Search

Acceptance and Commitment Therapy for depression (ACT-D) is a promising depression treatment which has not been evaluated on a large scale within VA. This study aimed to evaluate ACT-D's effectiveness in a national, treatment-seeking sample of Veterans. The sample comprised 831 Veterans who received a primary depression diagnosis and received at least two sessions of ACT-D during fiscal years 2015–2020. We used GLM to measure predictors of symptom change, treatment response (50 % reduction in PHQ-9 and AAQ-II scores), subthreshold depression symptoms (PHQ-9 < 10; AAQ-II < 27), and treatment completion. Veterans experienced an average reduction of 3.39 points on the PHQ-9 (Cohen's d = 0.56) and 3.76 points on the AAQ-II (Cohen's d = 0.43). On the PHQ-9, 40 % achieved subthreshold depression symptoms. On the AAQ-II, 36 % of Veterans achieved subthreshold psychological inflexibility scores. Service-connected disability rating for depression and higher levels of medical comorbidity were both related to lower levels of overall depression symptom change and treatment response. Substance use disorder and bipolar/psychosis diagnoses were associated with greater reductions in psychological inflexibility. This is an observational study without a control group, so we were unable to compare the effectiveness of ACT-D to other usual care for depression. We were also unable to assess variables that can influence treatment success, such as therapist fidelity and patient engagement. ACT-D achieved similar improvements in depression as reported in controlled trials. Adaptations to ACT-D may be needed to improve outcomes for Veterans with depression and comorbid PTSD. • Veterans experienced medium effect size decreases in depression over the course of ACT-D • We found similar effects for ACT-D as have been found in other studies of cognitive-behavioral therapies for depression. • Veterans with depression and comorbid PTSD experienced less change in depression symptoms. • ACT approaches might be helpful to incorporate for individuals for substance use disorder and bipolar/psychosis diagnoses [ABSTRACT FROM AUTHOR]

This study examined the population-based reach of Veterans Health Administration (VHA) employment services to VHA patients with psychiatric diagnoses. Reach of services includes the percentage and characteristics of people who accessed services compared with those who did not. Using clinical administrative data, we identified patients with a psychiatric diagnosis among a random sample of all patients who received VHA services in 1 yr. Among VHA patients with psychiatric diagnoses, we examined their likelihood of receiving any VHA employment services and specific types of employment services, including supported employment, transitional work, incentive therapy, and vocational assistance. We identified clinical and demographic characteristics associated with receiving employment services. Results indicated that 4.2% of VHA patients with a psychiatric diagnosis received employment services. After adjusting for clinical and demographic characteristics, VHA patients with schizophrenia and bipolar disorder were more likely to receive any employment services and to receive supported employment than were patients with depression, PTSD, or other anxiety disorders. VHA patients with depression and PTSD were more likely to receive transitional work and vocational assistance than patients with schizophrenia. Future studies should examine system-level barriers to receiving employment services and identify types of employment services most appropriate for Veterans with different psychiatric diagnoses. [ABSTRACT FROM AUTHOR]

Background: Although most veterans with posttraumatic stress disorder (PTSD) benefit from evidence-based treatments, questions persist concerning the profiles of those at risk for poor outcomes. To help address these gaps, this study analyzed a large clinical cohort of veterans receiving prolonged exposure (PE) or cognitive processing therapy (CPT).Methods: Cluster analysis using Ward's method with Euclidian distances identified clinically meaningful subgroups of veterans in a national cohort (n = 20,848) using variables maintained in the electronic medical record. The clusters were then compared via one-way analysis of variance and Tukey's HSD on indicators of treatment progress including PTSD symptom change, clinical recovery, clinically significant change, remission, and treatment completion.Results: Effect size differences on clinical outcome measures for PE and CPT were negligible. Less than half of veterans achieved at least a 15-point reduction in PCL-5 score and half completed treatment. We identified 10 distinct clusters. Higher rates of PTSD service-connected disability were linked to poorer outcomes across multiple clusters, especially when combined with Post-Vietnam service era. Non-White race was also linked with poorer clinical outcomes. Factors associated with better outcomes included a greater proportion of female veterans, especially when combined with recent service era, and longer PTSD diagnosis duration.Conclusions: This study suggests the need to improve PTSD treatment outcomes for non-White and male veterans, examine treatment response in Post-Vietnam era veterans, and consider ways in which the service connection process could hinder treatment response. The results from this study also indicate the benefits of integrating elements of clinical complexity into an analytic approach. [ABSTRACT FROM AUTHOR]

