs. 76%) as high quality. Sixty-one percent of Veterans in this study screened positive for mild unhealthy alcohol use, and 21%, 11%, and 8% screened positive for moderate, severe, and very severe unhealthy alcohol use, respectively. Of drinkers reporting unhealthy alcohol use, 44% of Veterans reported receipt of a brief intervention for unhealthy alcohol use in the previous year. Overall, 84% and 79% of Veterans rated their provider and VA healthcare as high quality, respectively. Thus, although the literature suggests providers may be concerned that discussions of unhealthy alcohol use may negatively impact relationships with their patients, study findings do not support concerns that delivering alcohol-related advice adversely affects patients’ perceptions of care.
Date: February 18, 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
- 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
- Predictors of Worsening Mental Health among OEF/OIF Veterans
This study sought to identify predictors of worsening mental health, including PTSD and alcohol use, as well as variables that are protective (resilience factors) against worsening mental health in a national sample of OEF/OIF Veterans. Findings showed that 14–25% of these returning OEF/OIF military personnel showed clinically worse mental health, PTSD, or alcohol use at 6-month follow-up. Eleven variables were significantly associated with a decline in overall mental health status from Time 1 to Time 2: Black race, being in the National Guard, more bothersome physical health problems, worse mental health at Time 1, less PTSD symptom severity, lack of psychiatric care between Time 1 and Time 2, more difficult deployment environment, less perceived threat, less sexual harassment, higher levels of hardiness, and lower levels of self-efficacy. Nine variables predicted a worsening of PTSD symptom severity: being younger than 26 years old, unemployed, divorced or separated, higher PTSD symptom severity at Time 1, lack of any psychiatric treatment between Time 1 and Time 2, difficult childhood family environment, greater sexual harassment in one’s unit, lower levels of deployment preparedness, and higher levels of post-deployment social support. Fourteen variables predicted worsening alcohol use, including being male, under 26 years old, less educated, Hispanic, separated or divorced, and being in the National Guard or Marines. National Guard and other Reserve soldiers worsened on both the general mental health and alcohol use measures from Time 1 to Time 2 compared to active duty soldiers, suggesting that these groups may require help with reintegration. Higher education, self-efficacy, unit support, and deployment preparedness had a protective effect on both worsening PTSD and alcohol use.
Date: October 1, 2014
- Affordable Care Act May Impact Continuity of Care for Homeless VA Healthcare Users
This study compared Veterans who are likely eligible for the Medicaid expansion (LEME) and those who are not LEME, stratified by homeless status. Findings showed that among all VA healthcare users under the age of 65, homeless Veterans were two times more likely to be LEME than non-homeless Veterans (64% vs. 30%). Regardless of housing status, Veterans who were LEME were physically healthier than those not LEME. However, Veterans who were LEME were more likely to have substance use disorders and PTSD. Among homeless VA healthcare users, those who were LEME were less than half as likely to be married, to be an OEF/OIF/OND Veteran, and had less than one-third the income of Veterans who were not LEME. Among non-homeless VA healthcare users, those who were LEME were younger and more likely to be OEF/OIF/OND Veterans. Cross-sytem use of VA and Medicaid-funded services may be advantageous for Veterans with extensive medical and psychiatric needs, but also risks fragmented care. Information and education for VA clinicians and patients about possible implications of the Affordable Care Act may be important.
Date: September 1, 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
- 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
- Strong Association between Substance Abuse and Homelessness among Veterans
This study examined the prevalence of alcohol and drug use disorders among homeless Veterans entering the HUD-VASH program, and its association with both housing and clinical outcomes. Findings showed that there was a strong association between substance abuse and homelessness, particularly in Veterans with comorbid alcohol and drug use disorders. The majority (60%) of homeless Veterans admitted to the HUD-VASH program had a substance use disorder (SUD), and the majority (54%) of those had both an alcohol and drug use disorder. In the first 6 months after entering the HUD-VASH program, significant improvements were observed in both housing and clinical outcomes, with no significant differences between Veterans with and without substance use disorders on housing outcomes. However, Veterans with any substance use disorder showed improvement at a slower rate than those with no SUD.
These findings suggest that despite strong associations between SUD and homelessness, the HUD-VASH program is able to successfully house homeless Veterans with SUD, although additional services may be needed to address their substance abuse after they become housed.
Before entering supported housing, homeless Veterans with comborbid alcohol and drug use disorders had more extensive histories of being homeless than Veterans with only alcohol or only drug use disorders, while those with no SUD had the least extensive homeless histories.
