Refugee-related trauma patterns and mental health symptoms across three generations of Hmong Americans.

Hmong adults who are Vietnam War refugees have been exposed to refugee-related trauma, but little is known about associations between patterns of trauma exposure and mental health outcomes in Hmong adults. We examined patterns of trauma exposure and mental health symptoms (i.e., somatization, depression, anxiety, and probable posttraumatic stress disorder [PTSD]) in three generations of Hmong adults (N = 219). Trauma exposure and probable PTSD were measured using the Harvard Trauma Questionnaire-Hmong Version. Somatization, depression, and anxiety symptoms were measured using the Brief Symptom Inventory. Latent class analysis (LCA) and auxiliary analysis of sociodemographic characteristics and mental health symptoms were performed. The best-fitting LCA model described three distinct classes: complex and pervasive trauma (60.3%), combat situation and deprivation trauma (26.0%), and low exposure to refugee-related trauma (13.7%). Participants in the complex and pervasive trauma class were the oldest, had the shortest U.S. residency, were the least proficient in English, and reported the most severe mental health symptoms; those in the combat situation and deprivation trauma class were the youngest, moderately proficient in English, and reported moderate mental health symptoms; and those in the low exposure to refugee-related trauma class were the most proficient in English, had the longest U.S. residency, and reported the least severe mental health symptoms. Our findings call for surveillance and a trauma-informed approach for Hmong elders with limited English proficiency, who have a high risk of experiencing accumulative effects of refugee-related trauma and are susceptible to poor mental health outcomes.

The My Life, My Story Program: Sustained Impact of Veterans' Personal Narratives on Healthcare Providers 5 Years After Implementation.

Patient-centered care promotes positive patient, staff, and organizational outcomes. Communication is one critical element of patient-centered care. Establishing a patient-provider relationship in which a patient feels comfortable sharing their goals, preferences, and values is important to support patient-centered care and positive health outcomes. The My Life, My Story (MLMS) program was developed in 2013 to elicit and share Veterans' life stories with their healthcare providers. Life stories become part of the Veteran's chart so providers can access, read, and utilize as appropriate. To evaluate the program's sustained value and impact 5 years after implementation, healthcare staff were recruited to complete a short survey with closed and open-ended items. Descriptive statistics were used to analyze the quantitative survey responses and thematic analysis was used to analyze qualitative responses. Approximately 94% of staff indicated they had read MLMS notes and over 86% agreed or strongly agreed that reading the notes was a good use of their clinical time and helped them provide better treatment or care. Staff also described making more personalized decisions about the plan of treatment or care delivery after knowing the Veteran better from their story. Our findings suggest the MLMS program has been well sustained over time, and the use of patient stories in healthcare may be a valuable, practical, and sustainable tool to support the delivery of patient-centered care.

Predischarge Injectable Versus Oral Naltrexone to Improve Postdischarge Treatment Engagement Among Hospitalized Veterans with Alcohol Use Disorder: A Randomized Pilot Proof-of-Concept Study.

BACKGROUND: Injectable naltrexone for alcohol use disorders (AUDs) has been efficacious in several studies. It has not been (i) compared head-to-head with oral naltrexone or (ii) examined in the hospital setting as an intervention that might facilitate treatment attendance after hospital discharge. METHODS: Fifty-four hospitalized veterans identified as having DSM-IV-TR alcohol dependence were randomized to receive (i) a 50 mg oral naltrexone plus a 30-day prescription or (ii) a 380 mg intramuscular naltrexone injection prior to discharge. Of 113 veteran inpatients deemed eligible based on screening criteria, 54 met final eligibility criteria and were enrolled and randomized. Baseline data included demographics, alcohol consumption, and comorbidity. Measures of treatment initiation and engagement and alcohol consumption were reassessed at 14- and 45-day follow-ups. RESULTS: Thirty-five participants (64.8%) completed the entire study protocol (received a study medication and completed 14- and 45-day follow-ups). Among those who received a study medication (n = 45), 77.8% completed all follow-up interviews. This pilot study was not designed to have sufficient statistical power for hypothesis testing, and thus, as expected, there were no significant differences between groups in medication adherence (self-report of >80% of daily doses taken in oral group; receipt of second injection in the injection group), treatment engagement (at least treatment 3 visits in the 30 days postdischarge, and 2 or more visits per month in each of the 3 months following discharge) or alcohol consumption at 14 or at 45 days (p > 0.05). The median number of drinks among the entire cohort in the 2 weeks prior to hospitalization (128 drinks) was significantly higher than at day 14 (0 drinks, p < 0.001) or day 45 (0 drinks, p < 0.001). Rates of medication adherence were 62% in the oral group and 61% in the injection group. CONCLUSIONS: Results indicate feasibility for larger, more definitive study. Both groups had significant reductions in alcohol consumption over time and high-treatment engagement rates. Both oral and injectable formulations are feasible to initiate prior to discharge for hospital inpatients identified as having an AUD.

