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Objective Acceptance and Commitment Therapy (ACT) is a behavioral intervention demonstrating sustained improvements in anxiety in individuals with chronic anxiety and psychological distress. Because anxiety disorders are associated with the development of cardiovascular disease (CVD), we hypothesized that a novel 1-day ACT workshop would both lower anxiety and improve vascular function in persons with moderate/high anxiety. Methods In a randomized controlled study, 72 adults (age 33.9 ± 8.6 (SD) years) with baseline moderate/high anxiety completed a one-day ACT intervention (n = 44, age 33.9 ± 8.7 years) or control (n = 28, age 37.1 ± 10.1 years). Pre-specified secondary outcomes were measured over 12 weeks: aortic stiffness (carotid-femoral pulse wave velocity [cfPWV]), forearm vascular endothelial function (post-ischemic peak forearm blood flow [FBF] via plethysmography), and brachial artery flow-mediated dilation (FMD). Carotid artery stiffness (β-stiffness index), and inflammatory markers (C-reactive protein and tumor necrosis factor-alpha) were also explored. Results Although the intervention had a significant and sustained effect on the primary outcome of anxiety as measured by the Beck Anxiety Inventory, the 1-day ACT workshop was not associated with improvement in vascular or inflammatory endpoints. The intervention was unexpectedly associated with increases in β-stiffness index that were also associated with changing trait anxiety. Conclusion Anxiety improvements did not translate into improvements in any of the vascular function outcomes. This may reflect a less-than-robust effect of the intervention on anxiety, failure in design to select those with vascular dysfunction, or not intervening on a relevant causal pathway. (Trial registration NCT02915874 at www.clinicaltrials.gov ).

Psychiatric diagnoses may be a risk factor for poor colorectal cancer (CRC) surgery outcomes. The authors investigated the risk of psychiatric diagnoses and benefit of mental health treatment for surgery outcomes among CRC patients.This retrospective cohort study of patients undergoing CRC surgery in the 2000-2014 period identified documentation of psychiatric diagnosis and mental health treatment (no treatment, medication only, psychotherapy only, or both medication and psychotherapy) 30 days before surgery. Associations between psychiatric diagnoses, mental health treatment, and postoperative outcomes (postoperative complications, length of stay [LOS], and 90-day readmission rate) were evaluated with multivariable generalized estimating equations.Among 58,961 patients undergoing CRC surgery, 9,029 (15.3%) had psychiatric diagnoses, 4,601 (51.0%) of whom received preoperative mental health treatment (90.0% psychiatric medication, 6.7% psychotherapy, and 3.0% medication and psychotherapy). Patients with psychiatric diagnoses had an increased risk for postoperative complications (odds ratio [OR]=1.09, 95% confidence interval [CI]=1.03-1.15) and 90-day readmission (OR=1.11, 95% CI=1.06-1.17) compared with patients without psychiatric diagnoses. Patients with psychiatric diagnoses who received no mental health treatment or only medication had a 7%-17% increased risk for postoperative complications and 90-day readmission compared with patients without psychiatric diagnoses. Patients who received medication only also had a 4% increase in LOS relative to patients without psychiatric diagnoses. Patients with psychiatric diagnoses receiving only psychotherapy and patients without psychiatric diagnoses had similar postoperative outcomes.Preoperative psychiatric diagnoses were associated with worse postoperative outcomes. Surgical quality-improvement efforts should focus on identifying patients with preoperative psychiatric diagnoses and addressing these conditions presurgery.

In patients with migraine, depression is associated with poorer medical prognosis, decreased quality of life, and increased risk of suicidality and disability; yet, behavioral interventions have rarely been investigated. The current study compared the efficacy of two 1-day (5- to 6-h) interventions for co-occurring migraine and depression: (1) acceptance and commitment therapy plus migraine education (ACT-ED), and (2) support plus migraine education (S-ED). One hundred and thirty-six patients with comorbid depression and migraine were randomized to a treatment. One hundred and three (76%) completed the ACT-ED (N = 56) or S-ED (N = 47) workshop. Primary outcomes were depression diagnosis and symptoms. Secondary outcomes were anxiety symptoms, headache-related disability and general functioning, and quality of life. Assessments were completed at baseline and 3 and 6 months following the workshop. At the 6-month follow-up, on categorical outcomes, a significantly greater number of people in the ACT-ED condition no longer met criteria for a major depressive episode and exhibited a > 50% drop in symptoms on the Hamilton Rating Scale of Depression. Similarly, though, weaker results were found when examining depressive symptoms dimensionally. On secondary outcomes, people in the ACT-ED condition exhibited significantly greater improvements in anxiety, headache-related disability, and quality of social relationships, compared to S-ED, No differences between groups were observed in general functioning. A 1-day (5- to 6-h) ACT workshop can deliver substantial and lasting benefits to depressed migraineurs, over and above those provided by group support and education. This approach is an attractive alternative to weekly psychotherapy. Clinicaltrials.gov # NCT02108678 ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s13311-019-00818-0) contains supplementary material, which is available to authorized users.

BACKGROUND Cognitive-behavioral therapies often are recommended for anxiety disorders. However, treatment adherence and compliance are major barriers for these treatments, which are often delivered in 10 to 12 sessions over several months. This randomized controlled trial (trial registration NCT02915874 at www.clinicaltrials.gov) examined the effectiveness and feasibility of a 1-day cognitive-behavioral intervention for mixed anxiety. METHODS A total of 72 adults with moderate-to-high anxiety were randomized into a 1-day acceptance and commitment therapy (ACT) work-shop (n = 44) or treatment as usual (n = 28). Follow-up assessments were conducted 6 and 12 weeks after the workshop. Clinical outcomes were anxiety (primary) and depressive (secondary) symptoms, as measured by the Beck Anxiety Inventory and Beck Depression Inventory-II, respectively. Proposed mediators of ACT-psychological flexibility and commit-ted action-also were examined. RESULTS Participants assigned to the ACT workshop showed significant improvements in anxiety (beta = -1.13; P = .02) and depression (beta = -1.09; P = .02) after 12 weeks. Consistent with the theoretical model, these clinical improvements were mediated by psychological flexibility and committed action. Notable limitations included the sample size, inability to blind to treatment condition, and a racially and ethnically homogeneous sample. CONCLUSIONS Our 1-day ACT workshop was effective for anxiety with co-occurring depressive symptoms. One-day interventions are a promising alternative to weekly treatments.