Compared to other homeless Veterans, those with both alcohol and drug use disorders were most likely to have comorbid psychotic or mood disorders. Homeless Veterans with both alcohol and drug use disorders or only a drug use disorder were more likely to also have PTSD.
Date: February 1, 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
- 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
- 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
- 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
- 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
- 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
- Substance Use Disorders Significantly Increase the Risk of All-Cause Mortality among Veterans with PTSD
This study sought to estimate the predictive association between substance use disorders (SUDs) and the risk of mortality among a cohort of Veterans with PTSD. Findings showed that having a substance use disorder significantly increased the risk of all-cause mortality among Veterans with PTSD. The association between SUDs and non-injury-related mortality was most pronounced in the youngest age group (<45 years), which included OEF/OIF Veterans, compared with the 45-64 or >65 group. Regardless of age group, SUD was a strong predictor of injury-related mortality. It was a significantly stronger predictor of injury-related vs. non-injury related death among Veterans in the 45-64 years and >65 years age groups. However, it is important to note that injury-related mortality accounted for a relatively small proportion of all deaths (~10%) among Veterans with PTSD.
Date: September 10, 2012
- Cannabis Use Disorder Diagnoses in the VA Healthcare System Double Over the Past Seven Years
The prevalence of cannabis use disorder (CUD) diagnoses overall within VA has increased nearly 60% (from 0.66% to 1.05%) over the past 7 years, with the prevalence of CUD diagnoses among those without other illicit substance use disorders (SUD) having risen 115% (from 0.27% to 0.58%) during the same time period. Rates of other substance use disorder diagnoses within VA (i.e., alcohol-only and other-drug disorder) increased to a much smaller degree. Although rates of CUD diagnosis within VA have increased dramatically, they remain significantly lower than rates of CUD observed in the U.S. population. States with laws allowing for the legal use of cannabis for medicinal purposes had significantly higher rates of CUD diagnoses within VA in 2002, 2008, and 2009. Rates of psychiatric diagnoses, and PTSD specifically, were higher among patients with a CUD diagnosis but no other illicit SUD, as compared to other SUD groups. Rates of specialty SUD treatment utilization among those with a CUD diagnosis but no other illicit SUD have decreased within VA.
Date: May 7, 2012
- Association between Alcohol Screening Scores and Alcohol-Related Risks among Women Veterans
Among the women Veterans in this study, 24% screened positive for alcohol misuse. Many of these women reported symptoms of alcohol misuse that would not be identified by VA’s current required alcohol screening program because of their lower AUDIT-C scores. Increasing scores on the AUDIT-C reflected increasing prevalence of self-reported alcohol-related risks and consequences. For three out of the five alcohol-related consequences (i.e., tolerance of alcohol, blackouts, feeling the need to cut down on drinking), adjusted prevalence increased at AUDIT-C scores >3. The remaining alcohol-related consequences (i.e., morning drinking, family/friends worried) increased at scores >4, as did self-reported problem drinking and drug use. Associations between health risks (i.e., >2 sexual partners, sexually transmitted diseases, injuries, domestic violence, hepatitis/cirrhosis) and AUDIT-C scores were less consistent, but prevalence generally increased at scores >5.
Date: May 1, 2012
- Integration of Primary Care and Mental Health Improves both Mental and Medical Care Utilization for OEF/OIF Veterans
There was a significant association between VA’s Primary Care-Mental Health Integration (PC-MHI) program and OEF/OIF Veterans’ receipt of short- or long-term mental or medical care. Of the 181 Veterans who participated in the PC-MHI program, 60% sought mental health care within one month after their initial encounter in PC-MHI, and 82% after one year, while 18% sought medical care within one month, and 74% within one year. The average length of time to a subsequent specialty mental health care visit after the Veterans’ first PC-MHI encounter was about 5 months. The average length of time to a subsequent medical care visit after the first PC-MHI encounter was about 10 months. While PTSD was the primary condition associated with OEF/OIF Veterans remaining in VA care for mental health care, retention in long-term medical care was not associated with mental health disorders measured in this study (PTSD, substance use disorder, major depressive disorder, and anxiety/phobia).
Date: April 30, 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
- Importance of Pre-Operative Alcohol Screening
Among the Veterans in this study, 16% of men and 5% of women screened positive for alcohol misuse at levels associated with increased post-operative complications in the year before surgery. A majority of male and female surgical patients with alcohol misuse were relatively healthy and did not have diagnoses or chronic conditions commonly associated with alcohol misuse that might alert providers to their alcohol misuse. This finding highlights the value of routine pre-operative alcohol screening to proactively identify Veterans who misuse alcohol and to potentially implement interventions before surgery. Screening positive for alcohol misuse (AUDIT-C >5) was more common among men who were: younger than 60 years old, divorced or separated, current smokers, or ASA class 1-2 (pre-operative assessment by anesthesiologist as healthy patient or patient with mild systemic disease), and among men with cirrhosis, hepatitis, or substance use disorders.
