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This study reports on gender differences in psychosocial symptoms and suicidal thoughts and behaviors from the first longitudinal, national survey of veterans with a recent nonfatal suicide attempt to inform women-tailored suicide prevention. We recruited all female veterans with a documented nonfatal suicide attempt between October 2018 and September 2019 and a stratified matched sample of males. Surveys were administered at baseline, month 6, and month 12; 968 veterans completed the baseline survey with valid gender data. Surveys assessed psychosocial constructs, suicidal ideation severity, and suicidal behavior. Administrative datasets provided healthcare and suicide attempt data during the one year follow up. Women retained higher social rejection and institutional betrayal, and lower self-compassion and autonomy than men over follow up. Higher overall self-compassion was associated with lower baseline suicide ideation for both women and men; however, this association was stronger for women (Δ = −0.19; 95 % CI = -0.31, −0.07; d = −0.15). Individuals with higher overall psychological distress had greater odds of a subsequent suicide attempt (AOR = 2.20, 95 % CI = 1.56, 3.11). Social rejection had the strongest association with worsening psychological distress, both within individuals (b = 0.18; 95 % CI = 0.14, 0.23; d = 0.23) and between individuals (b = 0.07; 95 % CI = 0.04, 0.10; d = 0.09). Results may not generalize beyond a VHA-utilizing veteran population. Findings from this study inform potential therapeutic targets and topics for future research on tailoring suicide prevention for women veterans. While all veterans may need support reducing distress, women may need additional support in multiple other areas. • Tailored suicide prevention strategies for women veterans are needed. • Psychological distress is a core contributor to suicide risk among veterans. • Women veterans carry higher psychosocial risk and lower resilience than men. • Chronic illness approaches are warranted for veterans with recent suicide attempts. [ABSTRACT FROM AUTHOR]

Objective: Health coaching has shown promise in helping patients manage their chronic disease and in improving health outcomes, yet the implementation of health coaching in healthcare systems is understudied. Further, evidence suggests that interdisciplinary care teams may be more effective in treating chronic pain than usual care. As such, we sought to examine the benefits and drawbacks to embedding health coaches within interdisciplinary pain care teams ("Whole Health Teams"). Design: As part of a multisite clinical trial (at five Veterans Health Administration sites) investigating the effectiveness of a Whole Health Team (WHT) approach to care for patients with chronic pain, qualitative interviews gathered data on how the experience of treating patients in the WHT differed from the experience treating patients outside the WHT, as well as provider experiences coordinating patient care within the WHT. Participants: Twenty-two WHT members, study investigators, and study coordinators. Approach: Data were analyzed using a rapid analysis approach. Results: Overall, stakeholders perceived considerable synergy within the interdisciplinary pain care team. Each provider brought a different perspective to the patient's health concerns, which stakeholders felt was valuable and increased patient progress towards goals. The team model was also viewed as efficient because everyone was committed to working together and communicating as a team. Logistically, however, stakeholders noted challenges to working as a team, especially regarding patient goal setting. Furthermore, multiple stakeholders believed the care team model required a high degree of dedication to teamwork and communication among its members to be successful. Conclusions: Embedding health coaches within interdisciplinary pain care teams may improve care processes and accelerate patient progress. Successful implementation would require adequate training, role clarification, and expectation setting to facilitate good communication across all care team members. Additional research is needed to evaluate the clinical outcomes of integrating health coaches on WHTs versus other implementation approaches. [ABSTRACT FROM AUTHOR]

Women are a minority veteran subpopulation experiencing particular risk for suicide and facing distinct challenges in accessing Veterans Health Administration (VHA) care. As part of efforts to enhance suicide prevention, the VHA established Suicide Prevention Coordinators (SPC) as clinicians who work exclusively to connect high-risk veterans to the scope of VHA's services. To understand the experiences of women veterans with suicide risk who access care, this study presents findings from qualitative interviews with SPCs regarding the care needs, preferences, and concerns of women veterans who utilize VHA for enhanced suicide-related care. We conducted qualitative interviews with 20 SPCs from 13 VAMCs around the United States. We specifically asked SPCs to share perspectives on women veterans' barriers to accessing care and their recommendations to improve suicide prevention for this subpopulation. We conducted a thematic content analysis to extract key themes. SPCs revealed that women veterans opt to avoid VHA due to prior negative experiences, often related to provider sensitivity to women's issues. Safety was another key concern, specifically related to feeling unwelcome or intimidated in the male dominated veteran community. Key provider recommendations include increasing the availability of gender-sensitive providers and making changes to the physical spaces of the VHA to better facilitate women veterans' access to care. SPCs underscored the importance of comfort and relatability between women patients and providers, especially in relation to enhanced care for suicide risk. This study presents important evidence in support of enhancing suicide prevention by better engaging women veterans in care that is more inclusive and more sensitive to their experiences and identity, in and outside VHA. [ABSTRACT FROM AUTHOR]