BackgroundGroup-based trajectory modeling holds promise for the study of prognostic indicators in the mood disorders because the courses that the individuals with these disorders follow are so highly variable. However, trajectory analyses of major depressive disorder have so far not included some of the more robust predictors of mood disorder outcome, nor have they described interactions between these predictors.MethodsA group of 186 individuals aged 15–20 years with past or current depressive symptoms, who had recently begun taking a serotonin reuptake inhibitors antidepressant, underwent extensive baseline evaluations and were then followed for up to 2 years. Trajectory analyses used weekly ratings of depressive symptoms and the resulting groups were compared by the risk factors of sex, psychiatric comorbidity, negative emotionality, and childhood adversity.ResultsA three-group solution provided the best statistical fit to the 2-year symptom trajectory. Negative emotionality and childhood adversity, though correlated, independently predicted membership in higher-morbidity groups. Female sex and comorbidity with generalized anxiety disorder (GAD) were also significantly more likely in the trajectory groups with higher symptom levels. However, the presence of GAD, rather than female sex, was the most important determinant of group membership. Negative emotionality was predictive of group membership only among women.ConclusionsTrajectory analyses indicated that week-to-week variations in depressive symptoms across individuals could best be condensed into low, remitting and persistent symptom patterns. Female sex, anxiety symptoms, negative emotionality and childhood adversity were each independently associated with trajectories of higher morbidity but negative emotionality may be prognostically important only among women.

Objectives Patient Health Priorities Identification (PHPI) is a values-based process in which trained facilitators assist older adults with multiple chronic conditions identify their health priorities. The purpose of this study was to evaluate patients' perceptions of PHPI. Design Qualitative study using thematic analysis. Setting In-depth semistructured telephone and in-person interviews. Participants Twenty-two older adults who participated in the PHPI process. Measurements Open-ended questions about patient perceptions of the PHPI process, perceived benefits of the process, enablers and barriers to PHPI, and recommendations for process enhancement. Results Patient interviews ranged from 9 to 63 minutes (median = 20 min; interquartile range = 15-26). The mean age was 80 years (standard deviation = 7.96), 64% were female, and all patients identified themselves as white. Of the sample, 73% reported no caregiver involvement in their healthcare; 36% lived alone. Most patients felt able to complete the PHPI process with ease. Perceived benefits included increased knowledge and insight into disease processes and treatment options, patient activation, and enhanced communication with family and clinicians. Patients identified several factors that were both enablers and barriers to PHPI including facilitator characteristics, patient demographic and clinical characteristics, social support, relationships between the patient and their primary care provider, and the changing health priorities of the patient. Recommendations for process enhancement included more frequent and flexible facilitator contacts, selection of patients for participation based on specific patient characteristics, clarification of process aims and expectations, involvement of family, written reminders of established health priorities, short duration between facilitation and primary care provider follow-up, and the inclusion of health-related tasks in facilitation visits. Conclusions Patients found the PHPI process valuable in identifying actionable health priorities and healthcare goals leading to enhanced knowledge, activation, and communication regarding their treatment options and preferences. PHPI may be useful for aligning the healthcare that patients receive with their values-based priorities.

Key Points Question What are the common goals and health care preferences of older adults with multiple health conditions? Findings In this cross-sectional study, 163 older adults reported 459 goals, most commonly encompassing activities with family and friends (24.2%), shopping (6.1%), exercising (4.6%), and living independently (4.4%). Medications most commonly cited as helpful were nonopioid pain medications (65.5% of users), sleep medications (52.9% of users), and inhalants (42.2% of users), whereas statins (25.8% of users) and antidepressants (32.5% of users) were the most commonly reported bothersome medications. Meaning Participants identified realistic and doable goals and health care preferences; this information can inform decision-making., This cross-sectional study describes the outcome goals and health care preferences of older adults with multiple chronic conditions., Importance Older adults with multiple chronic conditions (MCCs) vary in their health outcome goals and the health care that they prefer to receive to achieve these goals. Objective To describe the outcome goals and health care preferences of this population with MCCs. Design, Setting, and Participants This cross-sectional study included participants in the Patient Priorities Care study who underwent health priorities identification from February 1, 2017, to August 31, 2018, in a primary care practice. Patients eligible to participate were 65 years or older, English speaking, and had at least 3 chronic conditions; in addition, they used at least 10 medications, saw at least 2 specialists, or had at least 2 emergency department visits or 1 hospitalization during the past year. Of 236 eligible patients, 163 (69%) agreed to participate in this study. Data were analyzed from August 1 to October 31, 2020. Exposures Guided by facilitators, participants identified their core values, as many as 3 actionable and realistic outcome goals, health-related barriers to these goals, and as many as 3 helpful and 3 bothersome health care activities. Main Outcomes and Measures Frequencies were ascertained for outcome goals and health care preferences. Preferences included health care activities (medications, health care visits, procedures, diagnostic tests, and self-management) reported as either helpful or bothersome. Results Most of the 163 participants were White (158 [96.9%]) and women (109 [66.9%]), with a mean (SD) age of 77.6 (7.6) years. Of 459 goals, the most common encompassed meals and other activities with family and friends (111 [24.2%]), shopping (28 [6.1%]), and exercising (21 [4.6%]). Twenty individuals (12.3%) desired to live independently without specifying necessary activities. Of 312 barriers identified, the most common were pain (128 [41.0%]), fatigue (45 [14.4%]), unsteadiness (42 [13.5%]), and dyspnea (19 [6.1%]). Similar proportions of patients identified at least 1 medication that was helpful (130 [79.8%]) or bothersome (128 [78.5%]). Medications most commonly cited as helpful were pain medications, including nonopiods (36 of 55 users [65.5%]) and opioids (15 of 27 users [55.6%]); sleep medications (27 of 51 users [52.9%]); and respiratory inhalants (19 of 45 [42.2%]). Most often mentioned as bothersome were statins (25 of 97 users [25.8%]) and antidepressants (13 of 40 users [32.5%]). Thirty-two participants (19.6%) reported using too many medications. Health care visits were identified as helpful by 43 participants (26.4%); 15 (9.2%) reported too many visits. Procedures were named helpful by 38 participants (23.3%); 24 (14.7%) cited unwanted procedures. Among 48 participants with diabetes, monitoring of glucose levels was doable for 18 (37.5%) and too bothersome for 9 (18.8%). Conclusions and Relevance Participants identified realistic and actionable goals while varying in health care activities deemed helpful or bothersome. The goals and health care preferences of more diverse populations must be explored. Previous work suggests that clinicians can use this information in decision-making.