Depressed patients discharged from psychiatric hospitalizations face increased risks for adverse outcomes including suicide, yet antidepressant adherence rates during this high-risk period are unknown. Using Veterans Affairs (VA) data, we assessed antidepressant adherence and predictors of poor adherence among depressed veterans following psychiatric hospitalization. We identified VA patients nationwide with depressive disorders who had a psychiatric hospitalization between April 1, 1999 and September 30, 2003, received antidepressant medication, and had an outpatient appointment following discharge. We calculated medication possession ratios (MPRs), a measure of medication adherence, within 3 and 6 months following discharge. We assessed patient factors associated with having lower levels of adherence (MPRs < 0.8) after discharge. The criteria for 3- and 6-month MPRs were met by 20,931 and 23,182 patients respectively. The mean 3 month MPR was 0.79 (SD = 0.37). The mean 6 month MPR was 0.66 (SD = 0.40). Patients with poorer adherence were male, younger, non-white, and had a substance abuse disorder, but were less likely to have PTSD or other anxiety disorders. Poor antidepressant adherence is common among depressed patients after psychiatric hospitalization. Efforts to improve adherence at this time may be critical in improving the outcomes of these high-risk patients. [ABSTRACT FROM AUTHOR]

Objective To assess mental health symptoms, suicidal ideation/behaviors, and treatment among a nationally representative probability sample of student veterans. Participants: Student veterans enrolled in post-secondary educational institutions and matched comparison students. Methods: Sampled participants completed an online survey (n = 1,838). Analyses accounted for the complex sample design and non-response. Results: Substantial percentages of student veterans screened positive for: depression (36.9%, 95% CI: 31.1-42.7), PTSD (35.7%, 95% CI 29.9-41.5), anxiety (29.5%, 95% CI 26.8-32.2), and suicidal ideation (14.6%, 95% CI 12.1-17.1), with student veterans having odds ratios between 1.7 to 2.4 for positive screens compared to non-veteran students. Only 41.5% (95% CI 33.0-50.0) of student veterans with positive screens received treatment, although they had 50% higher odds of receiving treatment than non-veteran students. Conclusions: Student veterans have high rates of mental health symptoms and low rates of treatment. However, they are more likely to receive treatment than comparison students. [ABSTRACT FROM AUTHOR]

Background: The population of people with opioid use disorders (OUD) is aging. There has been little research on the effects of aging on mortality rates and causes of death in this group. We aimed to compare mortality in older (≥ 50 years of age) adults with OUD to that in younger (<50 years) adults with OUD and older adults with no history of OUD. We also examined risk factors for specific causes of death in older adults with OUD.Methods: Using data from the Veteran's Health Administration National Patient Care Database (2000-2011), we compared all-cause and cause-specific mortality rates in older adults with OUD to those in younger adults with OUD and older adults without OUD. We then generated a Cox regression model with specific causes of death treated as competing risks.Results: Older adults with OUD were more likely to die from any cause than younger adults with OUD. The drug-related mortality rate did not decline with age. HIV-related and liver-related deaths were higher among older OUD compared to same-age peers without OUD. There were very few clinically important predictors of specific causes of death.Conclusion: Considerable drug-related mortality in people with OUD suggests a need for greater access to overdose prevention and opioid substitution therapy across the lifespan. Elevated risk of liver-related death in older adults may be addressed through antiviral therapy for hepatitis C virus infection. There is an urgent need to explore models of care that address the complex health needs of older adults with OUD. [ABSTRACT FROM AUTHOR]