Background : In late 2018, VHA implemented a multi-stage suicide risk screening and evaluation initiative, Suicide Risk Identification Strategy, or "Risk ID," in primary care settings. Objective: The main objective of this study was to characterize VHA primary care patient perspectives regarding population-based suicide risk screening through the Risk ID program. Design: Mixed methods; survey and qualitative interviews. Participants: Veterans screened for suicide risk using Risk ID in primary care (n = 868) participated in a survey of veteran attitudes about screening (45% response rate); thirty additionally participated in follow-up qualitative interviews. Main Measures: The quantitative survey consisted of three questions on attitudes about screening for suicidal thoughts in primary care. In qualitative interviews, veterans were asked about their experiences with the Risk ID processes and recommendations for improving Risk ID. Key Results: Over 90% of veterans reported that it is appropriate for primary care providers or nurses/medical assistants to ask veterans about thoughts of suicide during primary care visits. Approximately half of veterans indicated that veterans should be asked about suicidal thoughts at every visit. Qualitative findings revealed that while most veterans were generally supportive and appreciated VHA screening for suicidal thoughts, they also expressed concern for the potential for inadvertent harm. Participants expressed conflicting preferences for how screening should be handled and delivered. Conclusions: Findings suggest that most veterans support the integration of standardized suicide risk assessment into routine primary care visits. However, findings also suggest that population-based suicide risk assessment should further consider patient experiences and preferences. Specifically, additional guidance or training for staff conducting suicide risk screening may be warranted to ensure patients feel heard (e.g., eye contact, expressing empathy) and increase patient understanding of the purpose of the screening and potential outcomes. These patient-centered approaches may improve patient experience and facilitate disclosure of suicidal thoughts. [ABSTRACT FROM AUTHOR]

This national, observational study examined factors associated with undetermined self-directed violence (SDV) classification among Veterans with a SDV event classified as either "suicide attempt" or "undetermined SDV" in in the Veterans Health Administration (VHA) between 2013 and 2018 (N = 55,878). Generalized estimating equations were used to examine associations of patient and SDV event factors with likelihood of an undetermined SDV classification. Veterans who used poisoning or other methods had 1.52 (95%CI: 1.38, 1.66) and 2.33 (95%CI: 2.16, 2.50) increased odds of having their SDV classified as undetermined, respectively. Veterans with a prior year substance use disorder diagnosis had 1.19 (95%CI: 1.14, 1.24) increased odds of having their SDV classified as undetermined. In sex-stratified analyses, associations of poisoning and substance use disorders held only among males. Additional clinical evaluation of patients with histories of substance use disorders or who use poisoning as method of SDV may be warranted when making SDV determinations. [ABSTRACT FROM AUTHOR]

Crisis line responders initiate emergency dispatches by activating 911 or other local emergency services when individuals are determined to be at imminent risk for undesired outcomes. This study examined the association of characteristics, psychiatric diagnoses, and somatic symptoms with emergency dispatches in a national sample. Veterans Crisis Line data were used to identify contacts (i.e., calls, texts, chats, emails) that were linked with medical records and had a medical encounter in the year prior to contact. Hierarchical logistic regression clustered by responders was used to identify the association among demographics, psychiatric diagnoses, and somatic disorders, and emergency dispatches. Analyses examined 247,340 contacts from 2017 to 2020, with 27,005 (10.9%) emergency dispatches. Odds of an emergency dispatch increased with each diagnosis (three diagnoses Adjusted Odds Ratio [AOR] (95% CI) = 1.88 [1.81,1.95]). Odds were highest among individuals with substance use disorders (SUD) (alcohol AOR (95% CI) = 1.85 [1.80,1.91]; drugs AOR (95% CI) = 1.63 [1.58, 1.68]), which may be a result of intoxication or overdose during contact, requiring further research. Having more psychiatric and somatic conditions was associated with greater odds of an emergency dispatch, indicating that comorbidity contributed to the need for acute care. [ABSTRACT FROM AUTHOR]

To examine the fit between core concepts of self-determination theory and patient experiences with health coaching, 18 participants at one large United States Veterans Affairs medical centre completed semi-structured, audio-recorded interviews (40–60 min) about their experiences with health coaching. Transcripts were analysed using thematic analysis, and self-determination theory concepts (autonomy, competence, relatedness, and self-integration) were applied to the data. Participant descriptions of their experiences with health coaching were consistent with the process of motivation and goal attainment proposed by self-determination theory. Participants felt the programme supported their sense of autonomy by helping them select goals that were important to them and recognising their ownership over outcomes. Competence was described as the 'confidence' to tackle any challenge and relatedness was discussed as a consistently strong rapport with the health coach. Participants spoke to self-integration by discussing their ability to maintain behaviour change beyond the coaching programme, with some explicitly making the connection between behaviours and their values and life purpose. This study provides initial support for the use of self-determination theory as a theoretical basis of health coaching. Support for patient autonomy, competence, and relatedness may be important components of health coaching practice. [ABSTRACT FROM AUTHOR]

In this study, we examined the indirect effect of the Virtual Hope Box (VHB) smartphone application on suicidal ideation, mediated through coping self-efficacy. A total of 117 veterans with suicidal ideation completed measures on coping self-efficacy and suicidal ideation at baseline and weeks 3, 6, and 12. Participants were randomly assigned to either the VHB or enhanced treatment as usual (eTAU) condition. Parallel process growth curve modeling (-0.20 [95% CI = -0.44, 0.00]) and auto-regressive modeling (-0.12 [95% CI = -0.35, -0.01]) revealed that a higher rate of change in coping self-efficacy in the VHB group was associated with a decrease in suicidal ideation severity, as compared to the eTAU group. Findings suggest that coping self-efficacy may be one mechanism by which the VHB operates to help reduce suicidal ideation. More broadly, the role of coping self-efficacy in reducing suicidal ideation is worthy of future study. [ABSTRACT FROM AUTHOR]