Date: April 11, 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
- 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
- Treating Comorbid Substance Use Disorder and PTSD
This trial sought to determine whether male Veterans with a substance use disorder (SUD) and co-occurring PTSD symptoms in a VA outpatient SUD clinic would benefit from a specialized treatment program for these comorbid disorders. Findings show that Seeking Safety, a manualized treatment approach for substance use disorder, was well received and associated with better drug use outcomes than treatment as usual (TAU) in male Veterans with PTSD. Compared to TAU, Seeking Safety also was associated with increased treatment attendance, client satisfaction, and active coping through treatment. Although these factors may be beneficial for promoting recovery more broadly, neither they – nor reduction in PTSD severity that occurred during treatment – accounted for reductions in drug use among Veterans during the study.
Date: September 16, 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
- Male Veterans Reporting Sexual Assault are More Likely to Engage in Unsafe Drinking than Veterans with No History of Sexual Assault
This study explored the rates of sexual assault in male Veterans reporting alcohol misuse – and the potential differences in alcohol use patterns and alcohol-related characteristics in those with and without a history of sexual assault. Findings showed that male Veterans reporting sexual assault are more likely to engage in increased alcohol consumption, experience more lifetime alcohol-related consequences, and have more risk factors for unsafe drinking when compared with their peers who have no history of sexual assault. In addition, the odds of using any illicit substance in the last 90 days were three times higher in the sexual assault group. There also was a two-to-four times greater likelihood of almost all risk factors for unsafe drinking in the sexual assault group. Authors note that SUD treatment settings may be a context in which a history of sexual assault is high and that it may interact with core indicators of treatment success (e.g., psychiatric and physical comorbidities). Therefore, universal sexual assault screening, like the approach in VA, may be relevant for men presenting to SUD treatment settings.
Date: September 1, 2011
- Differences in Communication between Providers in VA Mental Health Clinics and General Medical Providers in Treating Veterans with Serious Mental Illness
Integrated care for co-occurring substance use and general medical disorders is considered essential for improving quality of care for individuals with serious mental illness (SMI), and is one of VA’s priority goals. This study sought to describe the barriers and facilitators of integrated care (from the perspective of mental health providers) for nearly 20,000 Veterans with SMI. Findings show that mental health providers from VA mental health clinics with high versus low quality of care scores differed in their ability to communicate with general medical providers regarding care for Veterans with SMI. Among mental health providers from low-performing sites, lack of communication with primary care providers was a key barrier. Barriers to communication included lack of opportunities to interact on a face-to-face basis and lack of opportunities to have team meetings. In addition, they were concerned that primary care providers did not want to see patients with SMI because of the perception that they were difficult to treat. Stigma was not mentioned as a problem for providers among the high-performing sites, with general medical providers viewed as sensitive to the needs of Veterans with SMI. The authors suggest that these findings indicate that efforts to improve communication between mental health and primary care providers, as well as delineating roles and responsibilities across both types of providers may potentially facilitate integrated medical care for Veterans with serious mental illness.
Date: July 7, 2011
- Racial and Ethnic Differences in Blood Pressure Control among Veterans with Type 2 Diabetes
This study examined racial/ethnic differences in blood pressure control among Veterans with type 2 diabetes and uncontrolled BP at baseline. Findings showed that the adjusted proportion of Veterans with uncontrolled BP (>=140/90 mmHg) decreased in all groups over the study period. However, ethnic minority Veterans had significantly increased odds of poor BP control over a mean follow-up of 5 years compared to non-Hispanic White Veterans, independent of socio-demographic factors and comorbidity patterns. Compared to non-Hispanic Whites (45%), 54% of non-Hispanic Black Veterans, 48% of Hispanic Veterans, and 49% of Veterans with unknown race had poor blood pressure control. In using a more stringent BP cutoff (>=130/80 mmHg) to define poor BP control, 74% of non-Hispanic White Veterans had poor blood pressure control over the 5 years compared to 82% of non-Hispanic Black Veterans, 75% of Hispanic Veterans, and 79% of Veterans with unknown race/ethnicity. The presence of a hypertension diagnosis at the time of study entry appears to be associated with higher odds of achieving BP control over time. Among other comorbidities, cancer, coronary heart disease, congestive heart failure, and substance use disorders were all associated with increased odds of good BP control over time.