Measurement-based management of mental health quality and access in VHA: SAIL mental health domain.

We outline the development of a Mental Health Domain to track accessibility and quality of mental health care in the United States Veterans Health Administration (VHA) as part of a broad-based performance measurement system. This domain adds an important element to national performance improvement efforts by targeting regional and facility leadership and providing them a concise yet comprehensive measure to identify facilities facing challenges in their mental health programs. We present the conceptual framework and rationale behind measure selection and development. The Mental Health Domain covers three important aspects of mental health treatment: Population Coverage, Continuity of Care, and Experience of Care. Each component is a composite of existing and newly adapted measures with moderate to high internal consistency; components are statistically independent or moderately related. Development and dissemination of the Mental Health Domain involved a variety of approaches and benefited from close collaboration between local, regional, and national leadership and from coordination with existing quality-improvement initiatives. During the first year of use, facilities varied in the direction and extent of change. These patterns of change were generally consistent with qualitative information, providing support for the validity of the domain and its component measures. Measure maintenance remains an iterative process as the VHA mental health system and potential data resources continue to evolve. Lessons learned may be helpful to the broader mental health-provider community as mental health care consolidates and becomes increasingly integrated within healthcare systems. (PsycINFO Database Record

Using organizational and clinical performance data to increase the value of mental health care.

U.S. health systems, policy makers, and patients increasingly demand high-value care that improves health outcomes at lower cost. This study describes the initial design and analysis of the Mental Health Management System (MHMS), a performance data and quality improvement tool used by the Veterans Health Administration (VHA) to increase the value of its mental health care. The MHMS evaluates access to and quality of mental health care, organizational structure and efficiency, implementation of innovative treatment options, and, in collaboration with management, resource needs for delivering care. Performance on 31 measures was calculated for all U.S. VHA facilities (N = 139). Pearson correlations revealed that better access to care was significantly associated with fewer mental health provider staffing vacancies (r = -.24) and higher staff-to-patient ratios for psychiatrists (r = .19) and other outpatient mental health providers (r = .27). Higher staff-to-patient ratios were significantly associated with higher performance on a number of patient and provider satisfaction measures (range of r = .18-.51) and continuity of care measures (range of r = .26-.43). Relationships observed between organizational and clinical performance measures suggest that the MHMS is a robust informatics and quality improvement tool that can serve as a model for health systems planning to adopt a value perspective. Future research should expand the MHMS framework to measure patient and health systems costs and psychosocial outcomes, as well as evaluate whether quality improvement solutions implemented as a result of using organizational information leads to higher-value mental health care. (PsycINFO Database Record

Interprofessional Education in Patient Aligned Care Team Primary Care-Mental Health Integration.

Interprofessional education is an effective approach for preparing health care providers for team-based practice.

Maintenance of certification: How performance in practice changes improve tobacco cessation in addiction psychiatrists' practice.

BACKGROUND AND OBJECTIVES: In 2000, the American Board of Medical Specialties implemented the Maintenance of Certification (MOC), a structured process to help physicians identify and implement a quality improvement project to improve patient care. This study reports on findings from an MOC Performance in Practice (PIP) module designed and evaluated by addiction psychiatrists who are members of the American Academy of Addiction Psychiatry (AAAP). METHOD: A 3-phase process was utilized to recruit AAAP members to participate in the study. The current study utilized data from 154 self-selected AAAP members who evaluated the effectiveness of the MOC Tobacco Cessation PIP. RESULTS: Of the physicians participating, 76% (n = 120) completed the Tobacco PIP. A paired t-test analysis revealed that reported changes in clinical measure documentation were significant across all six measures. Targeted improvement efforts focused on a single clinical measure. Results found that simple change projects designed to improve clinical practice led to substantial changes in self-reported chart documentation for the selected measure. CONCLUSIONS: The current findings suggest that addiction psychiatrists can leverage the MOC process to improve clinical care. SCIENTIFIC SIGNIFICANCE: The study demonstrates that a quality improvement collaborative can support an MOC process to help addiction psychiatrists eliminate barriers to access to tobacco cessation treatment. (Am J Addict 2017;26:34-41).