Background: The OpenNotes initiative provides patients online access to their clinical notes. Mental health clinicians in the Veterans Health Administration report a need for guidance on how to provide care, write notes, and discuss them in the context of OpenNotes. Aim: To provide mental health clinicians recommendations identified by patients and clinicians that help them effectively practice in the context of OpenNotes. Method: Twenty-eight mental health clinicians and 28 patients in mental health care participated in semi-structured interviews about their experiences and perceptions with OpenNotes. A rapid review approach was used to analyze transcripts. Results: Analysis of interviews identified three domains of advice for mental health clinicians: writing notes that maintain the therapeutic relationship, communicating with patients about their notes and utilizing clinical notes as a patient resource to enhance care. Specific recommendations are provided. Conclusion: Findings provide mental health clinicians with guidance from service users and clinicians on how to leverage clinical notes to maintain - and potentially enhance -therapeutic relationships in a healthcare system in which patients are able to read their mental health notes online. [ABSTRACT FROM AUTHOR]

Developing a public health approach to suicide prevention among United States (US) military veterans requires additional data and guidance on where, when, for whom, and what prevention resources should be deployed. This study examines veteran suicide mortality across one US state (Oregon) to identify county-level "hotspots" for veteran suicide, identify community characteristics associated with increased suicide among veterans, and examine excess spatial risk after accounting for space, time, and community characteristics. We linked Oregon mortality data with VA databases to identify veterans who had resided in Oregon and died by suicide between January 1, 2009 and December 31, 2018 (n = 1727). Community characteristic data were gathered at the county level from publicly available datasets on social determinants of health known to be associated with poor health outcomes, including suicide risk. We estimated spatial generalized linear mixed models for the full 10-year period and for each 5-year period using integrated nested Laplace approximation with county as the higher hierarchy. Smoothed standardized mortality ratios were used to identify counties with higher risk of veteran suicide. We found a small clustering of counties in the southwestern corner of Oregon that held the highest risk for veteran suicide across the ten years studied. In multivariable models, higher prevalence of unmarried persons was the only community measure significantly associated with increased veteran suicide risk. However, social contextual factors as a group, along with geographic space, explained most risk for suicide among veterans at the population level. • Veterans are at increased risk for suicide relative to nonveterans. • Hotspots for veteran suicide in Oregon cluster in rural, southwestern counties. • Social determinants of health and space explain almost all variation in suicide. [ABSTRACT FROM AUTHOR]

Purpose: To identify temporal patterns of emergency dispatches as initiated by Veteran Crisis Line (VCL) responders and among moderate‐ and high‐risk contacts. Methods: Incidence rate ratios (IRRs) were used to examine the incidence of emergency dispatches among all 1,437,543 VCL contacts across 2019–2020. Results: Emergency dispatches were initiated in 57,077 (4.0%) contacts. IRRs were elevated during Labor Day, IRR (95% CI) = 1.33 (1.15–1.54), and Independence Day, IRR (95% CI) = 1.22 (1.05–1.43), weekends, Saturdays, IRR (95% CI) = 1.04 (1.01–1.08), Sunday (reference), and 6 pm to 11:59 pm, IRR (95% CI) = 1.06 (1.04–1.09). IRRs for moderate‐ and high‐risk contacts were higher on Memorial Day, IRR (95% CI) = 1.16 (1.00–1.33), Sunday (reference), and 6 pm to 11:59 pm (reference). Conclusions: The initiation of emergency dispatches fluctuates over time and were highest during Labor Day and Independence Day, weekends, and evenings. Moderate‐ and high‐risk contact also fluctuate over time and were highest on Memorial Day, Sundays, and midnight to 5:59 am. VCL policy makers can use knowledge of temporal fluctuations to allocate public health resources for increased efficiency and greatest impact; however, additional research on temporal stability and generalizability is needed. [ABSTRACT FROM AUTHOR]

Curiosity, the tendency to engage in novel and challenging opportunities, may be an important source of resilience for those at risk for suicide. We hypothesized that curiosity would have a buffering effect against risk conferred by multiple sources of distress, whereby curiosity would be associated with reduced suicidal ideation and increased coping efficacy. As part of a larger intervention trial designed to improve coping skills and reduce suicidal ideation, 117 military veterans with suicidal ideation completed measures of curiosity and distress (perceived stress, depression, anxiety, and sleep disturbances) at baseline, and completed measures of suicidal ideation and coping efficacy (to stop negative thoughts, to enlist support from friends and family) at baseline and 3-, 6-, and 12-week follow up. Growth curve models showed that curiosity moderated the association between distress and suicidal ideation at baseline and that curiosity moderated the association between distress and increased coping efficacy to stop negative thoughts over time. Findings suggest that curiosity may buffer against the effect of heightened levels of distress on suicidal ideation and help facilitate stronger gains in coping efficacy over time. Additional work should further examine the role of curiosity as a protective factor for veterans with suicidal ideation. [ABSTRACT FROM AUTHOR]

The article offers information on the health coaching, a patient-centered modality that focuses on personal goals, values, and strengths to facilitate well-being. It mentions the feasibility and acceptability of a telephone-delivered health coaching intervention among veterans with suicidal ideation; and also mentions the use of health coaching among clients with mental health conditions has examined the use of coaching among patients with suicidal ideation.