Background Understanding factors influencing retention in care (RIC) and viral load improvement (VLI) in people with HIV (PWH) who are out of care and hospitalized will assist in intervention development for this vulnerable population. Methods The study was a post hoc analysis of prospectively collected data. Hospitalized participants were enrolled if they were newly diagnosed with HIV during the hospitalization or out of HIV care. Participants completed surveys at baseline and 6 months postenrollment and laboratory studies of viral load (VL). Outcomes were RIC (2 completed visits, 1 within 30 days of discharge) and VLI (VL Results The study cohort included 417 participants enrolled between 2010 and 2013. The population was 73% male, 67% non-Hispanic black, 19% Hispanic, and 70% uninsured. Sixty-five percent had a baseline CD4 400 copies/mL or missing, and the population was generally poor with low educational attainment. After discharge from the hospital, 60% did not meet the definition for RIC, and 49% did not have VLI. Modifiable factors associated with the outcomes include drug use (including marijuana alone and other drugs), life instability (eg, housing, employment, and life chaos), and using avoidance coping strategies in coping with HIV. Conclusions Hospitalized out-of-care PWH in the United States are at high risk of poor re-engagement in care after discharge. Interventions for this population should focus on improving socioeconomic stability and coping with HIV and reducing drug use.

Objectives To develop a values‐based, clinically feasible process to help older adults identify health priorities that can guide clinical decision‐making. Design Prospective development and feasibility study. Setting Primary care practice in Connecticut. Participants Older adults with 3 or more conditions or taking 10 or more medications (N=64). Intervention The development team of patients, caregivers, and clinicians used a user‐centered design framework—ideate → prototype → test →redesign—to develop and refine the value‐based patient priorities care process and medical record template with trained clinician facilitators. Measurements We used descriptive statistics of quantitative measures (percentage accepted invitation and completed template, duration of process) and qualitative analysis of barriers and enablers (challenges and solutions identified, facilitator perceptions). Results We developed and refined a process for identifying patient health priorities that was typically completed in 35 to 45 minutes over 2 sessions; 64 patients completed the process. Qualitative analyses were used to elucidate the characteristics and training needed for the patient priorities facilitators, as well as perceived benefits and challenges of the process. Refinements based on our experience and feedback include streamlining the process for greater feasibility, balancing fidelity to the process while customizing to individuals, encouraging patients to share their priorities with their clinicians, and simplifying the template transmitted to clinicians. Conclusion Trained facilitators conducted this process in a busy primary care practice, suggesting that patient priorities identification is feasible and acceptable, although testing in additional settings is necessary. We hope to show that clinicians can align care with patients' health priorities.

Older adults with multiple chronic conditions (MCCs) receive care that is fragmented and burdensome, lacks evidence, and most importantly is not focused on what matters most to them. An implementation feasibility study of Patient Priorities Care (PPC), a new approach to care that is based on health outcome goals and healthcare preferences, was conducted. This study took place at 1 primary care and 1 cardiology practice in Connecticut and involved 9 primary care providers (PCPs), 5 cardiologists, and 119 older adults with MCCs. PPC was implemented using methods based on a practice change framework and continuous plan-do-study-act (PDSA) cycles. Core elements included leadership support, clinical champions, priorities facilitators, training, electronic health record (EHR) support, workflow development and continuous modification, and collaborative learning. PPC processes for clinic workflow and decision-making were developed, and clinicians were trained. After 10 months, 119 older adults enrolled and had priorities identified; 92 (77%) returned to their PCP after priorities identification. In 56 (46%) of these visits, clinicians documented patient priorities discussions. Workflow challenges identified and solved included patient enrollment lags, EHR documentation of priorities discussions, and interprofessional communication. Time for clinicians to provide PPC remains a challenge, as does decision-making, including clinicians' perceptions that they are already doing so; clinicians' concerns about guidelines, metrics, and unrealistic priorities; and differences between PCPs and patients and between PCPs and cardiologists about treatment decisions. PDSA cycles and continuing collaborative learning with national experts and peers are taking place to address workflow and clinical decision-making challenges. Translating disease-based to priorities-aligned decision-making appears challenging but feasible to implement in a clinical setting.

Introduction Migraine, a chronic neurological disorder characterized by episodic severe headache pain and functional impairment, affects approximately 12% of the general US population. Veterans returning from Iraq or Afghanistan have two to four times the incidence of migraine of the general population. Veterans with migraines are more than twice as likely to have comorbid psychiatric conditions as veterans without migraines, with depression and post-traumatic stress disorder being most prevalent. This psychiatric-migraine comorbidity is of major public health significance, as it leads to decreased quality of life, poorer response to migraine and mental health treatment, and overall worse prognosis. Unfortunately, acceptable and effective treatments for these comorbid problems have rarely been investigated. The aims of this study are to examine the acceptability, feasibility, and preliminary efficacy of a 1-d acceptance and commitment therapy (ACT) plus Migraine Education workshop. Method Twenty-five veterans with migraines and co-occurring depression and/or anxiety completed the 1-d ACT plus Migraine Education workshop. Veterans completed assessments of depressive and anxiety symptoms, general functioning, headache-related disability, and ACT-specific skills at baseline and 3 mo after the workshop. Changes from baseline to 3-mo follow-up on the self-report and clinician-rated measures were assessed using the paired t-test and Wilcoxon signed-rank test. Veterans also completed semistructured qualitative interviews documenting their experiences with the workshop 2 wk and 3 mo following the intervention. Qualitative data were analyzed via directed content analysis. Individual codes were aggregated into larger themes agreed upon by consensus. Results At 3-mo follow-up, veterans significantly improved in depressive and anxiety symptoms, general functioning, and headache-related disability compared with baseline. Additionally, veterans significantly improved in pain acceptance and engagement in valued life areas. In interviews, veterans indicated that the migraine education helped them feel more knowledgeable about their condition, and this empowered them to better manage their headaches, including talking to their physician about medication adjustments. The ACT component led to greater awareness of the role stress plays in exacerbating pain and ways to manage this stress, including greater acceptance and greater engagement in valued life activities. For some, however, the role of stress in exacerbating migraines needed to be highlighted more. Veterans appreciated being in a group with other veterans with similar health difficulties and wanted this to be incorporated into ongoing care at the Veterans Affairs medical center. The patient education manuals were useful to the veterans, with some referring to them during the months following the workshop. Conclusion Findings of this small trial have important implications pending replication in a more rigorously designed large-scale study. A 1-d ACT plus Migraine Education workshop is an acceptable and feasible treatment approach for veterans with migraines and significant distress. Significantly reduced distress and disability, as well as improved coping skills, suggest that veterans were activated to engage more fully in their lives and clinical care. The availability of an effective transdiagnostic intervention that can be completed in 1 d is particularly valuable for veterans who have multiple comorbid conditions and who encounter practical barriers to engaging in the usual prescribed weekly therapy treatments.