Effects of Cognitive Behavioral Stress Management on Negative Mood and Cardiac Autonomic Activity in ICD Recipients.

BACKGROUND: Behavioral intervention studies in patients with an implantable cardioverter-defibrillator (ICD) show promise in improving psychosocial outcomes but inconclusive effects on cardiovascular outcome. We assessed the effects of cognitive behavioral stress management (CBSM) on mood state and potentially arrhythmogenic cardiovascular responses to mental stress in ICD patients, in support of further larger scale arrhythmia trials. METHODS: A total of 103 ICD recipients were randomly assigned to 10-week programs of CBSM or "Patient Education" (ED). Of these, 83 patients continued to either CBSM (n = 44) or ED (n = 39) intervention. Study end points were mood change, heart rate variability (HRV), double product elevation (DP = heart rate × systolic blood pressure) by math and anger-recall stress, and arrhythmia up to 6 months follow-up. RESULTS: Adjusting for multiple testing, CBSM was associated with moderate effect size reductions in tension/anxiety (P = 0.010), anger/hostility (P = 0.020), perceived stress (P = 0.037), and total mood disturbance (P = 0.025), greatest immediately following intervention (P < 0.05), and partially attributable to increased negative mood following ED (P < 0.01). No significant intervention effects on high frequency or low frequency spectral power of HRV, DP responses, or cardiac arrhythmias were demonstrated. CONCLUSIONS: CBSM intervention in ICD recipients resulted in reduced anxiety, anger, and perceived stress, not sustained at 6 months follow-up, and without conclusive effect on cardiac autonomic or hemodynamic responses to mental stress, or arrhythmia. Findings support conduct of larger behavioral intervention arrhythmia trial, with consideration of reinforcement training and targeting of subgroup responders to therapy.

Effectiveness of nasal irrigation for chronic rhinosinusitis and fatigue in patients with Gulf War illness: protocol for a randomized controlled trial.

INTRODUCTION: Gulf War Illness (GWI) affects 1 in 7 returned Persian Gulf War veterans. Quality-of-life impact is large; there is no cure. Chronic sinus symptoms and fatigue are common. Nasal irrigation with saline (NI-S) or xylitol (NI-X) improve sinus symptoms and fatigue in the general population. This trial will assess the effect of NI-S and NI-X on sinus and fatigue symptoms, economic outcomes and pro-inflammatory milieu among participants with GWI. METHODS: 75 participants (age 35 to 65 years, 25 in each of three arms) with GWI will be recruited from the Veteran's Administration and the community. They will use routine care for sinus symptoms and fatigue and be randomized to continued usual care alone or additional therapy with NI-S or NI-X. Participants will be able to adjust specific elements of the NI procedure. The primary outcome (Sinonasal Outcome Test, SNOT-20) and other self-reported assessments will occur at baseline, 8 and 26 weeks; lab assessment of pro-inflammatory cellular and cytokine profiles will occur at baseline and 26 weeks. Other outcomes will include fatigue-specific and overall health-related quality of life, pro-inflammatory cellular and cytokine profiles, cost-effectiveness and participant satisfaction. RESULTS: Baseline demographic and clinical data from the first 10 participants show effective participant recruitment, enrollment, randomization, retention and data collection. CONCLUSION: Early study conduct suggests that our participant-oriented approach will yield high rates of participant adherence and data capture, facilitating robust analysis. Results of this study will clarify the value of NI for chronic sinus symptoms and fatigue among patients with GWI. CLINICAL TRIAL REGISTRATION: clinicaltrials.gov identifier NCT01700725.

Using Life Stories to Connect Veterans and Providers.