A total of 295 veterans who died by suicide in 2009 across 11 states and received Veterans Affairs (VA) health care in the 6 months prior to death were identified. The suicide risk factors documented and the care received at these veterans' last VA contacts are described, and the study explores whether veterans present differently to VA care (i.e., different risk factors documented or different care settings accessed) based on the proximity of their last contact to suicide. Many veterans were seen in primary care (n = 136; 46%) for routine follow-up (n = 168; 57%). Fifty-three (18%) were assessed for suicidal thoughts; 20 (38%) of whom endorsed such thoughts. Although higher frequencies of some risk factors at last contacts more proximal to suicide compared to those more distal were observed, findings overall highlight the challenges clinicians face detecting enhanced risk prior to suicide. [ABSTRACT FROM AUTHOR]

Objective We describe Veterans Affairs (VA) primary care received by veterans with mental health symptoms in the year prior to suicide to identify opportunities to improve care. Method Death certificate data from 11 states were linked to VA national patient care data for veterans who died by suicide in 2009 and had received VA care. We identified 118 age-, sex- and clinician-matched case–control pairs (suicide decedents and living controls) with mental health symptoms. Using McNemar's chi-square and paired t tests, we compare primary care follow-up received during the year prior to death. Results Cases and controls received similar primary care clinician follow-up and treatment for mental health symptoms. Cases were less likely than controls to fill 90 or more total days of an antidepressant during the year ( P = .02), despite no differences in prescription orders from clinicians ( P = .05). Cases and controls were equally likely to fill 90 or more consecutive days of an antidepressant ( P = .47). Across both groups, 48% ( n = 113) received assessment for suicidal ideation in primary care. Conclusion We identified two areas to improve primary care for veterans at risk for suicide: monitoring antidepressant treatment adherence and improving suicidal ideation assessment and follow-up for veterans with mental health symptoms. [ABSTRACT FROM AUTHOR]

Objective To describe Department of Veterans Affairs (VA) mental health clinician attitudes toward and experiences with OpenNotes (also known as Blue Button ), which provides patients direct access to clinical notes online. Method A 35-item online survey was administered to 263 mental health clinicians and nurses from one VA Medical Center. Results Seventy-nine percent of eligible subjects participated. Most respondents agreed or somewhat agreed that OpenNotes is a good idea in general, but only half agreed that making mental health notes available online is a good idea. Most believed that patients will better remember plans of care and be better prepared for visits. Most also felt that patients will worry more and request changes in notes. Many clinicians reported being less detailed and changing the tone of their notes. Conclusion As a group, mental health clinicians are positive about OpenNotes in general but ambivalent about the use of OpenNotes in mental health care. The results call for research on outcomes of OpenNotes use in mental health and to develop education and support to help clinicians adapt to OpenNotes. [ABSTRACT FROM AUTHOR]

We sought to understand Operation Enduring Freedom and Operation Iraqi Freedom ( OEF/ OIF) veterans' experiences with suicidal ideation. Semi-structured interviews with 34 OEF/ OIF veterans addressed circumstances leading up to disclosure of suicidal ideation during brief clinical assessments. We used an iterative, inductive and deductive thematic analysis approach. Results revealed three pervasive, persistent domains that reinforce the uniqueness of veteran suicidal thoughts: military culture, difficult deployment experiences, and postdeployment adjustment challenges. Within postdeployment, we identified four themes that serve as intervention targets: adjusting to civilian culture, changes to sense of self, feeling overwhelmed by stressors, and lacking life purpose or meaning. [ABSTRACT FROM AUTHOR]

Abstract: We evaluated the impact of brief structured suicidal ideation (SI) assessments on mental health care among new-to-care Operations Enduring Freedom and Iraqi Freedom (OEF/OIF) veterans. National datasets provided military, demographic, and clinical information. For all new-to-care OEF/OIF veterans administered depression screens (PHQ-2: Patient Health Questionnaire-2) and structured SI assessments in primary care or ambulatory mental health settings of three Veterans Affairs (VA) Medical Centers between April 2008 and September 2009 (N=465), generalized estimating equations were used to examine associations between SI and number of subsequent-year specialty mental health visits and antidepressant prescriptions. Approximately one-third of the veterans reported SI. In multivariate models, PTSD and anxiety diagnoses, severe depression symptoms, being married, and SI assessment by a mental health clinician were associated with more mental health visits in the subsequent year. Depression, PTSD, and anxiety diagnoses, and SI assessment by a mental health clinician were associated with receiving antidepressants. Presence of SI did not significantly affect subsequent year mental health utilization when adjusting for diagnostic and clinician variables, but inaugural visits involving mental health clinicians were consistently associated with subsequent mental health care. [Copyright &y& Elsevier]