Background Mild traumatic brain injury (mTBI) is a signature wound of Veterans of operations in Iraq and Afghanistan (i.e., OIF/OEF/OND). Most Veterans with mTBI also experience stress-based psychopathology (e.g., depression, posttraumatic stress disorder) and chronic pain. This combination – referred to as polytrauma - results in detrimental long-term effects on social, occupational, and community reintegration. This study will compare the efficacy of a one-day Acceptance and Commitment Training plus Education, Resources, and Support (ACT+ERS) workshop to a one-day active control group (ERS) on symptoms of distress and social, occupational, and community reintegration. We will also examine mediators and moderators of treatment response. Methods This is an ongoing randomized clinical trial. 212 OIF/OEF/OND Veterans with polytrauma are being recruited. Veterans are randomly assigned to a one-day ACT+ERS or a one-day ERS workshop with two individualized booster sessions approximately two- and four-weeks post-workshop. Veterans complete assessments prior to the workshop and again at six weeks, three months, and six months post-workshop. Of note, workshops were converted to a virtual format due to the COVID-19 pandemic. Results The primary outcomes are symptoms of distress and reintegration; secondary outcomes are post-traumatic stress disorder symptoms and pain interference. Secondary analyses will assess whether changes in avoidance at three months mediate changes in distress and reintegration at six months. Conclusion Facilitating the psychological adjustment and reintegration of Veterans with polytrauma is critical. The results of this study will provide important information about the impact of a brief intervention for Veterans with these concerns.

Depression and anxiety are highly comorbid psychiatric conditions and both are common in adult patients with migraine. This study aims to examine the unique associations between major depressive disorder (MDD) and generalized anxiety disorder (GAD) in a well-characterized group of older adolescents and college-age individuals with migraine. Participants (N = 227), between 15 and 20 years old, who were unmedicated or within 1 month of beginning antidepressant treatment underwent a comprehensive psychiatric assessment to establish the presence of MDD and GAD, according to the Diagnostic and Statistical Manual, Fourth Edition, Text Revision, and to rate their symptom severity using the Longitudinal Interval Follow-up Evaluation for Adolescents (A-LIFE). They then completed the ID-Migraine. The Student’s t test and chi-square test were used to compare continuous and categorical variables, respectively, across participants with vs. without migraine. Logistic regression analysis examined the association between the presence of migraine and psychopathology. A diagnosis of MDD was associated with significantly increased risk of having migraine. Moreover, more severe and persistent ratings of depression were associated with an even higher likelihood of having migraine. A diagnosis of GAD was also significantly associated with the presence of migraine. The prevalence of comorbid MDD and GAD was significantly higher in participants with migraine than those without migraine (55 vs. 22%, p

Background Patients with inflammatory bowel disease (IBD) are more susceptible to mental health problems than the general population; however, temporal trends in psychiatric diagnoses’ incidence or prevalence in the United States are lacking. We sought to identify these trends among patients with IBD using national Veterans Heath Administration data. Methods We ascertained the presence of anxiety, depression, or posttraumatic stress disorder among veterans with IBD (ulcerative colitis or Crohn’s disease) during fiscal years 2000–2015. Patients with prior anxiety, depression, or posttraumatic stress disorder before their first Veterans Health Administration IBD encounter were excluded to form the study cohort. We calculated annual prevalence, incidence rates, and age standardized and stratified by gender using a direct standardization method. Results We identified 60,086 IBD patients (93.9% male). The prevalence of anxiety, depression, and/or posttraumatic stress disorder increased from 10.8 per 100 with IBD in 2001 to 38 per 100 with IBD in 2015; 19,595 (32.6%) patients had a new anxiety, depression, and/or posttraumatic stress disorder diagnosis during the study period. The annual incidence rates of these mental health problems went from 6.1 per 100 with IBD in 2001 to 3.6 per 100 in 2015. This trend was largely driven by decline in depression. Conclusions The prevalence of anxiety, depression, and posttraumatic stress disorder is high among US veterans with IBD and increasing, given the chronicity of IBD and psychological diagnoses. Incidence, particularly depression, appears to be declining. Confirmation and reasons for this encouraging trend are needed.

Objective Experiential avoidance (EA) is a transdiagnostic construct that may underlie the high comorbidity between major depressive disorder (MDD) and generalized anxiety disorder (GAD). This analysis used data from a longitudinal study (conducted September 2010-April 2016) to examine whether adolescent EA varies by MDD and GAD symptomatology trajectory and predicts said trajectories. Longitudinal associations between EA, anxiety, and depression symptoms were also examined. Methods Adolescents aged 15 to 20 years (N = 183) were followed for 2 years using a comprehensive assessment battery. Symptom trajectory modeling, using weekly symptom ratings, identified 4 MDD and 4 GAD trajectories that were collapsed to form combined MDD/GAD trajectory groups: Persistent (n = 81), High-Decreasing (n = 44), Normal-Increasing (n = 37), and Minimal (n = 21). Group-based trajectory modeling, analyses of covariance, structural equation modeling, and linear regression analyses were performed. DSM-IV-TR criteria were used for MDD and GAD diagnoses. Results The Persistent adolescents had higher EA than other groups (P values ≤ .001), with greater EA stability versus High-Decreasing adolescents (P = .008). EA predicted anxiety and depressive symptoms alike (P values ≤ .005), which in turn did not predict EA (P values ≥ .188). EA, at both time points, predicted combined MDD/GAD trajectories after adjustment for depressive and anxiety symptoms and other confounders (P values Conclusions EA appears to be an important predictor of MDD and GAD symptomatology in older adolescents, potentially serving as a treatment target. Findings suggest a possible trait-like nature for EA, perhaps increasing risk for the emergence and persistence of MDD and/or GAD. Trial registration ClinicalTrials.gov identifier: NCT02147184​.

