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Community-engaged research (CEnR) builds on the strengths of the Clinical and Translational Science Awards (CTSA) framework to address health in underserved and minority communities. There is a paucity of studies that identify the process from which trust develops in CEnR partnerships. This study responds to the need for empirical investigation of building and maintaining trust from a multistakeholder perspective. We conducted a multi-institutional pilot study using concept mapping with to better understand how trust, a critical outcome of CEnR partnerships, can act as "social capital." Concept mapping was used to collect data from the three stakeholder groups: community, health-care, and academic research partners across three CTSAs. Concept mapping is a mixed-methods approach that allows participants to brainstorm and identify factors that contribute to a concept and describe ways in which those factors relate to each other. This study offers important insights on developing an initial set of trust measures that can be used across CTSAs to understand differences and similarities in conceptualization of trust among key stakeholder groups, track changes in public trust in research, identify both positive and negative aspects of trust, identify characteristics that maintain trust, and inform the direction for future research.

ObjectiveThis study examined the mental health status, need for services, and unmet need of community-dwelling Native Hawaiian and other Pacific Islanders (NHPI).MethodsSurvey data were collected from 223 NHPI adults of Samoan or Marshallese heritage. Surveys were translated into Samoan and Marshallese by using back-translation, with feedback from cultural experts. Severity of depression, anxiety, and alcohol use were measured, as were perceived need for and avoidance of, or delay in, seeking mental health services. Logistic regressions calculated adjusted odds ratios for past-year perceived need for services and avoidance or delay of needed services, controlling for depression, anxiety, and alcohol use.ResultsParticipants' screened prevalence of major depression, generalized anxiety disorder, and alcohol use disorder was 21%, 12%, and 22%, respectively. In the past year, 35% and 26% of participants reported needing services and avoiding or delaying needed services, respectively. Urban Samoan and rural Marshallese participants did not differ significantly in measures of depression, anxiety, or alcohol use, even though the groups had significant demographic differences. Female gender and greater familiarity-contact with persons with mental illness were significant predictors of both reporting service need and reporting avoiding or delaying services.ConclusionsCommunity-dwelling NHPIs reported a heavy burden of depression, anxiety, and alcohol use, and high perceived need for services, yet low levels of help-seeking. The large unmet need in the sample suggests that a gap may exist between service need and engagement in U.S. NHPI communities that could be targeted with culturally tailored approaches that promote engagement in care.

In this study, we examined the sociocultural factors underlying infant feeding practices. We conducted four focus groups with 19 Latina mothers of children 0 to 2 years of age enrolled in Early Head Start programs in the United States over a 1-year period. We found these mothers considered both science- and family-based feeding recommendations. However, advice from family was often inconsistent with science- and nutrition-based recommended feeding practices. In the interest of showing respect and preserving harmonious relationships, some mothers accepted family advice instead of recommended practices while others employed strategies to follow recommended practices without offending. Nutrition educators need to consider the intersection of macro, organizational, and community factors with micro-level processes in shaping the implementation of recommended feeding practices within family systems. Nutrition interventions for Latino families should capitalize on Latina mothers' strategies for navigating multiple information sources while preserving cultural values and family relationships.

The present study examines how both between group (i.e., ethnic group membership) and within group cultural factors (i.e., nativity status, age of immigration, and perceived discrimination) may contribute to anxiety and related symptoms in Latinx with anxiety disorders. Baseline data were examined from patients who participated in one of the largest intervention studies for adults with anxiety disorders in primary care settings; 196 Latinx and 568 NLW (non-Latinx White) patients participated. Proportions of anxiety disorders were similar between Latinx and NLWs; however, Latinx, on average, had a greater number of anxiety disorders than NLWs. Levels of anxiety and depression symptom severity, anxiety sensitivity, and mental functional impairment were similar between the ethnic groups. Latinx expressed greater somatization and physical functional impairment than NLWs. Among Latinx, perceived discrimination, but not other cultural variables, was predictive of mental health symptoms while controlling for age, gender, education, and poverty. Overall, these findings suggest more similarities than differences in types and levels of anxiety and anxiety-related impairment, with some important exceptions, including greater levels of somatization and physical functional impairment among Latinx patients. Further, perceived discrimination may be an important factor to consider when examining risk for greater symptom burden among Latinx with anxiety.