Date: June 14, 2011
- Journal Section Focuses on Implementing Evidence-Based Interventions for Substance Use Disorders
This article introduces a special section of Psychology of Addictive Behaviors, which provides an overview of conceptual frameworks for and research on the implementation of evidence-based practices and treatments for substance use disorders (SUDs). The types of treatments that are examined range from brief interventions to psychological treatments and continuing care to pharmacological treatment. The settings in which treatments are implemented range from primary care to specialty SUD care settings.
Date: June 1, 2011
- Women Veterans with History of Sexual Abuse at Higher Risk for Substance Use Disorder
This study examined the associations between rape history and substance use disorders among women Veterans (age <51 years) who received care at two Midwestern VAMCs. Findings showed that lifetime substance abuse disorder was higher for women Veterans with a history of rape. Two-thirds (62%) of study participants reported lifetime sexual assault, including 11% reporting attempted rape and 51% reporting at least one completed rape. Women with women as sex partners had significantly higher rates of rape and lifetime substance use disorder (73% of women with women as sex partners reported lifetime rape vs. 48% of exclusively heterosexual women). Women with lifetime rape were more likely to report abstinence from drinking (50%) than women with no rape (41%). Women reported the highest rates of rape during childhood and military service (51% and 25%, respectively), and those reporting rape in any period of their lives were significantly more likely to report rape in other periods. For example, women Veterans reporting in-military rape were significantly more likely to report post-military rape (18% vs. 9%).
Date: June 1, 2011
- Veterans Reporting a History of Military Sexual Trauma are Treated in a Variety of VA Outpatient Mental Health Settings
This study sought to determine the VA mental health outpatient settings in which patients with military sexual trauma (MST) are most likely to be treated, which might help set priorities for targeted MST-related education and training. Findings showed that more than one-third of female Veterans (36%) and 2% of male Veterans seen in VA outpatient mental healthcare settings during FY08 reported a history of military sexual trauma. Both women and men with MST were more likely to use more than one type of mental health clinic setting, compared to those without MST. A significantly larger proportion of women seen in MST specialty clinics reported MST as compared to all other settings (81% vs. 34%). However, there was a wide range of clinic visit settings for female Veterans with MST, including: MST specialty clinics, PTSD specialty clinics, psychosocial rehabilitation, and substance use disorder clinics. Male Veterans represented a small proportion of patients seen in all clinics, and a larger proportion of men seen in MST specialty clinics reported MST as compared to other settings (56% vs. 2%). These findings indicate that mental health providers who treat women Veterans, even if they work in settings that do not traditionally incorporate interventions focused on traumatic stress, may encounter issues related to MST. Therefore the authors suggest that training in how to respond to sexual trauma disclosure be an important component in all VA mental healthcare settings.
Date: May 1, 2011
- Veterans Receiving Higher-Dose Opioid Prescriptions for Pain at Increased Risk of Death from Overdose
This study examined the association of maximum prescribed daily opioid dose and dosing schedule (“as needed,” regularly scheduled, or both) with risk of opioid overdose death among Veterans with cancer, chronic pain, acute pain, and substance use disorders. Findings showed that among Veterans receiving opioid prescriptions for pain, higher opioid doses were associated with increased risk of death from opioid overdose. The frequency of fatal overdose among Veterans treated with opioids was rare – estimated to be 0.04% - and was directly related to the maximum prescribed daily dose of opioid medication. There was no significant increased risk of opioid overdose among Veterans who were treated with both “as-needed” and regularly scheduled opioids – a strategy for treating pain exacerbations – after adjusting for maximum daily dose and patient characteristics. Veterans who died from opioid overdose were significantly more likely to have chronic or acute pain, substance use disorders, and other psychiatric disorders, but they were less likely to have cancer. This study highlights the importance of implementing strategies for reducing opioid overdose among patients being treated for pain, for example, ascertaining history of substance abuse, using treatment contracts, and scheduling frequent follow-up visits and toxicological screens for patients at special risk.
Date: April 6, 2011
- Rates of Accidental Poisoning among VA Patients Higher than General Population
This study describes the rate of accidental poisoning mortality among Veterans who used VA healthcare services, compares this rate to the general U.S. population, and describes the drugs/medications involved. Findings show that for FY05, VA patients had nearly twice the rate of fatal accidental poisoning compared to adults in the general population. Among VA patients who died from accidental poisoning, opioid medications (including methadone) made up 32% of the reported deaths; cocaine also was common at 23%. In both the VA and U.S. general populations, the rate of accidental poisoning mortality was higher for men than women, and higher for individuals ages 30 to 64 as compared to those ages 18 to 29, or ages 65 and older. Although VA patients have a greater risk of suicide than death by accidental poisoning, their risk for accidental poisoning death relative to the general population is larger than that of suicide.