Background The population of people with opioid use disorders (OUD) is aging. There has been little research on the effects of aging on mortality rates and causes of death in this group. We aimed to compare mortality in older (≥50 years of age) adults with OUD to that in younger (<50 years) adults with OUD and older adults with no history of OUD. We also examined risk factors for specific causes of death in older adults with OUD. Methods Using data from the Veteran's Health Administration National Patient Care Database (2000–2011), we compared all-cause and cause-specific mortality rates in older adults with OUD to those in younger adults with OUD and older adults without OUD. We then generated a Cox regression model with specific causes of death treated as competing risks. Results Older adults with OUD were more likely to die from any cause than younger adults with OUD. The drug-related mortality rate did not decline with age. HIV-related and liver-related deaths were higher among older OUD compared to same-age peers without OUD. There were very few clinically important predictors of specific causes of death. Conclusion Considerable drug-related mortality in people with OUD suggests a need for greater access to overdose prevention and opioid substitution therapy across the lifespan. Elevated risk of liver-related death in older adults may be addressed through antiviral therapy for hepatitis C virus infection. There is an urgent need to explore models of care that address the complex health needs of older adults with OUD. [ABSTRACT FROM AUTHOR]

To better understand processes of mental health crisis line utilization by examining associations between reasons for contacting a crisis line with the initiation of emergency dispatches (i.e., activation of 911 or local emergency services) in a national sample. Contacts (i.e., calls, texts, email, and chats) to the Veterans Crisis Line (VCL) across 2017–2020 were used to examine associations among stated reasons for the contact and the use of an emergency dispatch. Hierarchical logistic regression models were used to determine the odds of an emergency dispatch by reason for the contact. Suicidal thoughts/crisis were present in 61.5% of contacts that ended in emergency dispatches and were associated with the largest adjusted odds of a dispatch, (Adjusted Odds Ratio [AOR] [95% CI] = 9.34 [9.21, 9.48]), followed by homicidal thoughts/crisis (AOR [95% CI] = 3.84 [3.73, 3.95]), and third-party concerns (AOR [95% CI] = 2.42 [2.37, 2.47]). Substance use/ addiction (AOR [95% CI] = 2.14 [2.10, 2.18]), abuse and violence (AOR [95% CI] = 1.89 [1.82, 1.96]), and physical health (AOR [95% CI] = 1.87 [1.84, 1.91]) were also associated with increased odds of a dispatch. Emergency dispatches are primarily used in response to imminent suicide risk but are also used in other potentially violent or lethal circumstances such as homicides, violence or abuse, and other crises. These findings highlight the role that crisis lines play in emergency service delivery, and the need to better understand how they are utilized under real world circumstances. • Veterans Crisis Line (VCL) contacts that were most likely to result in an emergency dispatch were those with suicidal thoughts/crisis • Homicidal thoughts/crisis, third party concerns, substance use/addiction, abuse and violence, and physical health were also associated with emergency dispatches • Emergency dispatches are primarily used for suicidal crises, but are also used for other contacts with potential for injury or death [ABSTRACT FROM AUTHOR]

Objective: Psychotherapy for depression is effective for many veterans, but the relationship between number of treatment sessions and symptom outcomes is not well established. The Dose-Effect model predicts that greater psychotherapeutic dose (total sessions) yields greater symptom improvement with each additional session resulting in smaller session-to-session improvement. In contrast, the Good-Enough Level (GEL) model predicts that rate of symptom improvement varies by total psychotherapeutic dose with faster improvement associated with earlier termination. This study compared the dose-effect and GEL model among veterans receiving psychotherapy for depression within the Veterans Health Administration. Method: The sample included 13,647 veterans with ≥2 sessions of psychotherapy for depression with associated Patient Health Questionnaire-9 (PHQ-9) scores in primary care (n = 7,502) and specialty mental health clinics (n = 6,145) between October 2014 and September 2018. Multilevel longitudinal modeling was used to compare the Dose-Effect and GEL models within each clinic type. Results: The GEL model demonstrated greater fit for both clinic types relative to dose-effect models. In both treatment settings, veterans with fewer sessions improved faster than those with more sessions. In primary care clinics, veterans who received 4–8 total sessions achieved similar levels of symptom response. In specialty mental health clinics, increased psychotherapeutic dose was associated with greater treatment response up to 16 sessions. Veterans receiving 20 sessions demonstrated minimal treatment response. Conclusions: These findings support the GEL model and suggest a flexible approach to determining length of psychotherapy for depression may be useful for optimizing treatment response and allocation of clinical resources. What is the public health significance of this article?: Rates of improvement and total number of psychotherapy sessions needed to achieve a good-enough depression symptom response vary substantially across individuals. Clinicians should tailor treatment duration to the rate of improvement of the individual patient. Health systems should anticipate wide variation in treatment duration when assessing mental health care quality and access. [ABSTRACT FROM AUTHOR]