Background/objectives Aligning healthcare decisions with patients' priorities may improve care for older adults with multiple chronic conditions (MCCs). We conducted a pilot study to assess the feasibility of identifying patient priorities in routine geriatrics care and to compare clinicians' recommendations for patients who did or did not have their priorities identified. Design Retrospective chart review. Setting Veterans Administration Medical Center Geriatrics Clinic. Participants Older adults with MCCs receiving Patient Priorities Care (PPC; n = 35) were matched with patients receiving usual care (UC; n = 35). Both PPC and UC patients were cared for by three primary care providers (PCPs) in an ambulatory geriatric clinic. Intervention In the PPC group, a clinician facilitator met with each patient to identify their healthcare priorities and transmitted patients' priorities in the electronic health record (EHR). Trained PCPs then sought to align healthcare decisions with patients' priorities. In the UC group, patients received usual care from the same PCPs. Measurements We matched patients by clinician seen, patient's age, number of active conditions, medications, hospitalizations, functional status, and prior hospitalizations. EHRs were reviewed to identify care decisions including medications added or stopped, referrals and consults added or avoided, referrals to community services and supports, self-management activities added or avoided, and total number of changes to care. Mean differences in recommended care between PPC and UC patients from the same PCPs were examined. Results Clinician facilitators could identify patient priorities during routine clinic encounters. Compared with patients in the UC group, those in the PPC group had, on average, fewer medications added (P = .05), more referrals to community services and supports (P = .03), and more priorities-aligned self-management tasks added (P = .005). Conclusion These findings support the feasibility of identifying and documenting patient priorities during routine encounters. Results also suggest that clinicians use patient priorities in recommending care.

Objectives To 1) develop and refine a 1-day trans-diagnostic psychotherapeutic “ACT on Life” workshop tailored for Veterans with mild traumatic brain injury, stress-based psychopathology, and pain; 2) examine the feasibility, acceptability, and preliminary effects of this intervention. Setting A Veterans Health Administration medical center. Participants Veterans returning from Operations Iraqi Freedom, Enduring Freedom, and New Dawn with mild TBI, stress-based psychopathology, and chronic pain. Design Phase I involved development of the intervention by experts and subsequent refinement based on Veteran feedback (N = 11). Phase II was a pilot randomized controlled trial comparing the effects of the revised intervention (N = 20) to treatment as usual (TAU; N = 12). Main measures For phase I, qualitative feedback at 2 weeks and 3 months post-workshop was obtained from Veterans. For phase II, quantitative measures included the PTSD Checklist, Depression Anxiety and Stress Scale, Military-to-Civilian Questionnaire, WHO-Disability Assessment Schedule, Brief Pain Inventory, Acceptance and Action Questionnaire. Results Veterans found the workshop acceptable, innovative and useful. Quantitative data from phase II suggested that participants in the ACT group, relative to TAU, showed improvement in psychiatric symptoms, functioning, and reintegration 3 months post-workshop. Unexpectedly, pain interference was lower in the TAU group at follow-up. Conclusions Preliminary results support the feasibility, acceptability, and promising effects on psychological distress and community reintegration of this 1-day, transdiagnostic workshop for Veterans. Future research examining the effectiveness of this workshop with a larger sample size is necessary.

The Patient Reported Outcomes Measurement System (PROMIS) offers standardized assessment measures of clinically relevant patient reported outcomes. This study evaluated the reliability and validity of select PROMIS measures with United States Military Veterans following orthopedic surgery. Data for the current study were collected as part of a pilot randomized control trial assessing the efficacy of a one day Acceptance and Commitment Therapy workshop on persistent post-surgical pain in at-risk Veterans undergoing orthopedic surgery. Sixty-seven participants completed surveys three months after surgery. Participants completed the following PROMIS instruments: PROMIS Anxiety Short Form 8a, PROMIS Depression Short Form 8b, and PROMIS pain interference short form 8a. PROMIS measures were compared to the Generalized Anxiety Disorder 7-item scale (GAD-7), the Patient Health Questionnaire 9-item scale (PHQ-9), and the Brief Pain Inventory (BPI) pain interference subscale (respectively). All three PROMIS measures demonstrated excellent internal consistency (Cronbach’s alphas ranged from .93 - .96) and each loaded onto a single factor. The PROMIS measures were moderately correlated with their respective comparison measures (r = .69 - .76). The PROMIS anxiety and PROMIS depression measures were highly correlated to one another (r = .91). Findings highlight the potential utility of these PROMIS measures in Veterans following orthopedic surgery and the overlap between the PROMIS depression and anxiety measures in this sample.

OBJECTIVE. Oncologic breast surgeries carry a risk for persistent postsurgical pain. This study was a randomized pilot and feasibility study of a single-session Acceptance and Commitment Therapy (ACT) intervention compared to treatment as usual among women undergoing surgery for breast cancer or ductal carcinoma in situ (DCIS). METHODS. Participants were recruited via letter of invitation and follow-up phone call from a single site in the United States from 2015–2017. Participants were at risk for persistent post-surgical pain, based on: young age (3 on a 0–10 numeric rating scale) in the operative breast or with arm movement. Written qualitative responses indicated that the majority of participants who received the intervention understood the concepts presented and reported continued practice of exercises learned in the session. The between group effect sizes for moderate-severe pain and elevated anxiety at 3-months post-surgery were small (Phi=0.08 and 0.16, respectively). The between group effect sizes for depression, pain acceptance, and pain catastrophizing at 3-months post-surgery were minimal. CONCLUSIONS. This study found small positive effects on post-surgical pain and anxiety for a single-session ACT intervention among women with breast cancer. This study supports the use of ACT with this population.