Abstract: Objective: To examine primary care clinician actions following positive suicide risk assessments administered to Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) veterans. Methods: We identified OEF/OIF veterans with positive templated suicide risk assessments administered in primary care settings of three Veterans Affairs (VA) Medical Centers. National VA datasets and manual record review were used to identify and code clinician discussions and actions following positive assessments. Bivariate analyses were used to examine relationships between patient characteristics and discussions of firearms access and alcohol/drug use. Results: Primary care clinicians documented awareness of suicide risk assessment results for 157 of 199 (79%) patients with positive assessments. Most patients were assessed for mental health conditions and referred for mental health follow-up. Clinicians documented discussions about firearms access for only 15% of patients. Among patients whose clinicians assessed for substance abuse, 34% received recommendations to reduce alcohol or drug use. Depression diagnoses and suicidal ideation/behavior severity were significantly associated with firearms access discussions, while patient sex, military service branch, and substance abuse diagnoses were significantly associated with recommendations to reduce substance use. Conclusion: Greater efforts are needed to understand barriers to clinicians' assessing, documenting and counseling once suicidal ideation is detected, and to develop training programs and systems changes to address these barriers. [Copyright &y& Elsevier]

Abstract: Background: We sought to determine the prevalence and correlates of suicidal ideation (SI) among Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) veterans following the Department of Veterans Affairs′ (VA) 2007 implementation of required brief SI assessments for veterans who screen positive for depression and post-traumatic stress disorder. Methods: We retrospectively identified OEF/OIF veterans screened for depression using the Patient Health Questionnaire (PHQ-2) between April 2008 and September 2009 at three geographically-distinct VA Medical Centers′ primary care or mental health clinics. Veteran responses to a two-item risk assessment tool (VA Pocket Card) or PHQ-9 9th item, administered following a positive depression screen (PHQ-2≥3), were determined using manual chart review. Generalized estimating equations were used to calculate adjusted odds ratios for demographic and clinical correlates of positive SI assessments. Results: Of 1340 OEF/OIF veterans with positive depression screens, 32.4% reported SI. In multivariate models, odds of SI were lower for non-Hispanic white veterans (AOR=0.68) and greater for those with PHQ-2≥5 (AOR=1.87), depression (AOR=1.45), bipolar disorder/schizophrenia (AOR=2.84), and 2 or ≥3 diagnoses (AORs=1.59 and 2.49, respectively). Limitations: Study findings may not be generalizable to non-veteran patient populations and the study does not address the reliability and validity of tools employed for brief suicidal ideation assessment. Conclusions: SI is common among OEF/OIF veterans who receive VA care, perhaps more so among non-white veterans. Targeting veterans with higher PHQ-2 scores for SI assessment should be considered to reduce patient and administrative burden. [Copyright &y& Elsevier]

Research on warning signs, defined as acute risk factors for suicide or suicide attempt, has been slow due to the difficulty of examining the hours and minutes preceding suicidal behavior. This study sought to identify new warning signs and to re-examine warning signs that have been proposed. Narrative stories of adult patients with substance use problems hospitalized following a suicide attempt were transcribed. The narrative segments describing the 24-h period prior to suicide attempt were examined with directed qualitative content analysis using codes based on prior literature and new codes developed inductively. The sample (N = 35) was mean age = 40, 51% female, and 49% White non-Hispanic. Analysis of the transcripts of the 24-h periods (M word count = 637) yielded a broad range of cognitive (e.g., cognitive disturbance such as rumination), behavioral (e.g., alcohol use), emotional (e.g., dramatic mood changes), and social (e.g., social withdrawal) warning signs, along with a small number of cognitions and behaviors that appeared to mark a dangerous shift to acute preparation and intent for attempt, for example 'self-persuasion to attempt suicide.' We posit that a broad range of cognitive, behavioral, emotional, and social warning signs increase acute risk for suicidal behavior by creating the conditions for a shift to acute preparation and intent, a highly potent category of warning signs. [ABSTRACT FROM AUTHOR]

We describe prior use and willingness to try complementary and alternative medicine (CAM) among 401 veterans experiencing chronic noncancer pain and explore differences between CAM users and nonusers. Participants in a randomized controlled trial of a collaborative intervention for chronic pain from five Department of Veterans Affairs (VA) primary care clinics self-reported prior use and willingness to try chiropractic care, massage therapy, herbal medicines, and acupuncture. Prior CAM users were compared with nonusers on demographic characteristics, pain-related clinical characteristics, disease burden, and treatment satisfaction. A majority of veterans (n = 327, 82%) reported prior use of at least one CAM modality, and nearly all (n = 399, 99%) were willing to try CAM treatment for pain. Chiropractic care was the least preferred option, whereas massage therapy was the most preferred (75% and 96%, respectively). CAM users were less likely to have service-connection disabilities (54% vs 68%; chi square = 4.64, p = 0.03) and reported having spent a larger percentage of their lives in pain (26% vs 20%; Z = 1.40, p = 0.04) than nonusers. We detected few differences between veterans who had tried CAM and those who had not, suggesting that CAM may have broad appeal among veterans with chronic pain. Implications for VA policy and practice and for clinicians treating veterans with chronic pain are discussed. [ABSTRACT FROM AUTHOR]

Oregon Violent Death Reporting System data were linked with Veterans Affairs (VA) administrative data to identify and describe veterans who completed suicide in Oregon from 2000 to 2005 ( n = 968), and to describe their VA health care utilization in the year prior to death. Twenty-two percent had received health care in the VA system. Of these, 57% did not have mental health diagnoses and 58% had not seen mental health professionals. A larger proportion of those who accessed care were VA-enrolled and received service-connected disability benefits. Fifty-five veterans were hospitalized during the year prior to death. Of these, 33% completed suicide within 30 days of a hospitalization. Further development of suicide prevention strategies for veterans in the community, including general medical treatment settings, is indicated. [ABSTRACT FROM AUTHOR]