ObjectivesCollaborations between communities, healthcare practices and academic institutions are a strategy to address health disparities. Trust is critical in the development and maintaining of effective collaborations. The aim of this pilot study was to engage stakeholders in defining determinants of trust in community academic research partnerships and to develop a framework for measuring trust.MethodsThe study was conducted by five collaborating National Institute of Health' Clinical and Translational Sciences Awardees. We used concept mapping to engage three stakeholders: community members, healthcare providers and academicians. We conducted hierarchical cluster analysis to assess the determinants of trust in community-academic research partnerships.ResultsA total of 186 participants provided input generating 2,172 items that were consolidated into 125 unique items. A five cluster solution was defined: authentic, effective and transparent communication; mutually respectful and reciprocal relationships; sustainability; committed partnerships; and, communication, credibility and methodology to anticipate and resolve problems.ConclusionResults from this study contribute to an increasing empirical body of work to better understand and improve the underlying factors that contribute to building and sustaining trust in community academic research partnerships.

Community-academic research partnerships aim to build stakeholder trust in order to improve the reach and translation of health research, but there is limited empirical research regarding effective ways to build trust. This multisite study was launched to identify similarities and differences among stakeholders' perspectives of antecedents to trust in research partnerships. In 2013-2014, we conducted a mixed-methods concept mapping study with participants from three major stakeholder groups who identified and rated the importance of different antecedents of trust on a 5-point Likert-type scale. Study participants were community members ( n = 66), health care providers ( n = 38), and academic researchers ( n = 44). All stakeholder groups rated "authentic communication" and "reciprocal relationships" the highest in importance. Community members rated "communication/methodology to resolve problems" ( M = 4.23, SD = 0.58) significantly higher than academic researchers ( M = 3.87, SD = 0.67) and health care providers ( M = 3.89, SD = 0.62; p < .01) and had different perspectives regarding the importance of issues related to "sustainability." The importance of communication and relationships across stakeholders indicates the importance of colearning processes that involve the exchange of knowledge and skills. The differences uncovered suggest specific areas where attention and skill building may be needed to improve trust within partnerships. More research on how partnerships can improve communication specific to problem solving and sustainability is merited.

ImportanceIndividuals with co-occurring mental and substance use disorders have increased rates of mortality relative to the general population. The relationship between measures of treatment quality and mortality for these individuals is unknown.ObjectiveTo examine the association between 5 quality measures and 12- and 24-month mortality.Design, setting and participantsRetrospective cohort study of patients with co-occurring mental illness (schizophrenia, bipolar disorder, post-traumatic stress disorder and major depression) and substance use disorders who received care for these disorders paid for by the Veterans Administration between October 2006 and September 2007. Logistic regression models were used to examine the association between 12 and 24-month mortality and 5 patient-level quality measures, while risk-adjusting for patient characteristics. Quality measures included receipt of psychosocial treatment, receipt of psychotherapy, treatment initiation and engagement, and a measure of continuity of care. We also examined the relationship between number of diagnosis-related outpatient visits and mortality, and conducted sensitivity analyses to examine the robustness of our findings to an unobserved confounder.Main outcomes measureMortality 12 and 24 months after the end of the observation period.ResultsAll measures except for treatment engagement at 24 months were significantly associated with lower mortality at both 12 and 24 months. At 12 months, receiving any psychosocial treatment was associated with a 21% decrease in mortality; psychotherapy, a 22% decrease; treatment initiation, a 15% decrease, treatment engagement, a 31% decrease; and quarterly, diagnosis-related visits a 28% decrease. Increasing numbers of visits were associated with decreasing mortality. Sensitivity analyses indicated that the difference in the prevalence of an unobserved confounder would have to be unrealistically large given the observed data, or there would need to be a large effect of an unobserved confounder, to render these findings non-significant.Conclusions and relevanceThis is the first study to show an association between process-based quality measures and mortality in patients with co-occurring mental and substance use disorders, and provides initial support for the predictive validity of the measures. By devising strategies to improve performance on these measures, health care systems may be able to decrease the mortality of this vulnerable population.