Background Patient Priorities Care (PPC) is a model of care that aligns health care recommendations with priorities of older adults who have multiple chronic conditions. Following identification of patient priorities, this information is documented in the patient’s electronic health record (EHR). Objective Our goal is to develop and validate a natural language processing (NLP) model that reliably documents when clinicians identify patient priorities (ie, values, outcome goals, and care preferences) within the EHR as a measure of PPC adoption. Methods This is a retrospective analysis of unstructured National Veteran Health Administration EHR free-text notes using an NLP model. The data were sourced from 778 patient notes of 658 patients from encounters with 144 social workers in the primary care setting. Each patient’s free-text clinical note was reviewed by 2 independent reviewers for the presence of PPC language such as priorities, values, and goals. We developed an NLP model that utilized statistical machine learning approaches. The performance of the NLP model in training and validation with 10-fold cross-validation is reported via accuracy, recall, and precision in comparison to the chart review. Results Of 778 notes, 589 (75.7%) were identified as containing PPC language (kappa=0.82, P Conclusions An automated NLP model can reliably measure with high precision, recall, and accuracy when clinicians document patient priorities as a key step in the adoption of PPC.

Patient Priorities Care (PPC) is a model of care that aligns health care recommendations with priorities of older adults with multiple chronic conditions. Social workers (SW), after online training, document PPC in the patient’s electronic health record (EHR). Our goal is to identify free-text notes with PPC language using a natural language processing (NLP) model and to measure PPC adoption and effect on long term services and support (LTSS) use. Free-text notes from the EHR produced by trained SWs passed through a hybrid NLP model that utilized rule-based and statistical machine learning. NLP accuracy was validated against chart review. Patients who received PPC were propensity matched with patients not receiving PPC (control) on age, gender, BMI, Charlson comorbidity index, facility and SW. The change in LTSS utilization 6-month intervals were compared by groups with univariate analysis. Chart review indicated that 491 notes out of 689 had PPC language and the NLP model reached to precision of 0.85, a recall of 0.90, an F1 of 0.87, and an accuracy of 0.91. Within group analysis shows that intervention group used LTSS 1.8 times more in the 6 months after the encounter compared to 6 months prior. Between group analysis shows that intervention group has significant higher number of LTSS utilization (p=0.012). An automated NLP model can be used to reliably measure the adaptation of PPC by SW. PPC seems to encourage use of LTSS that may delay time to long term care placement.

Latent infection with toxoplasmosis is a prevalent condition that has been linked in animal studies to high-risk behaviors, and in humans, to suicide and suicide attempts. This analysis investigated a relationship between suicide attempt history and toxoplasmosis titers in a group of older adolescents who had recently begun treatment with an SSRI. Of 108 participants, 17 (15.7 %) had a lifetime history of at least one suicide attempt. All were given structured and unstructured diagnostic interviews and provided blood samples. Two individuals (11.9%) with a past suicide attempt, and two (2.1%) without this history, had toxoplasmosis titers ≥ 10 IU/ml (p = 0.166). Those with a past suicide attempt had mean toxoplasmosis titers that were significantly different (p = 0.018) from those of patients who lacked this history. An ROC analysis suggested a lower optimal threshold for distinguishing patients with and without suicide attempts (3.6 IU/ml) than that customarily used to identify seropositivity. Toxoplasmosis titers may quantify a proneness to suicidal behavior in younger individuals being treated with antidepressants.

Objective Persistent post-surgical pain is common among patients undergoing surgery, is detrimental to patients' quality of life, and can precipitate long-term opioid use. The purpose of this randomized controlled trial is to assess the effects of a behavioral intervention offered prior to surgery for patients at risk for poor post-surgical outcomes, including persistent pain and impaired functioning. Methods Described herein is an ongoing randomized, patient- and assessor-blind, attention-controlled multisite clinical trial. Four hundred and thirty Veterans indicated for total knee arthroplasty (TKA) with distress and/or pain will be recruited for this study. Participants will be randomly assigned to a one-day (~5 h) Acceptance and Commitment Therapy workshop or one-day education and attention control workshop. Approximately two weeks following their TKA surgery, patients receive an individualized booster session via phone. Following their TKA, patients complete assessments at 1 week, 6 weeks, 3 months, and 6 months. Results The primary outcomes are pain intensity and knee-specific functioning; secondary outcomes are symptoms of distress and coping skills. Mediation analyses will examine whether changes in symptoms of distress and coping skills have an impact on pain and functioning at 6 months in Veterans receiving ACT. This study is conducted mostly with older Veterans; therefore, results may not generalize to women and younger adults who are underrepresented in this veteran population. Conclusions The results of this study will provide the first evidence from a large-scale, patient- and assessor-blind controlled trial on the effectiveness of a brief behavioral intervention for the prevention of persistent post-surgical pain and dysfunction.

High levels of pain, significant anxiety, or depressive symptoms before surgery put patients at elevated risk for chronic pain and prolonged opioid use following surgery. The purpose of this preliminary study was to assess the efficacy of a 1-day Acceptance and Commitment Therapy (ACT) workshop in “at-risk” veterans for the prevention of chronic pain and opioid use following orthopedic surgery. In a randomized controlled trial, 88 at-risk veterans undergoing orthopedic surgery were assigned to treatment as usual (TAU; n = 44) or TAU plus a 1-day ACT workshop (n = 44). Pain levels and opioid use were assessed up to 3 months following surgery. Pain acceptance and values-based behavior were assessed at baseline and 3-month follow-up. Participants who completed the ACT workshop reached pain and opioid cessation sooner than those in TAU. Postoperative complications exhibited a moderating effect on these outcomes, such that the effects of ACT were greater in patients without complications. Increases in pain acceptance and values-based behavior, processes targeted in ACT, were related to better outcomes. These promising results merit further investigation in a larger clinical trial. Providing an intervention before surgery for at-risk veterans has the potential to change clinical practice from a focus on management of postoperative pain to prevention of chronic pain in at-risk individuals. Perspective This pilot study compared the effects of a 1-day preventive behavioral intervention (ACT) to TAU in at-risk veterans undergoing orthopedic surgery. Three months following the intervention, veterans receiving ACT exhibited quicker cessation of pain and opioid use. Focusing on preoperative pain management may help prevent chronic postsurgical pain.