Objectives: To assess possession of household firearms among veterans receiving mental health care and the frequency of their discussions with clinicians about firearms. Methods: We surveyed random samples of veterans receiving mental health care in each of five purposively chosen, geographically diverse VA facilities; 677 (50% of recipients) responded. Results: 45.3% (95% CI 41.2, 49.3) of veteran respondents reported household firearms; 46.9% of those with suicidal thoughts and 55.6% with a suicide plan had household firearms. Only 27.5% of all veteran respondents and 44% of those with recent suicidal ideation and household firearms had had a firearm-related discussion with a clinician. Discussion: Many veterans receiving mental health care can readily access firearms, a highly lethal means for suicide. Increasing clinician-patient discussions and health system efforts to reduce firearm access might reduce suicide in this clinical population. [ABSTRACT FROM AUTHOR]

Objective: Assess whether neighborhood characteristics predict patient-reported outcomes for depression.Data Sources: VA electronic medical record data and U.S. census data.Study Design: Retrospective longitudinal cohort.Data Extraction Methods: Neighborhood and individual characteristics of patients (N = 4,269) with a unipolar depressive disorder diagnosis and an initial Patient Health Questionnaire (PHQ-9) score ≥10 were used to predict 50 percent improvement in 4-8-month PHQ-9 scores.Principal Findings: The proportion of a patient's neighborhood living in poverty (OR = 0.98; 95% CI: 0.97-.1.00; P = 0.03) was associated with lower likelihood of depression symptom improvement in addition to whether the patient was black (OR = 0.76; 95% CI:0.61-0.96; P = 0.02) had PTSD (OR = 0.59; 95% CI:0.50-0.69; P < 0.001) or had any service-connected disability (OR = 0.73; 95% CI:0.61-0.87; P < 0.001).Conclusions: Neighborhood poverty should be considered along with patient characteristics when determining likelihood of depression improvement. [ABSTRACT FROM AUTHOR]

Highlights • We investigated predictors of PTSD treatment response in residential settings. • Significant factors included psychological, social, and physical health resources. • Treatment modifications may be needed for subgroups at risk of poor response. Abstract Objective Although several treatments for PTSD have demonstrated efficacy, a substantial portion of patients do not experience clinically significant improvement. Predictors of treatment response are poorly understood. The current study was designed to investigate predictors of PTSD symptom change in a large national sample of treatment-seeking Veterans with PTSD. Method We analyzed predictors of treatment response among Veterans engaged in residential PTSD treatment from 2012 to 2013 (N = 2715). Multilevel modeling was used to assess the association between individual-level factors and symptom improvement from treatment entry to post-discharge. Guided by the theory of Resources, Life Events and Changes in Psychological States, we hypothesized that individuals with greater psychological, social/contextual, material, and physical health resources would exhibit better treatment response. Results In adjusted analyses, accounting for facility, factors that predicted better treatment response included female gender, more psychological and social/contextual protective factors, and more years of education. Factors that predicted worse treatment response included Black race, comorbid personality disorder, greater pain severity, and current application for disability-related compensation. Conclusions These findings highlight factors that place individuals at risk of poor treatment response. Treatment modifications may be needed in order to optimize response for subgroups who are less likely to benefit from residential PTSD treatment. [ABSTRACT FROM AUTHOR]

