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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]

Purpose: The purpose of this study was to identify posttraumatic stress disorder (PTSD) symptom groups and assess their longitudinal progression during their first year of reintegration among United States (US) National Guard (NG) service members.Methods: A cohort of NG service members (n = 886) completed surveys at 6 and 12 months following their return from deployment to Iraq or Afghanistan. Latent class analysis (LCA) and latent transition analysis (LTA) were used to empirically derive groups based on their PTSD symptoms and examine their longitudinal course, respectively.Results: The best fitting model at both assessments was the four-class model, comprising an asymptomatic class (6 months = 54%; 12 months = 55%), a mild symptom class with elevated hyperarousal symptoms (6 months = 22%; 12 months = 17%), a moderate symptom class (6 months = 15%; 12 months = 15%), and a severe symptom class (6 months = 10%; 12 months = 13%). Based on LTA, stability of class membership at the two assessments was 0.797 for the asymptomatic class, 0.453 for the mild class, 0.560 for the moderate class, and 0.580 for the severe class. Estimated transition probabilities were greater with respect to transitioning to less severe, rather than more severe, classes over time.Conclusions: The four latent PTSD classes were distinguished primarily by severity; however, the mild symptom class was characterized by higher levels of hyperarousal than other symptoms. Although the absolute number of individuals within classes remained fairly constant between 6 and 12 months, there was movement between severity classes. Most NG service members without symptoms continued to do well during the first year, with only an estimated 7% moving to the moderate or severe class. [ABSTRACT FROM AUTHOR]

This study measured the prevalence of evidence-based psychotherapy (EBP) templated notes in VA and tested the hypothesis that template use would be associated with care quality for posttraumatic stress disorder (PTSD). Across 130 facilities, an average of 3.6% of patients with a PTSD diagnosis received at least one EBP template in 2015. Among patients receiving psychotherapy for PTSD, an average of 8.5% received an EBP template. In adjusted models, facility-level EBP template use was associated with a greater proportion of PTSD-diagnosed patients treated in specialty clinics, greater facility-level rates of diagnostic assessment, and greater facility-level rates of psychotherapy adequacy. [ABSTRACT FROM AUTHOR]

Objective: To determine associations between need, enabling, and predisposing factors with mental health service use among National Guard soldiers in the first year following a combat deployment to Iraq or Afghanistan.Data Sources/study Setting: Primary data were collected between 2011 and 2013 from 1,426 Guard soldiers representing 36 units.Study Design: Associations between Guard soldier factors and any mental health service use were assessed using multivariable logistic regression models in a cross-sectional study. Further analysis among service users (N = 405) assessed VA treatment versus treatment in other settings.Principal Findings: Fifty-six percent of Guard soldiers meeting cutoffs on symptom scales received mental health services with 81 percent of those reporting care from the VA. Mental health service use was associated with need (mental health screens and physical health) and residing in micropolitan communities. Among service users, predisposing factors (middle age range and female gender) and enabling factors (employment, income above $50,000, and private insurance) were associated with greater non-VA services use.Conclusion: Overall service use was strongly associated with need, whereas sector of use (non-VA vs. VA) was insignificantly associated with need but strongly associated with enabling factors. These findings have implications for the recent extension of veteran health coverage to non-VA providers. [ABSTRACT FROM AUTHOR]

Chronic pain is associated with increased risk of suicide, and opioids are commonly used to treat moderate to severe pain. However, the association between opioid dose and suicide mortality has not been examined closely. This retrospective data analysis described the risk of suicide associated with differing prescribed opioid doses. Data were from Veterans Affairs health care system treatment records and the National Death Index. Records analyzed were those of Veterans Affairs patients with chronic pain receiving opioids in fiscal years 2004 to 2005 (N = 123,946). Primary predictors were maximum prescribed morphine-equivalent daily opioid dose and opioid fill type. The main outcome measured was suicide death, by any mechanism, and intentional overdose death during 2004 to 2009. Controlling for demographic and clinical characteristics, higher prescribed opioid doses were associated with elevated suicide risk. Compared with those receiving ≤20 milligrams/day (mg/d), hazard ratios were 1.48 (95% confidence intervals [CI], 1.25-1.75) for 20 to <50 mg/d, 1.69 (95% CI, 1.33-2.14) for 50 to <100 mg/d, and 2.15 (95% CI, 1.64-2.81) for 100+ mg/d. The magnitude of association between opioid dose and suicide by intentional overdose was not substantially different from that observed for the overall measure of suicide mortality. Risk of suicide mortality was greater among individuals receiving higher doses of opioids, and treatment providers may want to view high opioid dose as a marker of elevated risk for suicide. Additional research is needed on opioid use, pain treatment, and suicide. [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]