To evaluate effects of an online, hour-long migraine education and management education program on health outcomes in people with migraine experiencing significant depressive symptoms.Eligible individuals in the community with comorbid migraine and depressive symptoms (n = 95) participated in the 12-week study. Participants completed self-report questionnaires examining general functioning, headache-specific disability, migraine frequency, pain, and depressive symptoms, before, and at 2, 6, and 12 weeks following the migraine education and management program. Primary analyses evaluated change over time in each outcome, using individual linear growth curve models.After watching the migraine education and management video, there were significant effects of time (across all time points) for average pain level in the past 30 days (b = -0.20, p .001), most intense pain level in the past 30 days (b = -0.33, p .001) depression (Patient Health Questionnaire-8; b = -0.28, p = .002), and headache-specific disability (Headache Disability Inventory; b = -1.32, p .001), such that each of these outcomes improved linearly over time.A brief, online educational video is practical and effective and can lead to enhanced migraine knowledge and self-management skills and lessen the burden of migraine and concurrent depressive symptoms.

Patient Priorities Care (PPC) is an approach to clinical conversations that focuses on aligning care with patient priorities. This approach involves identifying and incorporating patient values, goals, and preferences into care for patients with multiple comorbid conditions. We have previously described how this clinically feasible and sustainable approach has been implemented in VA and private healthcare settings, and how this approach results in documented care aligned with patient goals. In this paper, we describe the way PPC has been adapted and implemented in a VA geriatrics clinic for Veterans with dementia and their caregivers. We discuss results from a funded pilot project in which we investigated the role of caregivers in patient goal setting; assessed patient functioning using self-reported and sensor measures; and examined clinical conversations and interviews. We use these results to discuss implementation strategies targeting: (1) caregiver activation and involvement in clinical conversation and decision-making, (2) patient and caregiver education about the disease trajectory of dementia, (3) life space function and using physical sensor data in dementia care, (4) measures of community integration for patients and caregivers, and (5) features of successful clinical conversations in this context.

OBJECTIVE Substantial evidence exists to indicate bidirectional relationships between obesity and depressive disorders and the importance of fat distribution to this relationship. This analysis used a well-characterized sample of individuals in late adolescence to determine the association between depressive illness and fat distribution. METHOD Medically healthy 15- to 20-year-olds, one-half of whom had recently begun treatment with a selective serotonin reuptake inhibitor, underwent a comprehensive psychiatric evaluation that resulted in diagnostic classification and weekly psychiatric disorder ratings over the prior 4 months using the Longitudinal Interval Follow-Up Evaluation. A whole-body scan, using dual-energy x-ray absorptiometry, allowed estimations of total body less head (TBLH), total mass, fat mass, and visceral adipose tissue (VAT) mass. Assessments occurred between September 2010 and April 2014. Multivariable linear regression analyses, adjusted for relevant covariates, examined the association between DSM-IV-TR-diagnosed major depressive disorder (MDD) and VAT, the primary outcome of interest. These procedures also determined whether significant associations were confined to overweight/obese participants. RESULTS The analysis included data from 200 participants (71% female; mean age = 19.0 ± 1.6 years), of whom 128 had current MDD. The presence of MDD was associated with increased fat mass among overweight/obese participants (Cohen d = 0.79, P < .02), but not normal weight participants. This was true of both visceral and nonvisceral fat mass measures. Accounting for the presence of generalized anxiety disorder (GAD) did not alter the findings. CONCLUSION In adolescents, relationships between central adiposity and MDD may be confined to those who are overweight/obese. Despite the high comorbidity of GAD and depressive disorders, only the latter appeared to be significantly associated with central adiposity.

Objective The Blue Button feature of online patient portals promotes patient engagement by allowing patients to easily download their personal health information. This study examines the adoption and use of the Blue Button feature in the Department of Veterans Affairs’ (VA) personal health record portal, My HealtheVet. Materials and methods An online survey presented to a 4% random sample of My HealtheVet users between March and May 2012. Questions were designed to determine characteristics associated with Blue Button use, perceived value of use, and how Veterans with non-VA providers use the Blue Button to share information with their non-VA providers. Results Of the survey participants (N=18 398), 33% were current Blue Button users. The most highly endorsed benefit was that it helped patients understand their health history better because all the information was in one place (73%). Twenty-one percent of Blue Button users with a non-VA provider shared their VA health information, and 87% reported that the non-VA provider found the information somewhat or very helpful. Veterans’ self-rated computer ability was the strongest factor contributing to both Blue Button use and to sharing information with non-VA providers. When comparing Blue Button users and non-users, barriers to adoption were low awareness of the feature and difficulty using the Blue Button. Conclusions This study contributes to the understanding of early Blue Button adoption and use of this feature for patient-initiated sharing of health information. Educational efforts are needed to raise awareness of the Blue Button and to address usability issues that hinder adoption.

Patient Priorities Care (PPC) is an approach to decision-making for older adults with multiple chronic conditions (MCC). PPC trains facilitators to have structured conversations with patients to identify their priorities (the outcomes that matter most given what care they are willing/able to do or receive). Clinicians then align care to achieve patient priorities rather than focusing on multiple single-disease guidelines. We piloted PPC in a VA geriatrics clinic and compared it to usual care (UC) for multimorbid adults. This retrospective cohort study (n=36 PPC, 36 UC) describes changes made by clinicians after Veterans with MCC had facilitated conversations in a VA geriatric clinic. UC Veterans were matched by prognosis, same primary clinician, and timeframe. Coders used a standardized rubric to assess documented care within medical records. Changes to care examined include medications added/removed, referrals made/avoided, self-care recommendations, and recommendations for social engagement. Although PPC and UC patients were seen by the same clinicians, patients receiving PPC had fewer added medications (mean difference -.47, t(70)=-1.99, p=.05); received more recommendations for self-care aligned with priorities (mean difference .25, t(69)=2.14, p=.003); received more recommended consultations with desired care, including podiatry, transportation, and dermatology (mean difference .55, t(70)=2.06, p=.01), and more recommendations for care and services to facilitate social interactions (p