The My Life, My Story patient-centered program uses veterans' personal narratives by veterans to create a strong connection between patients and providers.

Family care map: Sustaining family-centered care in Polytrauma Rehabilitation Centers.

The study assessed sustainability of the Family Care Map, a family-centered approach to providing care for Veterans with polytrauma-related injuries, in four Department of Veterans Affairs Polytrauma Rehabilitation Centers. We applied a mixed-methods approach. Staff surveys used standardized measures of sustainability, commitment to change, information, and participation during implementation. Qualitative inquiry assessed Family Care Map implementation and facilitators and barriers to sustainability. Staff sustainability perceptions had a significant positive correlation with affective commitment to change, participation, and information received about the change process. Family Care Map integration into standard practices and use of its concepts with patients and families related to staff perceptions about sustainability. The degree of use and integration of the Family Care Map in traumatic brain injury/polytrauma care varied among the Polytrauma Rehabilitation Centers. Some successful sustainability strategies included integration into daily workflow and organizational culture. Examples of sustainability barriers included staff awareness and use and outdated information. Some practices, such as measuring and documenting the use of the Family Care Map in treatment plans, may not routinely occur. The focus on family-centered care will require further evaluation of organization-, staff-, and innovation-level attributes that influence sustainability of changes designed to improve family-centered care.

Psychiatry student interest groups: what they are and what they could be.

OBJECTIVE: Medical student interest groups across all specialties help students explore various specialties. There are no published reports on psychiatry student interest group (PSIG) curricula. The aim was to develop elements of a curriculum for such groups, based on data elicited from medical students and faculty members through a multi-institutional online survey. METHOD: The authors electronically surveyed 172 United States psychiatric residency training directors to determine the activities they felt to be important for inclusion in PSIG curricula. Similarly, they surveyed U.S. medical student PSIG leaders to ascertain the activities they felt important to include in such groups, and the current content of their groups. RESULTS: Authors received responses from 64 program directors and 44 PSIG leaders. Based on integration of the results of both surveys, and the practices of existing groups, they propose elements of a curriculum for PSIGs. Medical student PSIG leaders are particularly interested in activities that involve residents. Other curricular topics of interest both to students and training directors include those that focus on student/physician mental health and various psychiatry subspecialties or practice settings. Training directors are willing to be involved with a wide variety of PSIG activities. CONCLUSIONS: The results of these surveys should help to guide PSIG leaders and faculty members in optimizing their PSIG curricula by helping them to include those activities felt to be of most interest by students and of most relevance by training directors.

Suicide attempts in veterans with bipolar disorder during treatment with lithium, divalproex, and atypical antipsychotics.

Suicide attempt rates were assessed in 1306 subjects in this 6 year retrospective study of Bipolar disorder. Participants were Veterans from 5 different Veterans Administration Hospitals who met criteria for bipolar type 1 or 2 and who had at least one prescription for lithium or divalproex or both during the study period. This study focused on the impact of atypical antipsychotics on the suicide attempt rate when used in addition to or in place of lithium or divalproex. Medication exposure was calculated using computerized pharmacy records. Suicide attempts were established through chart review including emergency room records, inpatient records, and outpatient records. There were a total of 117 suicide attempts and 2 suicide completions during the study period. Most attempts (59%) occurred when patients were on no medications. Nearly 90% of subjects spent an average of 45 months during the 6 year period on none of the aforementioned medications. The lowest percentage of suicide attempts (15%) occurred while on lithium, 21% while on divalproex and 24% while on atypical antipsychotics. When total months of exposure were taken into account, the lowest attempt rate occurred on lithium plus divalproex (6.3 attempts per 10,000 months of exposure), followed by divalproex alone (7.0 attempts/10,000 months of exposure), and lithium alone (7.7 attempts per 10,000 months of exposure). Patients on atypical antipsychotics alone had an attempt rate of 26.1 attempts per 10,000 months of exposure. In this study, lithium and divalproex provided protection against suicide attempts. Results need to be replicated in future prospective studies and clearly strategies for improving medication compliance among veterans are warranted.

Sustainability in primary care and Mental Health Integration projects in Veterans Health Administration.