Objective This study sought to identify patient characteristics and care processes related to reengagement in VA psychotherapy. Methods Using national VA data, a retrospective cohort was constructed ( N = 24,492) of veterans who received a new PTSD diagnosis in FY08/FY09 and attended only one to five PTSD psychotherapy sessions. A nested case-control study was conducted comparing veterans who reengaged in psychotherapy ( n = 9649) in a 1:5 ratio with those who did not reengage by the end of FY12. Conditional logistic regression models were run to examine differences in sociodemographic, mental health, and service utilization factors between cases and controls. Results Among veterans in the study cohort, 39.4% reengaged in psychotherapy. In adjusted analyses, all measured types of health system encounters (primary care [OR = 1.61], primary care mental health [OR = 1.61], non-PTSD psychotherapy [OR = 1.76], other non-PTSD mental health care [OR = 1.43], other non-psychotherapy PTSD care [OR = 3.31], emergency room [OR = 1.14], and psychiatric hospitalization [OR = 1.56]) were related to greater odds of reengagement in PTSD psychotherapy. Conclusions Veterans' receipt of a broad range of care services may play an important role in reengagement in PCT psychotherapy, suggesting providers across care settings should be knowledgeable in how to support a Veteran's return to psychotherapy for PTSD. [ABSTRACT FROM AUTHOR]

The Veterans Health Administration (VHA) designed the Opioid Safety Initiative (OSI) to help decrease opioid prescribing practices associated with adverse outcomes. Key components included disseminating a dashboard tool that aggregates electronic medical record data to audit real-time opioid-related prescribing and identifying a clinical leader at each facility to implement the tool and promote safer prescribing. This study examines changes associated with OSI implementation in October 2013 among all adult VHA patients who filled outpatient opioid prescriptions. Interrupted time series analyses controlled for baseline trends and examined data from October 2012 to September 2014 to determine the changes after OSI implementation in prescribing of high-dosage opioid regimens (total daily dosages >100 morphine equivalents [MEQ] and >200 MEQ) and concurrent benzodiazepines. Across VHA facilities nationwide, there was a decreasing trend in high-dosage opioid prescribing with 55,722 patients receiving daily opioid dosages >100 MEQ in October 2012, which decreased to 46,780 in September 2014 (16% reduction). The OSI was associated with an additional decrease, compared to pre-OSI trends, of 331 patients per month (95% confidence interval [CI] -378 to -284) receiving opioids >100 MEQ, a decrease of 164 patients per month (95% CI -186 to -142) receiving opioids >200 MEQ, and a decrease of 781 patients per month (95% CI -969 to -593) receiving concurrent benzodiazepines. Implementation of a national health care system-wide initiative was associated with reductions in outpatient prescribing of risky opioid regimens. These findings provide evidence for the potential utility of large-scale interventions to promote safer opioid prescribing. [ABSTRACT FROM AUTHOR]

Although improving residential PTSD care is a priority for the Department of Veterans Affairs, previous evaluations have been limited by a lack of systematic data collection across more than two timepoints. This study used recently available data to assess symptom trajectories in a large, national sample of veterans who engaged in residential PTSD treatment. Group-based trajectory analysis PROC TRAJ was used to identify PTSD residential treatment response in a national cohort of veterans (n = 10,832) and the subset of veterans (n = 6515) receiving evidence-based psychotherapy (EBP). PTSD symptoms were assessed at intake, discharge, and 4-month follow-up. Predictors of trajectory membership were estimated using multinomial models. For the full cohort, a three-group trajectory model provided the best fit with the following identified groups: "Severe/Stable" (51.8%), "Moderate/Rebound" (40.1%), and "Mild/Rebound" (8.1%). For the EBP sub-cohort, a three-group trajectory model was selected with the following groups: "Severe/Stable" (58.5%), "Moderate/Rebound" (34.1%), and "Mild/Rebound" (7.4%). Across all trajectories, psychological distress, pain severity, substance use, Iraq/Afghanistan combat era, non-White race, and treatment dropout were associated with poorer treatment response. In the EBP sub-cohort, homelessness and unemployment at the time of admission were also associated with poorer treatment outcomes to varying degrees. This study demonstrates that residential treatment for PTSD is associated with heterogeneous treatment trajectories which highlight the need to continue to explore and improve residential PTSD treatment outcomes. Our results underscore the importance of obtaining follow-up data and identifying ways to maintain therapeutic gains following discharge. • We estimated treatment trajectories for a full and EBP subcohort of Veterans. • The full and EBP subcohort demonstrated similar trajectories over three timepoints. • More work is needed to improve maintenance of gains after treatment. [ABSTRACT FROM AUTHOR]