Date: April 1, 2011
- Complications Following Total Joint Arthroplasty Significantly Related to Pre-Operative Alcohol Misuse among Veterans
This study evaluated the association between a standardized, pre-operative alcohol screening score (AUDIT-C [Alcohol Use Disorders Identification Test – Consumption]) and the risk of post-operative complications in Veterans who underwent total joint arthroplasty at one VA facility between 2004 and 2007. Findings show that complications following total joint arthroplasty were significantly related to alcohol misuse. Of the 185 Veterans in this study, 32 had alcohol screening scores suggestive of alcohol misuse, and 12 Veterans had at least one post-operative complication. Therefore, AUDIT-C scores signified a 29% increase in the expected mean number of complications with every additional AUDIT-C point above 1. The authors suggest that pre-operative alcohol misuse screening, and perhaps pre-operative counseling or referral to treatment for heavy drinkers, may be indicated for patients undergoing total joint arthroplasty.
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
- 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
- VA’s Brief Alcohol Intervention Strategy Successful
This study evaluated the prevalence of documented brief interventions among VA outpatients with alcohol misuse before, during, and after implementation of a national performance measure linked to incentives and dissemination of an electronic clinical reminder for brief interventions. Findings show that VA’s strategy of implementing brief alcohol interventions with a performance measure supported by a clinical reminder meaningfully increased documentation of brief interventions over a one-year period. Among Veteran outpatients with alcohol misuse, the prevalence for brief interventions increased significantly over successive phases of implementation – from 5.5% at baseline – to 7.6% after announcement of the brief intervention performance measure – to 19.1% following implementation of the measure – to 29% following dissemination of the clinical reminder. Brief interventions increased among patients without prior alcohol use disorders or addictions treatment, as well as those with recognized drinking problems, with proportionately greater increases among the former group after clinical reminder dissemination.
Date: September 28, 2010
- Alcohol Screening Results Up to One Year Prior to Surgery Associated with Increased Post-Operative Complications for Veterans
This study evaluated whether results of alcohol screening with the AUDIT-C (Alcohol Use Disorders Identification Test – Consumption), administered up to one year before surgery, were associated with the risk of post-operative complications in Veterans undergoing major non-cardiac surgery in VA. Findings showed that AUDIT-C scores of 5 or higher up to one year before surgery were associated with increased post-operative complications. Overall, 16% of the total study population screened positive for alcohol misuse with AUDIT-C scores >5, and 8% had post-operative complications. There also was a dose-response relationship between AUDIT-C scores and post-operative complications, with complications increasing from 6% among low-risk drinkers to 14% among Veterans with the highest AUDIT-C scores. The authors suggest that AUDIT-C scores could be electronically loaded into surgery consults, surgery clinic notes, or pre-operative templates in VA’s computerized patient record system in order to alert clinicians to alcohol misuse at the time of referral to surgery.
Date: September 28, 2010
- Validated Alcohol Screening Questionnaire Not Enough to Ensure Quality of Screening
This study evaluated the quality of clinical alcohol screening among VA outpatients by comparing Alcohol Use Disorders Identification Test - Consumption Questions (AUDIT-C) results documented during routine clinical care to AUDIT-C results from a confidential mailed survey completed within 90 days of the clinical screen. Of the national sample, 61% of VA outpatients who screened positive for alcohol misuse with the AUDIT-C on mailed surveys screened negative during the same time period with the AUDIT-C in VA outpatient clinical settings. Overall, 11% of Veterans screened positive on the survey screen vs. only 6% on the clinical screen. Patients who screened positive on the AUDIT-C survey were much more likely to have discordant clinical screening results, e.g., among patients whose clinical screens indicated no alcohol use in the past year, 22% reported drinking on the survey screens. Discordance was significantly increased among African American Veterans compared with white Veterans. There were also differences across VA networks: the proportion of Veterans with positive survey screens who had negative clinical screens varied from 43% to 100% across different networks.