Previous research has linked drinking with health, but has yet to address alcohol consumption and the relationship between drinking and health among very old veterans. To help fill this gap, the authors present a cross-sectional self-report study on 1105 veterans age 90 and older who completed the national Veteran’s Affairs (VA) Survey of the Health Experiences of Patients (SHEP) for fiscal year (FY) 2005. Alcohol consumption was measured using Alcohol Use Disorders Identification Test scores (AUDIT-C).1 Health status was measured using the Veterans Rand Health Survey: VR-12.2 Among men (n = 1063), 60% were abstainers. No significant differences in mental health component (MCS; F3,1040 = 1.80, P = .15) or physical health component (PCS; F3,1040 = 1.48, P = .22) scores were detected across consumption categories. Among women (n = 42), 47% were abstainers. These results suggest many very old veterans abstain from alcohol and, among men, the associations between health status and drinking observed in younger groups may not be present in very old age. [ABSTRACT FROM AUTHOR]

Rationale: The rate of suicide mortality among women is increasing in the United States (U.S.), especially among military veterans. Prior research suggests that important gender differences in suicide risk exist, but not enough is known to tailor prevention approaches by gender. Objective: The goal of this study is to understand gender differences in the development of suicidal behaviors (suicide risk) among U.S. veterans to inform future research and gender-tailored prevention efforts. Methods: Using a modified grounded theory approach, this qualitative study interviewed 50 (25 men, 25 women) U.S. veterans who had made a recent (prior 6 months) suicide attempt. Veterans were recruited from Veterans Health Administration (VHA) healthcare facilities across the U.S. Semi-structured, hour-long interviews examined participants' experiences with military service, suicidal thoughts and attempts, and healthcare following their attempt. Results: The analysis revealed two gendered narratives of suicidal thoughts and attempts that incorporated the primary themes of self-concept, social power, relationships, coping, and stress. When discussing reasons for their suicide attempts, women discussed negative self-evaluative processes describing themselves as, "shameful," "tainted," and "worthless," whereas men discussed becoming overwhelmed, and recalled thinking, "it just wasn't worth it," "I've had enough," and, "screw this." Conclusions: This study provides an in-depth, nuanced understanding of the gender differences in suicide risk among veterans and suggests several ways in which future work may address gender-tailored suicide prevention efforts. Specifically, women veterans may benefit from methods to increase self-worth through positive social relationships, while men veterans may benefit from methods that increase their sense of purpose in life and help them achieve their ideal selves through successful experiences. • Gender differences exist in the development of suicidal behavior among veterans. • Women veterans describe feeling low self-worth and devalued by others. • Men veterans relay frustration with the external world and their lack of success. • Findings suggest the importance of considering gender in suicide prevention efforts. [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]

Background: Suicide rates are higher among veterans than non-veterans; this difference is particularly salient for females. Knowledge is sparse regarding correlates of suicidal ideation (SI) among female veterans, particularly in non-VHA samples. As such, and given that SI confers a strong risk for subsequent suicidal behavior, this study aimed to: (1) compare prevalence of recent SI by sex; and (2) determine whether deployment stressors, mental health symptoms, and recent psychosocial stressors are associated with recent SI, by sex, among post-9/11 veterans.Methods: A sex-stratified analysis of cross-sectional data from 809 post-9/11, deployed veterans was conducted using the Survey of Experiences of Returning Veterans (SERV); statistical interactions between sex and correlates of interest were assessed.Results: Self-reported prevalence of recent SI did not differ by sex. A statistically significant interaction between sex and combat was observed; greater combat experience was associated with increased SI for females only. While significant interactions were not observed for other correlates, differences in significant predictors and predictor effect sizes were noted across sex-stratified models. Recent housing and financial concerns were only associated with increased SI prevalence among females, whereas concern about other recent stressful life events was associated with increased SI prevalence only among males.Limitations: This is a cross-sectional analysis of a national survey with limited power to detect statistical sex interactions.Conclusions: While correlates of SI are relatively consistent for males and females notable differences suggest that tailored assessment and intervention based on sex may hold merit in mitigating SI among post-9/11 era Veterans. [ABSTRACT FROM AUTHOR]

This article aims to expand our understanding of military culture as it relates to gender and veterans' mental health, drawing from rich qualitative data. Fifty in-depth interviews (25 men, 25 women) were conducted with veterans who had a recent suicide attempt (within 6 months). Interviews revealed major themes of unequal standards and a hostile environment in the military. Women strived to fit in and experienced differential treatment in their physical training, professional expectations, and family life; men recollected masculine bonds and camaraderie through drinking. Women described the hostile environment of the military through their experiences of sexual violence and both genders described a culture of silence where signs of weakness were shamed. Findings support a cultural shift toward equitable gender norms for military members. Policy should focus on increased transparency institutionally—and between members—as well as improving protection and response to reported abuse. [ABSTRACT FROM AUTHOR]