Abstract. Objective: To compare mental health symptoms and service utilization among returning student and nonstudent service members/veterans (SM/Vs). Participants: SM/Vs (N = 1,439) were predominately white (83%) men (92%), half were over age 30 (48%), and 24% were students. Methods: SM/Vs completed surveys 6 months post deployment (October 2011–July 2013). Results: Students and nonstudent SM/Vs did not differ in positive screens for depression, anxiety, hazardous drinking, or posttraumatic stress disorder. Students (n = 81) and nonstudents (n = 265) with mental health symptoms had low levels of mental health service use (eg, Department of Veterans Affairs [VA], civilian, or military facilities), at 47% and 57%. respectively. Fewer students used VA mental health services. Common barriers to treatment seeking included not wanting treatment on military records and embarrassment. Conclusions: Like other returning SM/Vs, student SM/Vs have unmet mental health needs. The discrepancy between potential need and treatment seeking suggests that colleges might be helpful in further facilitating mental health service use for student SM/Vs. [ABSTRACT FROM AUTHOR]

Purpose: Low social support and small social network size have been associated with a variety of negative mental health outcomes, while their impact on mental health services use is less clear. To date, few studies have examined these associations in National Guard service members, where frequency of mental health problems is high, social support may come from military as well as other sources, and services use may be suboptimal.Methods: Surveys were administered to 1448 recently returned National Guard members. Multivariable regression models assessed the associations between social support characteristics, probable mental health conditions, and service utilization.Results: In bivariate analyses, large social network size, high social network diversity, high perceived social support, and high military unit support were each associated with lower likelihood of having a probable mental health condition (p < .001). In adjusted analyses, high perceived social support (OR .90, CI .88-.92) and high unit support (OR .96, CI .94-.97) continued to be significantly associated with lower likelihood of mental health conditions. Two social support measures were associated with lower likelihood of receiving mental health services in bivariate analyses, but were not significant in adjusted models.Conclusions: General social support and military-specific support were robustly associated with reduced mental health symptoms in National Guard members. Policy makers, military leaders, and clinicians should attend to service members' level of support from both the community and their units and continue efforts to bolster these supports. Other strategies, such as focused outreach, may be needed to bring National Guard members with need into mental health care. [ABSTRACT FROM AUTHOR]

Abstract: Objectives: Electroconvulsive therapy (ECT) is the most effective treatment for severe or treatment resistant depression; however, the lack of widely accepted methods for determining when ECT is indicated may contribute to disparities and variation in use. We examined receipt of ECT among depressed patients in the largest coordinated health system in the US, the Veterans Health Administration. Methods: Using administrative data, we conducted a multivariable logistic regression to identify individual clinical and sociodemographic predictors of receiving ECT, including variables of geographic accessibility to ECT, among patients diagnosed with major depressive disorder between 1999 and 2004. Results: 307 (0.16%) of 187,811 patients diagnosed with major depression received ECT during the study period. Black patients were less likely to receive ECT than whites (odds ratio 0.33; 95% confidence interval: 0.20, 0.55), and patients living in the South (OR: 0.71; 95% CI: 0.53, 0.95) or West (OR: 0.59; 95% CI: 0.42, 0.82) were less likely to receive ECT than patients living in the central US. Patients whose closest VA facility provided ECT had a higher likelihood of receiving ECT (OR: 3.02; 95% CI: 2.22, 4.10). Depressed patients with no major medical comorbidities were also more likely to receive ECT (OR: 2.42; 95% CI: 1.65, 3.55). Limitations: Findings are not adjusted for depression severity. Conclusions: ECT use for major depression was relatively uncommon. Race, US region, geographic accessibility, and general medical health were all associated with whether or not patients received ECT. Clinicians and health systems should work to provide equitable access and more consistent use of this safe and effective treatment. [Copyright &y& Elsevier]