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 the U.S. Department of Veterans Affairs (VA) has prioritized care for posttraumatic stress disorder (PTSD), many patients with PTSD remain symptomatic. Patterns of PTSD symptom change are not well understood. Thus, the current study was designed to categorize and investigate potential predictors of symptom trajectories in patients with PTSD. The sample comprised 2,237 VA patients who were diagnosed with PTSD in 2013 and completed at least 4 PTSD Checklist (PCL) assessments over 12 weeks. Latent trajectory analysis was used to identify latent classes of patients based on PCL scores. Based on model fit indices, 3 trajectories were identified. Compared to patients in the mild-improving trajectory (21.9%), those in the severe-stable trajectory (34.3%) were more likely to be male, relative risk ratio (RRR) = 1.48, 95% CI [1.08, 2.02]; non-White, RRR = 1.77, 95% CI [1.33, 2.35]; Hispanic, RRR = 2.07, 95% CI [1.40, 3.04]; and have comorbid depression, RRR = 1.58, 95% CI [1.25, 1.99]. Compared to patients in the moderate-improving trajectory (43.8%), those in the severe-stable trajectory were more likely to have sleep disorders, RRR = 1.25, 95% CI [1.01, 1.55]. Our findings suggest that male veterans, minority veterans, and veterans with certain comorbid conditions may be less likely to achieve improved PTSD symptoms. Targeted efforts are needed to improve outcomes for PTSD patients on nonremitting trajectories and to improve the consistency of PTSD assessment across the VA health care system. [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]

The article looks at the results of a study on deaths from drug overdose among patients receiving prescription opioid analgesics for the treatment of acute and chronic pain. Topics mentioned include increased risk of death from drug overdose associated with the receipt of benzodiazepines among veterans receiving opioids, use of data from the Veterans Health Administration covering U.S. veterans in 2004 to 2009, and adjustments for characteristics of patients at baseline.

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]

The increasing prevalence of quinolone-resistant Neisseria gonorrhoeae (QRNG) in the United States is a cause for concern. Detecting resistance is complicated by the widespread use of molecular tests that do not provide isolates for susceptibility testing. The Michigan Department of Community Health developed a sentinel surveillance program to detect antimicrobial drug resistance in N. gonorrhoeae. Sentinel surveillance from 11 laboratories submitted 1,122 isolates for antimicrobial drug susceptibility testing and detected 2 clusters of QRNG from January 2003 to September 2004. These clusters were epidemiologically distinct: one involved young, heterosexual youth, and the other involved older men who have sex with men. This finding led to changes in local treatment recommendations that limited spread of resistant strains. Development of the sentinel program, collection of data, and epidemiologic analysis of the clusters are discussed. [ABSTRACT FROM AUTHOR]

Abstract: Background: Initiation of antidepressant treatment for depression may be associated with new onset (emergent) anxiety. Objective: The purpose of this study was to assess demographic and clinical factors associated with emergent anxiety following a new antidepressant start among Department of Veterans Affairs (VA) Health System patients with depression. Methods: Using a retrospective cohort design, we obtained data from 328,888 VA patients with depression who were newly prescribed 1 of the 7 most commonly used antidepressant drugs between April 1999 and September 2004 from the VA National Depression Registry. We examined the prevalence of emergent anxiety, defined as either a new anxiety diagnoses or by new antianxiety medication starts, during the 12 weeks following new antidepressant start. In multivariate analyses, we assessed the hazard ratios for emerging anxiety associated with patient characteristics and specific antidepressant agents. Results: Approximately 3% of patients developed clinically significant anxiety within 12 weeks of starting an antidepressant drug regimen. Younger age (age <45 years and 45–64 years) was associated with higher risks for emergent anxiety than older age (≥65 years) (hazard ratio [HR] = 1.72 and 1.55; 95% CI, 1.59–1.85, and 1.38–1.72, respectively). Female gender was associated with higher risks than male gender (HR = 1.17; 95% CI, 1.10–1.26), and white and other races compared with black race were associated with higher risks of emergent anxiety (HR = 1.49 and 1.13; 95% CI, 1.30–1.59 and 1.04–1.23, respectively). Finally, filling antidepressant drug prescriptions in years subsequent to 1999 was associated with lower risks of emergent anxiety. Conclusions: Only a small proportion of patients developed emergent anxiety following a new antidepressant start, resulting in a new diagnosis or antianxiety medication use. Anxiety occurred more often in young adults, whites, and women. [Copyright &y& Elsevier]