While screening and treatment options for patients who disclose suicidal ideation in clinical settings have grown in recent decades, little is known about patient experiences following disclosure. We characterize patient perspectives of responses following disclosure of suicidal ideation in Veteran Health Administration (VHA) primary care and mental health settings. Qualitative thematic analysis using a conventional/directed hybrid approach. A national sample comprised of sixty participants who recently screened for suicidal ideation in primary care (n = 28) and mental health (n = 32) settings completed interviews. Many patients described therapeutic experiences following disclosure, including caring staff, timely follow-up care, and offers of multiple treatment options. Other patients, however, reported deficits in staff empathy, long waits for follow-up care, or inadequate treatment options. While many VA clinical settings provided empathic and helpful responses, these experiences were not universal. Our findings reinforce the importance of a patient-centered approach to screening and response to disclosure, including collaboration with patients in treatment planning. Improved follow-up care coordination processes are needed. Following disclosure, contact with the staff who received the disclosure also helps patients feel cared about, and provides opportunity to troubleshoot barriers a patient may experience in accessing care. [ABSTRACT FROM AUTHOR]

Objective: The current study sought to describe a nationally representative sample of Veterans diagnosed with co-occurring PTSD and substance use disorder (SUD) who initiated and completed evidence-based psychotherapy (EBP) for PTSD, and explored whether completion rates differed by SUD subtype. Methods: Using electronic health record data from the Veterans Health Administration (VHA) Corporate Data Warehouse, Veterans with a dual diagnosis of PTSD and SUD who initiated either Cognitive Processing Therapy (CPT) or Prolonged Exposure (PE) between January 01, 2019 and July 16, 2019 were identified (N = 2,996). Logistic analyses were employed to determine whether there were differences in EBP completion rates among Veterans with an alcohol use disorder (AUD; n = 1,383) versus all other SUDs (n = 1,613). Results: On average, Veterans were 45 years old, and identified as male, White, and non-Hispanic. Logistic regression analyses revealed there was not a significant difference between Veterans with AUD only and other SUDs in the probability of completing EBP treatment, OR = 1.02, 95% CI =0.87, 1.17, p = 0.79. Conclusions: No differences in EBP completion rates were observed between SUD subtypes, indicating that EBPs for PTSD are tolerated well for individuals with various types of SUDs and may be offered as treatment options. [ABSTRACT FROM AUTHOR]

Objective: To inform measure selection when examining gender differences in suicide risk, this paper evaluates measure performance for a set of gender‐relevant constructs and examines gender differences in mean scores. Methods: A national sample of veterans (n = 968) who had recently attempted suicide (past 6 months) completed measures assessing life experience‐, psychosocial‐, and health‐related constructs. A multigroup latent variable model was used to assess similarity of measurement properties between women and men. Results: Metric and scalar invariance indicated that the latent variables functioned similarly between women and men. Women had higher scores on negative coping, institutional betrayal, and social rejection; men had higher scores on self‐compassion, autonomy, and suicide ideation. Conclusions: Measurement properties and gender differences in mean values support the use of these measures for research on gender differences. Findings also suggest further investigation of social rejection, institutional betrayal, and negative coping among women veterans at risk for suicide. [ABSTRACT FROM AUTHOR]

Background The Whole Health model of the U.S. Department of Veterans Affairs (VA) emphasizes holistic self-care and multimodal approaches to improve pain, functioning, and quality of life. w HOPE (Whole Health Options and Pain Education) seeks to be the first multisite pragmatic trial to establish evidence for the VA Whole Health model for chronic pain care. Design w HOPE is a pragmatic randomized controlled trial comparing a Whole Health Team (WHT) approach to Primary Care Group Education (PC-GE); both will be compared to Usual VA Primary Care (UPC). The WHT consists of a medical provider, a complementary and integrative health (CIH) provider, and a Whole Health coach, who collaborate with VA patients to create a Personalized Health Plan emphasizing CIH approaches to chronic pain management. The active comparator, PC-GE, is adapted group cognitive behavioral therapy for chronic pain. The first aim is to test whether the WHT approach is superior to PC-GE and whether both are superior to UPC in decreasing pain interference in functioning in 750 veterans with moderate to severe chronic pain (primary outcome). Secondary outcomes include changes in pain severity, quality of life, mental health symptoms, and use of nonpharmacological and pharmacological therapies for pain. Outcomes will be collected from the VA electronic health record and patient-reported data over 12 months of follow-up. Aim 2 consists of an implementation-focused process evaluation and budget impact analysis. Summary This trial is part of the Pain Management Collaboratory, which seeks to create national-level infrastructure to support evidence-based nonpharmacological pain management approaches for veterans and military service personnel. [ABSTRACT FROM AUTHOR]

Background The NIH-DOD-VA Pain Management Collaboratory (PMC) supports 11 pragmatic clinical trials (PCTs) on nonpharmacological approaches to management of pain and co-occurring conditions in U.S. military and veteran health organizations. The Stakeholder Engagement Work Group is supported by a separately funded Coordinating Center and was formed with the goal of developing respectful and productive partnerships that will maximize the ability to generate trustworthy, internally valid findings directly relevant to veterans and military service members with pain, front-line primary care clinicians and health care teams, and health system leaders. The Stakeholder Engagement Work Group provides a forum to promote success of the PCTs in which principal investigators and/or their designees discuss various stakeholder engagement strategies, address challenges, and share experiences. Herein, we communicate features of meaningful stakeholder engagement in the design and implementation of pain management pragmatic trials, across the PMC. Design Our collective experiences suggest that an optimal stakeholder-engaged research project involves understanding the following: i) Who are research stakeholders in PMC trials? ii) How do investigators ensure that stakeholders represent the interests of a study's target treatment population, including individuals from underrepresented groups?, and iii) How can sustained stakeholder relationships help overcome implementation challenges over the course of a PCT? Summary Our experiences outline the role of stakeholders in pain research and may inform future pragmatic trial researchers regarding methods to engage stakeholders effectively. [ABSTRACT FROM AUTHOR]