OBJECTIVE: To explore staff perceptions about sustainability, commitment to change, participation in change process, and information received about the change project within the Veterans Administration Primary Care and Mental Health Integration (PC-MHI) initiative and to examine differences from the Veterans Health Administration Mental Health Systems Redesign (MHSR) initiative. DATA SOURCES: Surveys of change team members involved in the Veterans Affairs PC-MHI and MHSR initiatives. STUDY DESIGN: One-way analysis of variance examined the relationship between commitment, participation and information, and sustainability. Differences in PC-MHI sustainability were explored by location and job classification. Staff sustainability perceptions were compared with MHSR results. PRINCIPAL FINDINGS: Sustainability differed by staff discipline. Difference between MHSR and PC-MHI existed by job function and perceptions about the change benefits. Participation in the change process and information received about the change process were positively correlated with sustainability. Staff commitment to change was positively associated with staff perceptions about the benefits of change and staff attitudes toward change. CONCLUSIONS: Sustainability is an important part of organizational change efforts. Change complexity seems to influence perception about sustainability and impacts staff perceptions about the benefits of change. These perceptions seem to be driven by the information received and opportunities to participate in the change process. Further research is needed to understand how information and participation influence sustainability and affect employee commitment to change.

Exemplars in the use of technology for management of depression in primary care.

PURPOSE: Depression care management as part of larger efforts to integrate behavioral health care into primary care has been shown to be effective in helping patients and primary care clinicians achieve improved outcomes within the primary care environment. Central to care management systems is the use of registries which enable effective clinic population management. The aim of this article is to detail the methods and utility of technology in depression care management processes while also highlighting the real-world variations and barriers that exist in different clinical environments, namely a federally qualified health center and a Veterans Administration clinic. METHODS: We analyzed descriptive data from the registries of Access Community Health Centers and the William S. Middleton Veterans Administration clinics along with historical reviews of their respective care management processes. RESULTS: Both registry reviews showed trend data indicating improvement in scores of depression and provided baseline data on important system variables, such as the number of patients who are not making progress, the percentage of patients who are unreachable by phone, and the kind of actions needed to ensure evidence-based and efficient care. Both sites also highlighted systemic technical barriers to more complete implementation of care management processes. CONCLUSIONS: Care management processes are an effective and efficient part of population-based care for depression in primary care. Implementation depends on available resources including hardware, software, and clinical personnel. Additionally, care management processes and technology have evolved over time based on local needs and are part of an integrated method to support the work of primary care clinicians in providing care for patients with depression.

Measuring sustainability within the Veterans Administration Mental Health System Redesign initiative.

OBJECTIVE: To examine how attributes affecting sustainability differ across Veterans Health Administration organizational components and by staff characteristics. SUBJECTS: Surveys of 870 change team members and 50 staff interviews within the Veterans Affairs' Mental Health System Redesign initiative. METHODS: A 1-way ANOVA with a Tukey post hoc test examined differences in sustainability by Veteran Integrated Service Networks, job classification, and tenure from staff survey data of the Sustainability Index. Qualitative interviews used an iterative process to identify "a priori" and "in vivo" themes. A simple stepwise linear regression explored predictors of sustainability. RESULTS: Sustainability differed across Veteran Integrated Service Networks and staff tenure. Job classification differences existed for the following: (1) benefits and credibility of the change and (2) staff involvement and attitudes toward change. Sustainability barriers were staff and institutional resistance and nonsupportive leadership. Facilitators were commitment to veterans, strong leadership, and use of quality improvement tools. Sustainability predictors were outcomes tracking, regular reporting, and use of Plan, Do, Study, Adjust cycles. CONCLUSIONS: Creating homogeneous implementation and sustainability processes across a national health system is difficult. Despite the Veterans Affairs' best evidence-based implementation efforts, there was significant variance. Locally tailored interventions might better support sustainability than "one-size-fits-all" approaches. Further research is needed to understand how participation in a quality improvement collaborative affects sustainability.

A review of atypical antipsychotic medications for posttraumatic stress disorder.