BackgroundBroadly disseminating and implementing evidence-based psychotherapies with high fidelity, particularly cognitive behavioral therapy (CBT), has proved challenging for many health-care systems, including the Department of Veterans Affairs, especially in primary care settings such as small or remote clinics. A computer-based tool (based on the coordinated anxiety learning and management (CALM) program) was designed to support primary care-based mental health providers in delivering CBT. The objectives of this study are to modify the CALM tool to meet the needs of mental health clinicians in veterans affairs (VA) community-based outpatient clinics (CBOCs) and rural "veterans", use external facilitation to implement CBT and determine the effect of the CALM tool versus a manualized version of CALM to improve fidelity to the CBT treatment model, and conduct a needs assessment to understand how best to support future implementation of the CALM tool in routine care.Methods/designFocus groups will inform the redesign of the CALM tool. Mental health providers at regional VA CBOCs; CBT experts; VA experts in implementation of evidence-based mental health practices; and veterans with generalized anxiety disorder, panic disorder, social anxiety disorder, posttraumatic stress disorder, "with or without" depression will be recruited. A hybrid type III design will be used to examine the effect of receiving CBT training plus either the CALM tool or a manual version of CALM on treatment fidelity. External facilitation will be used as the overarching strategy to implement both CBT delivery methods. Data will also be collected on symptoms of the targeted disorders. To help prepare for the future implementation of the CALM tool in VA CBOCs, we will perform an implementation need assessment with mental health providers participating in the clinical trial and their CBOC directors.DiscussionThis project will help inform strategies for delivering CBT with high fidelity in VA CBOCs to veterans with anxiety disorders and PTSD with or without depression. If successful, results of this study could be used to inform a national rollout of the CALM tool in VA CBOCs including providing recommendations for optimizing the adoption and sustained use of the computerized CALM tool among mental health providers in this setting.Trial registrationClinicalTrials.gov, NCT02488551.

Compared with people living in the community, researchers often have different frameworks or paradigms for thinking about health and wellness. These differing frameworks are often accompanied by differences in terminology or language. The purpose of this commentary is to describe some of our "Aha!" moments from conducting two pilot studies funded by the Patient-Centered Outcomes Research Institute. Over time, we came to understand how our language and word choices may have been acting as a wedge between ourselves and our community research partners. We learned that fruitful collaborative work must attend to the creation of a common language, which we refer to as the language of engagement. Such patient-centered language can effectively build a bridge between researchers and community partners. We encourage other researchers to think critically about their cultural competency, to be mindful of the social power dynamics between patient and physician, to reflect on how their understanding might differ from those of their patient partners, and to find ways to use a common language that engages patients and other community partners.

BackgroundBroadly disseminating and implementing evidence-based psychotherapies with high fidelity, particularly cognitive behavioral therapy (CBT), has proved challenging for many health-care systems, including the Department of Veterans Affairs, especially in primary care settings such as small or remote clinics. A computer-based tool (based on the coordinated anxiety learning and management (CALM) program) was designed to support primary care-based mental health providers in delivering CBT. The objectives of this study are to modify the CALM tool to meet the needs of mental health clinicians in veterans affairs (VA) community-based outpatient clinics (CBOCs) and rural "veterans", use external facilitation to implement CBT and determine the effect of the CALM tool versus a manualized version of CALM to improve fidelity to the CBT treatment model, and conduct a needs assessment to understand how best to support future implementation of the CALM tool in routine care.Methods/designFocus groups will inform the redesign of the CALM tool. Mental health providers at regional VA CBOCs; CBT experts; VA experts in implementation of evidence-based mental health practices; and veterans with generalized anxiety disorder, panic disorder, social anxiety disorder, posttraumatic stress disorder, "with or without" depression will be recruited. A hybrid type III design will be used to examine the effect of receiving CBT training plus either the CALM tool or a manual version of CALM on treatment fidelity. External facilitation will be used as the overarching strategy to implement both CBT delivery methods. Data will also be collected on symptoms of the targeted disorders. To help prepare for the future implementation of the CALM tool in VA CBOCs, we will perform an implementation need assessment with mental health providers participating in the clinical trial and their CBOC directors.DiscussionThis project will help inform strategies for delivering CBT with high fidelity in VA CBOCs to veterans with anxiety disorders and PTSD with or without depression. If successful, results of this study could be used to inform a national rollout of the CALM tool in VA CBOCs including providing recommendations for optimizing the adoption and sustained use of the computerized CALM tool among mental health providers in this setting.Trial registrationClinicalTrials.gov, NCT02488551.

When treating anxious patients with co-occurring depression, research demonstrates that both types of symptoms independently improve. The current analyses examined how reductions in anxiety and depression may be interrelated both during treatment, as well as over time following treatment. Participants were 503 individuals with one or more DSM-IV anxiety disorders who completed a collaborative care anxiety management program. Anxiety and depression were assessed at each treatment session (i.e., session by session data) and also at 6, 12, and 18-month post-baseline assessments (i.e., long-term outcomes data). Mediation analyses examined changes in symptoms in session by session data and long-term outcomes data. Anxiety and depression changed reciprocally in session by session data; change in anxiety mediated change in depression to a greater extent than vice versa. In the long-term outcomes data, change in anxiety mediated change in depression. However, the reverse mediation model of the long-term outcomes period revealed that accounting for changes in depression altered the effect of time on anxiety. Thus, temporal change during active treatment may share similarities with those related to maintaining gains after treatment, although differences arose in the reverse mediation models. Limitations of the methodology and implications of anxiety treatment for depression outcomes are discussed.