Mental health applications (apps) can improve access to evidence- based, mental health strategies. This study evaluated predictors of use for the Virtual Hope Box (VHB), a smartphone app designed to enhance coping among high-risk mental health populations. We also explored the impact of usage on health outcomes. We analyzed data drawn from the treatment arm of a randomized clinical trial of the VHB (n=58). Veterans at high risk of suicide used the app over 12 weeks and completed psychosocial assessments throughout the study. We received usage data from each participant's smartphone. We then used negative binomial regression to evaluate demographic and clinical predictors of usage and generalized estimating equations to explore the longitudinal association between usage and psychosocial outcomes. The most commonly used subcomponents were designed to provide distractions and reminders of sources of meaning. Lower levels of usage were associated with younger and having a 2-year college degree or higher. Exploratory findings suggested a possible relationship between usage and protective factors. Certain subgroups had lower VHB usage. The findings suggest usage may be associated with changes in health outcomes. Future studies should recruit larger, more diverse samples to further explore relationships between usage and demographic predictors. [ABSTRACT FROM AUTHOR]

Objective: Enhanced patient involvement in care has the potential to improve patient experiences and health outcomes. As such, large national and global healthcare systems and organizations, including the US Department of Veterans Affairs (VA), have made patient-centered care a primary goal. Little is known about mental health clinician perspectives on, and experiences with, providing patient-centered care. Our main objective was to better understand VA mental health clinicians' perceptions of patient-centered care, and ascertain possible facilitators and barriers to patient-centered practices in mental health settings.Design: Qualitative study of six focus groups conducted in late 2013.Setting and Participants: Thirty-five mental health clinicians and staff from a large VA Medical Center.Outcomes: Transcripts were analyzed using an inductive and deductive thematic analysis approach.Results: Participants described patient-centered care ideally as a process of shared discovery, and expressed general enthusiasm for patient-centered care. Participants described several ongoing patient-centered care practices but conveyed concerns about the practicalities of its full implementation. Participants expressed a strong desire to change the current biomedical culture and policies of the institution that may hinder clinicians' flexibility and clinician-clinician collaboration when serving patients. In particular, clinicians worried about being held responsible for addressing all of the needs or goals that a patient may identify.Conclusions: If patient-centered care is to be practiced fully in mental health settings, healthcare institutions need to develop multimodal strategies to enhance clinician-clinician and clinician-patient collaborations to promote and support a focus on discovery and shared accountability for outcomes. [ABSTRACT FROM AUTHOR]

A 'Hope Box' is a therapeutic tool employed by clinicians with patients who are having difficulty coping with negative thoughts and stress, including patients who may be at risk of suicide or nonsuicidal self-harm. We conducted a proof-of-concept test of a 'Virtual' Hope Box ( VHB)-a smartphone app that delivers patient-tailored coping tools. Compared with a conventional hope box integrated into VA behavioral health treatment, high-risk patients and their clinicians used the VHB more regularly and found the VHB beneficial, useful, easy to set up, and said they were likely to use the VHB in the future and recommend the VHB to peers. [ABSTRACT FROM AUTHOR]

Abstract: Objectives: We describe processes, rates, and patient and system correlates of brief structured assessments (BSAs) for suicidal ideation among Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) veterans with positive depression screens. Methods: Electronic Veterans Affairs (VA) medical record and Department of Defense data were used to identify individual-level and BSA-process variables for 1662 OEF/OIF veterans at three VA Medical Centers. Results: Overall, 1349/1662 (81%) veterans received BSAs for suicidal ideation within 1 month of depression screening; 94% of BSAs were conducted within 1 day. Stratified analyses revealed significant intersite differences in veteran demographics, instruments used, clinical setting and staff performing assessments, and correlates of assessment completion. At two sites, men were more likely to be assessed than women [odds ratio (OR)=2.15 (95% confidence interval {CI}=1.06–4.38) and 3.14 (CI=1.27–7.76)]. In a combined model adjusted for intrasite correlation, assessment was less likely during months 8–12 and 13–18 of the study period [OR=0.39 (CI=0.28–0.54) and OR=0.48 (95% CI=0.35–0.68), respectively] and more likely to occur among veterans receiving depression or posttraumatic stress disorder diagnoses on the day of depression screening [OR=1.83 (CI=1.36–2.46) and OR=1.50 (CI=1.13–1.98), respectively]. Conclusions: Most veterans with positive depression screens receive timely BSAs for suicidal ideation. Processes used for brief assessment for suicidal ideation vary substantially across VA settings. [Copyright &y& Elsevier]

This article summarizes several papers on medical rehabilitation. The first paper examines the effect of prosthetic ankle units on persons with bilateral transtibial amputations during walking. The second article discusses the impact of the type and mode of propulsion on hand-cycling biomechanics in nondisabled persons. Another paper focuses on self-management among people with neurological disorders.