Date: September 22, 2010
- Negative Emotionality May Contribute to Worse Post-Deployment PTSD and Poorer Intimate Relationships among National Guard Iraq War Soldiers
This study examined the contribution of the pre-existing personality trait of negative emotionality (NEM) and comorbid problem drinking to the association between post-deployment PTSD symptoms and relationship distress among combat-exposed OIF National Guard soldiers. Findings show that NEM predisposes combat-exposed soldiers to more severe PTSD symptoms, which, in turn, contribute to poorer intimate relationships. Higher levels of pre-existing NEM predicted higher levels of post-deployment PTSD symptoms. Soldiers with probable PTSD were more likely to experience relationship distress than those without probable PTSD. Soldiers with positive hazardous drinking screens were more likely to screen positive for PTSD than those with negative drinking screens, however, those with positive drinking screens were no more likely to experience relationship distress than those with negative drinking screens.
Date: September 16, 2010
- Measuring the Quality of Mental Healthcare: Barriers and Strategies
This article discusses the barriers to mental health quality measurement – and identifies strategies to enhance the development and use of quality measures in order to improve outcomes for people with mental health disorders. The authors suggest that key reasons for the lag in mental health performance measurement include: lack of sufficient evidence regarding appropriate mental health care, poorly defined quality measures, limited descriptions of mental health services from existing clinical data, and lack of linked electronic health information. The refinement of quality measures and, ultimately, enhanced outcomes in mental health will require investment in information technology, additional studies to support the evidence base, and the development of a culture of measurement-based care. Sustaining efforts to improve mental health performance measurement will require rethinking how quality measurement is used to promote the uptake of evidence-based mental healthcare across systems of care. In addition, measurement systems should cut across mental health disorders, physical disorders, and substance use disorders, which often co-occur.
Date: September 1, 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
- Homelessness Affects Substance Use Treatment Outcomes and Costs among Veterans
This analysis evaluated homelessness among Veterans who had entered VA outpatient substance use disorder treatment, and also explored associations between housing status, treatment outcomes, and use of VA services over one year. Findings suggest that the problem of homelessness among Veterans with substance use disorders remains large, with 65% of 622 Veterans in this study spending at least one night homeless at some point during the study period. Veterans experiencing homelessness during the six months prior to treatment admission had more severe alcohol, medical, employment, legal, and psychiatric problems than Veterans with housing. Abstinence rates did not differ between the homeless and housed groups, and about 65% of participants in each group remained engaged in treatment for 90 days. In addition, results showed that homeless Veterans used more services and had higher total costs than housed Veterans, e.g., homeless Veterans had more inpatient admissions and were more likely to use the emergency room.
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
- Pharmacotherapy May Be Underused for Veterans with Alcohol Addiction
In FY06 and FY07, only about 3% of more than a quarter of a million VA patients with alcohol use disorders received treatment with one of four drugs specifically approved for treating alcohol dependence. [This apparent underutilization is not unique to VA, as utilization rates are within the range of rates reported in other settings.] Receipt of pharmacotherapy was more likely among Veterans receiving specialty addiction care, Veterans with alcohol dependence (vs. abuse), Veterans younger than 55 years old, and women. SSRI antidepressants were used about five times as often as alcohol use disorder medications in Veterans with an alcohol use disorder but without a psychiatric indication for SSRIs.
Date: April 1, 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
- Effectiveness of Residential Substance Use Disorder Programs in Treating Veterans with SUDs and Mental Illness
This study compared processes and outcomes for alcohol-dependent Veterans with and without comorbid psychiatric illness at one and five years following treatment in 15 residential substance use disorder (SUD) treatment programs affiliated with VA. Findings show that dually-diagnosed (DD) Veterans did not perceive SUD programs as positively as Veterans with SUD alone, and DD Veterans had worse proximal outcomes at discharge from treatment. For example, DD patients saw fewer benefits to quitting and had less self-efficacy in regard to staying abstinent. Results also showed that dually-diagnosed Veterans did as well as SUD patients on 1-year and 5-year substance use outcomes but had worse psychiatric outcomes. Veterans from both groups who perceived treatment more positively and had better outcomes at discharge had better longer-term outcomes; however, DD patients perceived the programs to be less supportive and clear, and were less satisfied with treatment. The authors suggest that SUD programs either need to add resources directed toward treating psychiatric problems, or that DD Veterans need to be treated in sequential or integrated programs. They note, however, that standard SUD programs may offer more components of integrated treatment than standard psychiatric programs do.
Date: December 1, 2009
- Candidate Quality Measures for VA Alcohol Use Disorder Treatment
The goal of this study was to identify patterns of VA care that are associated with both facility- and patient-level outcomes in order to develop a new process-of-care measure for VA outpatient alcohol use disorder (AUD) treatment quality. Findings show that nine candidate process measures of outpatient AUD treatment quality can predict facility-level and patient-level improvement. The candidate measures with the strongest association with improvement in outcomes focused on Veterans who received 3 to 6 outpatient visits in the first month of care. Results also showed that while the literature indicates that longer duration of care should produce better patient outcomes, the investigators found no such link with overall outcomes.