ObjectiveThe presence of anxiety disorders is associated with poorer alcohol use disorder treatment outcomes, but little is known about the impact of alcohol use problems on anxiety disorder treatment outcomes despite their high comorbidity. The current study examined the impact of alcohol use symptom severity on anxiety disorder treatment outcomes in a multi-site primary care effectiveness study of anxiety disorder treatment.MethodData came from the Coordinated Anxiety Learning and Management (CALM) effectiveness trial. Participants (N=1004) were randomized to an evidence-based anxiety intervention (including cognitive behavioral therapy and medications) or usual care in primary care. Participants completed measures of alcohol use, anxiety, and depression at baseline, 6-, 12-, and 18-month follow-up periods. Patients with alcohol dependence were excluded.ResultsThere were no significant moderating (Treatment Group × Alcohol Use Severity) interactions. The majority of analyses revealed no predictive effects of alcohol use severity on outcome; however, alcohol problems at baseline were associated with somewhat higher anxiety and depression symptoms at the 18-month follow-up.ConclusionsThese data indicate that patients with alcohol problems in primary care can be effectively treated for anxiety disorders. Baseline alcohol problems were associated with some poorer long-term outcomes, but this was evident across CALM and usual care. These findings provide preliminary evidence that there may be no need to postpone treatment of anxiety disorders until alcohol problems are addressed, at least among those who have mild to moderate alcohol problems. Replication with more severe alcohol use disorders is needed.

ObjectiveAnxiety is linked to a number of medical conditions, yet few studies have examined how symptom severity relates to medical comorbidity.PurposeThe current study assessed associations between severity of anxiety and depression and the presence of medical conditions in adults diagnosed with anxiety disorders.MethodNine-hundred eighty-nine patients diagnosed with panic, generalized anxiety, social anxiety, and posttraumatic stress disorders reported on the severity of anxiety and depressive symptoms and on diagnoses of 11 medical conditions.ResultsSeverity of anxiety and depressive symptoms was strongly associated with having more medical conditions over and above control variables, and the association was as strong as that between BMI and disease. Odds of having asthma, heart disease, back problems, ulcer, migraine headache and eyesight difficulties also increased as anxiety and depressive symptom severity increased. Anxiety symptoms were independently associated with ulcer, whereas depressive symptoms were independently associated with heart disease, migraine, and eyesight difficulties.ConclusionsThese findings add to a growing body of research linking anxiety disorders with physical health problems and indicate that anxiety and depressive symptoms deserve greater attention in their association with disease.

BackgroundAlthough self-efficacy (SE) and outcome expectancy (OE) have been well researched as predictors of outcome, few studies have investigated changes in these variables across treatments. We evaluated changes in OE and SE throughout treatment as predictors of outcomes in a large sample with panic disorder, generalized anxiety disorder, social anxiety disorder, or posttraumatic stress disorder. We hypothesized that increases in SE and OE would predict reductions in anxiety and depression as well as improvement in functioning.MethodsParticipants (mean age = 43.3 years, SD = 13.2, 71.1% female, 55.5% white) were recruited from primary care centers throughout the United States and were randomized to receive either Coordinated Anxiety Learning and Management (CALM) treatment - composed of cognitive behavioral therapy, psychotropic medication, or both - or usual care. SE and OE ratings were collected at each session for participants in the CALM treatment (n = 482) and were entered into a structural equation model as predictors of changes in Brief Symptom Inventory, Anxiety Sensitivity Index, Patient Health Questionnaire (PHQ), and Sheehan Disability Scale outcomes at 6, 12, and 18 months after baseline.ResultsThe best-fitting models predict symptom levels from OE and SE and not vice versa. The slopes and intercept of OE significantly predicted change in each outcome variable except PHQ-8. The slope and intercept of SE significantly predicted change in each outcome variable.ConclusionOver and above absolute level, increases in SE and OE were significant predictors of decreases in symptoms and increases in functioning. Implications for treatment are discussed, as well as future directions of research.