ObjectivesWhile patients' health priorities should inform healthcare, strategies for doing so are lacking for patients with multiple conditions. We describe challenges to, and strategies that support, patients' priorities-aligned decision-making.DesignParticipant observation qualitative study.SettingPrimary care and cardiology practices in Connecticut.ParticipantsTen primary care clinicians, five cardiologists, and the Patient Priorities implementation team (four geriatricians, physician expert in clinician training, behavioral medicine expert). The patients discussed were ≥ 66 years with >3 chronic conditions and ≥10 medications or saw ≥ two specialists.ExposureFollowing initial training and experience in providing Patient Priorities Care, the clinicians and Patient Priorities implementation team participated in 21 case-based, group discussions (10 face-to-face;11 telephonic). Using emergent learning (i.e. learning which arises from interactions among the participants), participants discussed challenges, posed solutions, and worked together to determine how to align care options with the health priorities of 35 patients participating in the Patient Priorities Care pilot.Main outcomesChallenges to, and strategies for, aligning decision-making with patient's health priorities.ResultsCategories of challenges discussed among participants included uncertainty, complexity, and multiplicity of problems and treatments; difficulty switching to patients' priorities as the focus of decision-making; and differing perspectives between patients and clinicians, and among clinicians. Strategies identified to support patient priorities-aligned decision-making included starting with one thing that matters most to each patient; conducting serial trials of starting, stopping, or continuing interventions; focusing on function (i.e. achieving patient's desired activities) rather than eliminating symptoms; basing communications, decision-making, and effectiveness on patients' priorities not solely on diseases; and negotiating shared decisions when there are differences in perspectives.ConclusionsThe discrete set of challenges encountered and the implementable strategies identified suggest that patient priorities-aligned decision-making in the care of patients with multiple chronic conditions is feasible, albeit complicated. Findings require replication in additional settings and determination of their effect on patient outcomes.

Objective To determine whether a 1-day behavioral intervention, aimed at enhancing psychological flexibility, improves headache outcomes of migraine patients with comorbid depression. Background Migraine is often comorbid with depression, with each disorder increasing the risk for onset and exacerbation of the other. Managing psychological triggers, such as stress and depression, may result in greater success of headache management. Method Sixty patients with comorbid migraine and depression were assigned to a 1-day Acceptance and Commitment Training plus Migraine Education workshop (ACT-ED; N = 38) or to treatment as usual (TAU; N = 22). Patients completed a daily headache diary prior to, and for 3 months following, the intervention. Clinical variables examined included headache frequency/severity, medication use, disability, and visit to a health care professional. Comparisons were made between baseline findings and findings at the 3-month follow up. Results Participants assigned to the ACT-ED condition exhibited significant improvements in headache frequency, headache severity, medication use, and headache-related disability. In contrast, the TAU group did not exhibit improvements. The difference in headache outcomes between ACT-ED and TAU was not statistically significant over time (ie, the treatment by time interaction was nonsignificant). These results complement those of a previous report showing effects of ACT-ED vs TAU on depression and disability. Conclusion A 1-day ACT-ED workshop targeting psychological flexibility may convey benefit for patients with comorbid migraine and depression. These pilot study findings merit further investigation using a more rigorously designed large-scale trial.

We compared the administration of the 9-item Patient Health Questionnaire (PHQ-9) to assess depressive symptoms using interactive voice response (IVR) technology with the method of administration using paper-and-pencil. Data were collected from 51 veterans participating in an 8-week randomized controlled trial of an illness management programme for heart failure. To counter possible bias in answering questions via IVR technology, the anchoring responses of the PHQ-9 questionnaire were reversed so that lower numbers corresponded to more severe depression. The mean for the pencil-and-paper administered PHQ-9 was 4.1 (SD = 4.5) and the mean for IVR administration was 2.8 (SD = 3.1). The internal consistency (Cronbach's alpha) of the PHQ-9 was 0.76 for IVR administration and 0.82 for paper administration. The intraclass correlation coefficient for the two modes of administration was 0.65, indicating moderate agreement. IVR administration of the PHQ-9 produces similar results to pencil-and-paper administration, but the former is not as sensitive to higher levels of depressive symptom severity. This suggests that a lower threshold for probable depression is warranted when assessing depressive symptoms with IVR.

Background Depression in medically ill patients occurs at twice the rate found in the general population. Though pharmacologic and psychotherapeutic interventions for depression are effective, response to treatment and access to care are barriers for this population. A multidimensional telehealth intervention was designed to focus on these barriers by delivering a phone based intervention that addressed managing one's illness and coping emotionally. Methods Veterans with diabetes, hypertension, or chronic pain and depressive symptoms were randomized to one of three conditions: Usual Care (n=23), Illness Management Only (n=31), or Combined Psychotherapy and Illness Management (n=29). Those randomized to the Combined or Illness Management Only intervention group received 10 phone visits. Veterans in the Combined group received all aspects of the illness management program plus a manualized depression intervention. Subjects completed assessments at baseline, week 5, and 10 to test the main hypothesis that veterans in the Combined condition would have a greater decline in depressive symptoms. Results The Combined intervention yielded a significant decline in depressive symptoms when compared with Usual Care. However, the there was no significant difference between the Combined and Illness Management Only groups. Limitations This is a pilot study with a small sample size relative to a standard randomized controlled trial in psychotherapy. Conclusions This telephone-based intervention succeeded in reducing depressive symptoms in veterans with chronic illness. It adds to the building evidence base for providing phone-delivered mental health services.

Migraine is a common and disabling disorder that is highly comorbid with depression. The comorbidity of depression and migraine is a major health concern as it results in poorer prognosis and quality of life. Yet, effective treatments have rarely been investigated.45 patients with comorbid migraine and depression were assigned to a 1-day Acceptance and Commitment Training plus Migraine Education workshop (ACT-ED; N = 31) or to Wait List/Treatment as Usual (WL/TAU; N = 14). Assessment of depressive symptoms, general functioning, and migraine related disability were completed at baseline and 2-, 6-, and 12 weeks after the workshop.At the 3-month follow up, participants in the ACT-ED condition exhibited significantly greater improvements in depressive symptoms, general functioning, and migraine-related disability than patients in the WL/TAU group.A 1-day ACT-ED workshop is a promising approach to the treatment for depression and disability in migraineurs that merits further investigation.