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
- Subjective Reactions to Cannabis Use Associated with Use and Dependence
Using data from VA’s Vietnam Era Twin Registry (VETR), investigators in this study were able to adjust for genetic and environmental factors while assessing the effects of cannabis use on 464 VETR offspring (adolescents and young adults age 12-32). These offspring were then categorized into four classes (or subsets) of cannabis responders: high (39%), positive (28%), mixed/relaxed (22%), and low (11%). Findings show that cannabis use, abuse, and dependence is associated with the type of subjective response even after adjusting for genetic influence and environmental factors, as well as demographic and psychiatric variables. For example, compared to mixed/relaxed responders and positive responders, high responders were more likely to have cannabis abuse and dependence. In addition, compared to low responders, members of the other three classes were heavier users of cannabis. Among sociodemographic variables, only male gender was associated with subjective response, as evidenced by a lower prevalence of males in mixed/relaxed and low responder classes as compared to high and positive responder classes.
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
- Low Rates of HIV Screening among Veterans with Substance Use Disorders
This study sought to determine the rate of HIV screening among Veterans with substance use disorders. Findings show that among the 371,749 Veterans with substance use disorders in this study, only 20% had evidence of ever having been screened for HIV. HIV screening was lowest among Veterans with alcohol use disorders alone (11%), and highest among Veterans treated in substance use programs (28%) or receiving inpatient care (28%). Authors suggest that these findings support the need for more widespread interventions to expand routine voluntary HIV screening nationally – within and outside VA.
Date: October 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
- Study Questions Validity of HEDIS Quality Measures for Substance Use Disorder Specialty Care
Healthplan Employer Data and Information Set (HEDIS) is the most widely used set of quality measures, thus many healthcare systems now track HEDIS measures of Initiation and Engagement in Alcohol and Other Drug Dependence Treatment. Using VA data, this study identified 320,238 Veterans who received at least one of the HEDIS-specified substance use disorder (SUD) diagnoses during FY06. Investigators then developed a model to determine their progression through Initiation and Engagement, with a focus on clinical setting and care specialty. Findings show that Veterans who have contact with SUD specialty treatment have higher rates of advancing from diagnosis to Initiation – and from Initiation to Engagement – compared to Veterans who are diagnosed with substance use disorders in psychiatric or other medical locations. For example, outpatients who were diagnosed in SUD specialty treatment settings were much more likely to “initiate” than those who were diagnosed in psychiatric and other specialty settings. Results also showed that 85% of the Veterans who received an SUD diagnosis in FY06 did so first in an outpatient setting, and that more than 40% of “engagement” occurred outside of SUD specialty care. Therefore, the usual combining of inpatient and outpatient performance on these measures into overall facility scores may affect measurement and interpretation. The authors suggest that these particular quality measures be considered measures of facility performance rather than measures of the quality of SUD specialty care.
Date: August 1, 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
- Alcohol Screening Scores Predict Fracture Risk
The Alcohol Use Disorder Identification Test – Consumption (AUDIT-C) is a three-item screen that can be routinely administered to primary care patients and has been widely adopted for alcohol screening. Research is needed to determine whether it might be valid for purposes other than screening, such as predicting alcohol-related health problems such as osteoporotic and other bone fractures. This study examined the association between AUDIT-C scores and the risk for fractures among Veterans who received care at seven VA primary care clinics across the country. Findings show that after adjusting for comorbidities and demographics, having an AUDIT-C score of 10 or greater was associated with doubling the risk of an osteoporotic fracture compared to AUDIT-C scores of 1 to 3, while an AUDIT-C of 6 or greater was associated with about a 1.5-fold increase in the risk of a fracture that was not typical of osteoporosis. This suggests that alcohol screening scores could help clinicians quickly assess and provide feedback to patients on their alcohol-related fracture risks, much the way other screening tests (e.g. blood pressure or lipids) are used.
Date: July 1, 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
- VA Treatment for Drinking Problems in Primary Care vs. Referral-Based Management
Relying upon the Chronic Care Model, this study identified organizational factors that distinguish primary care (PC) practices using PC-based approaches versus referral-based management of Veterans with drinking problems in the VA healthcare system. Findings show that PC- and referral-based practices did not differ on the sufficiency of their structural resources, physician staffing, or on the availability of specialty services. However, PC-based practices were found to take more responsibility for managing Veterans’ chronic conditions and had more staff for decision support activities.