ObjectiveIn the current study, we compared measures of treatment outcome and engagement for Latino and non-Latino White patients receiving a cognitive behavioral therapy (CBT) program delivered in primary care.MethodParticipants were 18-65 years old and recruited from 17 clinics at 4 different sites to participate in a randomized controlled trial for anxiety disorders, which compared the Coordinated Anxiety Learning and Management (CALM) intervention (consisting of CBT, medication, or both) with usual care. Of those participants who were randomized to the intervention arm and selected CBT (either alone or in combination with medication), 85 were Latino and 251 were non-Latino White; the majority of the Latino participants received the CBT intervention in English (n = 77). Blinded assessments of clinical improvement and functioning were administered at baseline and at 6, 12, and 18 months after baseline. Measures of engagement, including attendance, homework adherence, understanding of CBT principles, and commitment to treatment, were assessed weekly during the CBT intervention.ResultsFindings from propensity-weighted linear and logistic regression models revealed no statistically significant differences between Latinos and non-Latino Whites on symptom measures of clinical improvement and functioning at almost all time points. There were significant differences on 2 of 7 engagement outcomes, namely, number of sessions attended and patients' understanding of CBT principles.ConclusionsThese findings suggest that CBT can be an effective treatment approach for Latinos who are primarily English speaking and likely more acculturated, although continued attention should be directed toward engaging Latinos in such interventions.

Background:The COVID-19 pandemic prompted the widespread adoption of telemedicine to deliver health care services while minimizing in-person contact. However, concerns persist regarding equitable access to telemedicine, especially for vulnerable populations. This study examines the utilization patterns of telemedicine by race in the United States, considering different modalities, medical specialties, and geographic regions. Methods:A comprehensive review of 26 articles published between January 2020 and August 2022 was conducted to analyze racial disparities in telemedicine use during the pandemic. Data from electronic health records and self-reported race were compiled for analysis. Variations based on geography, clinical care types, telemedicine modalities (audio or video), and study design were explored. Results:The findings indicate the presence of racial disparities in telemedicine utilization, with minority groups exhibiting lower usage rates compared with Whites. The location of outpatient clinics and clinical care types did not significantly influence telemedicine use by race. Among studies comparing telemedicine modalities, African Americans were more likely to choose audio/phone visits over video visits. Studies employing a pre-post design were less likely to identify disparities in telemedicine use by race. Conclusions:This study consistently demonstrates increasing racial disparities in telemedicine use. Future research should focus on identifying contributing factors and developing strategies to address these disparities. Policymakers should consider implementing initiatives promoting equitable access to telemedicine, including financial assistance, improved broadband infrastructure, and digital literacy programs. By addressing these barriers, telemedicine can play a crucial role in reducing health care disparities and improving access to care for all Americans. [ABSTRACT FROM AUTHOR]

ObjectiveTo evaluate the effects of medical comorbidity on anxiety treatment outcomes.MethodsData were analyzed from 1004 primary care patients enrolled in a trial of a collaborative care intervention for anxiety. Linear-mixed models accounting for baseline characteristics were used to evaluate the effects of overall medical comorbidity (two or more chronic medical conditions [CMCs] versus fewer than two CMCs) and specific CMCs (migraine, asthma, and gastrointestinal disease) on anxiety treatment outcomes at 6, 12, and 18 months.ResultsAt baseline, patients with two or more CMCs (n = 582; 58.0%) reported more severe anxiety symptoms (10.5 [95% confidence interval {CI} = 10.1-10.9] versus 9.5 [95% CI = 9.0-10.0], p = .003) and anxiety-related disability (17.6 [95% CI = 17.0-18.2] versus 16.0 [95% CI = 15.3-16.7], p = .001). However, their clinical improvement was comparable to that of patients with one or zero CMCs (predicted change in anxiety symptoms = -3.9 versus -4.1 at 6 months, -4.6 versus -4.4 at 12 months, -4.9 versus -5.0 at 18 months; predicted change in anxiety-related disability = -6.4 versus -6.9 at 6 months, -6.9 versus -7.3 at 12 months, -7.3 versus -7.5 at 18 months). The only specific CMC with a detrimental effect was migraine, which was associated with less improvement in anxiety symptoms at 18 months (predicted change = -4.1 versus -5.3).ConclusionsEffectiveness of the anxiety intervention was not significantly affected by the presence of multiple CMCs; however, patients with migraine displayed less improvement at long-term follow-up. Trial Registration ClinicalTrials.com Identifier: NCT00347269.

Abstract Background Investigators recently tested the effectiveness of a collaborative-care intervention for anxiety disorders: Coordinated Anxiety Learning and Management(CALM) []) in 17 primary care clinics around the United States. Investigators also conducted a qualitative process evaluation. Key research questions were as follows: (1) What were the facilitators/barriers to implementing CALM? (2) What were the facilitators/barriers to sustaining CALM after the study was completed? Methods Key informant interviews were conducted with 47 clinic staff members (18 primary care providers, 13 nurses, 8 clinic administrators, and 8 clinic staff) and 14 study-trained anxiety clinical specialists (ACSs) who coordinated the collaborative care and provided cognitive behavioral therapy. The interviews were semistructured and conducted by phone. Data were content analyzed with line-by-line analyses leading to the development and refinement of themes. Results Similar themes emerged across stakeholders. Important facilitators to implementation included the perception of "low burden" to implement, provider satisfaction with the intervention, and frequent provider interaction with ACSs. Barriers to implementation included variable provider interest in mental health, high rates of part-time providers in clinics, and high social stressors of lower socioeconomic-status patients interfering with adherence. Key sustainability facilitators were if a clinic had already incorporated collaborative care for another disorder and presence of onsite mental health staff. The main barrier to sustainability was funding for the ACS. Conclusions The CALM intervention was relatively easy to incorporate during the effectiveness trial, and satisfaction was generally high. Numerous implementation and sustainability barriers could limit the reach and impact of widespread adoption. Findings should be interpreted with the knowledge that the ACSs in this study were provided and trained by the study. Future research should explore uptake of CALM and similar interventions without the aid of an effectiveness trial.

The negative association between religiosity (religious beliefs and church attendance) and the likelihood of substance use disorders is well established, but the mechanism(s) remain poorly understood. We investigated whether this association was mediated by social support or mental health status.We utilized cross-sectional data from the 2002 National Survey on Drug Use and Health (n = 36,370). We first used logistic regression to regress any alcohol use in the past year on sociodemographic and religiosity variables. Then, among individuals who drank in the past year, we regressed past year alcohol abuse/dependence on sociodemographic and religiosity variables. To investigate whether social support mediated the association between religiosity and alcohol use and alcohol abuse/dependence we repeated the above models, adding the social support variables. To the extent that these added predictors modified the magnitude of the effect of the religiosity variables, we interpreted social support as a possible mediator. We also formally tested for mediation using path analysis. We investigated the possible mediating role of mental health status analogously. Parallel sets of analyses were conducted for any drug use, and drug abuse/dependence among those using any drugs as the dependent variables.The addition of social support and mental health status variables to logistic regression models had little effect on the magnitude of the religiosity coefficients in any of the models. While some of the tests of mediation were significant in the path analyses, the results were not always in the expected direction, and the magnitude of the effects was small.The association between religiosity and decreased likelihood of a substance use disorder does not appear to be substantively mediated by either social support or mental health status.

Purpose: Many veterans who face mental illness and live in rural areas never obtain the mental health care they need. To address these needs, it is important to reach out to community stakeholders who are likely to have frequent interactions with veterans, particularly those returning from Operations Enduring and Iraqi Freedom (OEF/OIF). Methods: Three community stakeholder groups--clergy, postsecondary educators, and criminal justice personnel--are of particular importance for OEF/OIF veterans living in rural areas and may be more likely to come into contact with rural veterans struggling with mental illness or substance abuse than the formal health care system. This article briefly describes the conceptualization, development, initial implementation, and early evaluation of a Veterans Affairs (VA) medical center-based program designed to improve engagement in, and access to, mental health care for veterans returning to rural areas. Findings: One year since initial funding, 90 stakeholders have attended formal training workshops (criminal justice personnel = 36; educators = 31; clergy = 23). Two training formats (a 2-hour workshop and an intensive 2.5-day workshop) have been developed and provided to clergy in 1 rural county with another county scheduled for training. A veteran outreach initiative, which has received 32 referrals for various student services, has been established on 4 rural college campuses. A Veterans Treatment Court also has been established with 16 referrals for eligibility assessments. Conclusions: While this pilot program is in the early stages of evaluation, its success to date has encouraged program and VA clinical leadership to expand beyond the original sites.

A study was conducted to evaluate and compare the efficacy of evidence-based treatment such as Coordinated Anxiety Learning and Management (CALM) for multiple anxiety disorders like depression, anxiety, panic and post-traumatic stress disorders in primary care as against usual care (UC). Results indicated that in the case of such patients CALM proved more effective than UC in improving adverse conditions.