Date: June 1, 2009
- Smoking Cessation Services for Veterans in VA Psychiatric Facility
This study had two goals: 1) determine staff characteristics that are associated with attitudes about providing smoking cessation services to Veterans who are psychiatric patients, and 2) seek suggestions from staff about what would be important to include in a tobacco cessation program. Findings show that nearly 75% of staff in this study thought that VA should do more to assist Veterans to quit smoking, yet only about 25% said that they personally provide cessation services. However, more than 50% felt moderately, very, or extremely confident in providing cessation services. Interestingly, nurses were less likely than other staff to feel that it was important to provide cessation services, which could be because of competing job demands. The most common reasons given by all respondents for not providing services were not enough time and lack of training. When asked how VA could best assist smokers to quit, most responses focused on educating Veterans about tobacco use and how they can quit, as well as providing tobacco cessation medications.
Date: June 1, 2009
- Alcohol Misuse and Counseling among Minority Veterans
This study sought to describe alcohol consumption across race and ethnicity groups among Veterans treated in VA during FY05, and examine associations between race and ethnicity and receipt of alcohol-related advice by clinicians. Findings show that overall, less than one-third of patients who drank at all and one-third of patients with positive alcohol misuse screens reported receiving alcohol-related advice. After adjusting for demographics, health status, and alcohol consumption, Veterans who self-identified as black, Hispanic, or American Indian/Alaska Native were more likely to report receiving alcohol-related advice from their VA healthcare providers compared to non-Hispanic whites. In addition, women and older Veterans were less likely to receive alcohol-related advice than their male and younger counterparts, respectively.
Date: May 1, 2009
- Continuity of Care Performance Measure Not Associated with Improved Outcomes for Veterans with Substance Use Disorders
The Continuity of Care (CoC) performance measure specifies that patients should receive at least two substance use disorder (SUD) outpatient visits in each of the three consecutive 30-day periods after they qualify as new SUD patients. Findings from this study show that meeting the CoC performance measure was not associated with patient-level improvements in the Addiction Severity Index (ASI) alcohol or drug composites, days of alcohol intoxication, or days of substance-related problems. Higher facility-level rates of CoC were negatively associated with improvements in ASI alcohol and drug composites – and were not associated with follow-up abstinence rates.
Date: April 1, 2009
- Study Suggests Additional Interventions for Veterans with SUD and History of Abuse
Men with a history of physical or sexual abuse had more severe drug problems at intake, but by six months there were no group differences in drug use. However, veterans with a history of sexual abuse had more severe psychiatric problems at all time points and were more likely to report significant suicidality at intake and 6 month follow-up. This suggests that additional interventions may be warranted for veterans with SUD and a history of sexual abuse. Also, routine screening for suicidality in SUD treatment programs may be warranted given the prevalence of lifetime sexual abuse among SUD patients and the relationship between sexual abuse and attempted suicide.
Date: December 1, 2008
- Is Music Therapy Efficacious in Treating Patients with Addictions?
Investigators reviewed the literature to evaluate the evidence that music therapy improves outcomes of patients with addictions. Findings show that few descriptions of music therapies, and even fewer studies reporting outcomes of music therapies exist for the treatment of patients with addiction. Investigators found only 19 articles that either described music therapy or were music therapy studies. Moreover, of the existing literature there was no consensus regarding the effects of music therapy on outcomes for patients with addictions.
Date: November 1, 2008
- 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
- Factors that Contribute to Cannabis Abuse and/or Dependence among Young Adults
Using data from a study of twin members of the Vietnam Era Twin Registry, their biological offspring, and mothers, findings show that cannabis abuse and dependence (CAD) was significantly more likely among male offspring. Offspring cannabis use/dependence was associated with siblings’ use of illicit drugs (with or without cannabis, but not cannabis only), as well as friends’ and peers’ use of drugs. Female gender was associated with reduced risk of young adult CAD.
Date: October 1, 2008
- Continuity of Care Improves Abstinence among Veterans with Substance Use Disorder
The use of outpatient mental health services in the year prior to treatment and the staff's continuity of care practices were the most important factors for increasing abstinence rates, while engagement in continuing care was a key post-treatment factor. Veterans also were more likely to be abstinent when staff provided continuing care appointments prior to discharge, developed discharge plans that called for patients to attend continuing care at least once a week, and arranged drug-free and sober living arrangements.
Date: September 1, 2008
- Mental Illness and Substance Use Costs among Veteran Clinic Users with Diabetes
Alcohol and drug use among veterans with diabetes increased healthcare costs due to greater use of inpatient services, regardless of the presence or severity of mental illness.
Date: July 1, 2008