Posttraumatic stress disorder (PTSD) can be a chronic and disabling illness with a limited response to antidepressant treatment, particularly in the case of combat-induced PTSD. The purpose of this study is to review randomized controlled and open-label trials of atypical antipsychotics for the treatment of PTSD. We conducted PUBMED and PILOTS database searches for clinical trials of atypical antipsychotic medications for PTSD in May 2010. Eighteen clinical trials (10 double-blind placebo-controlled, eight open-label) of atypical antipsychotics for PTSD were found and reviewed. Effect sizes of double-blind placebo-controlled trials were small, but were positive for risperidone and quetiapine. Intrusive and hypervigilance symptom subscales showed the most improvement. We concluded that atypical antipsychotic medications have a modest benefit for the treatment of PTSD. Larger randomized controlled trials are needed to clarify the potential utility of these medications in the treatment of PTSD and more rigorous examination of metabolic side effects is warranted.

Nonconsensual sexual experiences and alcohol consumption among women entering college.

The authors investigated the relationship between precollege nonconsensual sexual experiences (NSEs) and drinking among women entering college. College women (N = 797) at a midwestern university participated. Eighteen percent reported one or more NSE prior to arriving at college. Having a precollege NSE was associated with recent drinking, binge drinking, and negative drinking consequences. The authors discuss implications for intervention and prevention programs targeting college women.

Age-related changes in drinking patterns from mid- to older age: results from the Wisconsin longitudinal study.

BACKGROUND: Drinking has generally been shown to decline with age in older adults. However, results vary depending on the measure of alcohol consumption used and the study population. The goals of this study were to (i) describe changes in drinking in a current cohort of older adults using a variety of measures of drinking and (ii) examine a number of different possible predictors of change. METHODS: This is a longitudinal study of a community-based sample surveyed at 2 time points, ages 53 and 64 years. We estimated a series of logistic regressions to predict change and stability in drinking categories of nondrinking, moderate drinking, and heavy drinking. Linear regressions were used to predict change in past-month drinking days, past-month average drinks per drinking day, and past-month total drinks. RESULTS: From age 53 to 64, average drinks per drinking day and heavy drinking decreased. Frequency of drinking increased for men and women, and total drinks per month increased for men. The most consistent predictors of drinking changes were gender, health, and education. Other factors predicted drinking change but were not consistent across drinking measures including: adolescent IQ, income, lifetime history of alcohol-related problems, religious service attendance, depression, debt, and changes in employment. CONCLUSIONS: Heavy drinking decreases with age, but we may see more frequent moderate drinking with current and upcoming cohorts of older adults. Components of quantity and frequency of drinking change differently. Composite measures of total alcohol consumption may not be adequate for describing relevant changes in drinking over time. A number of factors predicted patterns of change in drinking and warrant further exploration.

Longitudinal course of substance treatment benefits in older male veteran at-risk drinkers.

BACKGROUND: This investigation aims to determine the 12-month drinking trajectory of older at-risk drinkers in treatment. Furthermore, the drinking trajectory between at-risk drinkers who had met the threshold suggestive of alcohol dependence (problem at-risk drinkers) and those who did not meet this threshold (nonproblematic at-risk drinkers) were compared. METHODS: This investigation is a component of the PRISM-E (Primary Care Research in Substance Abuse and Mental Health for the Elderly) Study, a multisite randomized trial comparing service use, outcomes, and cost between Integrated (IC) versus Enhanced Specialty Referral (ESR) care models for older (65+ years) adults with depression, anxiety, and/or at-risk alcohol consumption. This investigation focuses only on at-risk drinkers, generally defined as exceeding recommended drinking limits, which in the case of older adults has been classified as consuming more than one drink per day. Two hundred fifty-eight randomized older at-risk drinkers were examined, of whom 56% were problem drinkers identified through the Short Michigan Alcohol Screening Test-Geriatric version. RESULTS: Over time, all at-risk drinkers showed a significant reduction in drinking. Problem drinkers showed reductions in average weekly consumption and number of occurrences of binge drinking at 3, 6, and 12 months, whereas nonproblematic drinkers showed significant reductions in average weekly consumption at 3, 6, and 12 months and number of occurrences of binge drinking at only 6 months. IC treatment assignment led to higher engagement in treatment, which led to better binge drinking outcomes for problem drinkers. Despite significant reductions in drinking, approximately 29% of participants displayed at-risk drinking at the end of the study. CONCLUSIONS: Results suggest that older at-risk drinkers, both problem and nonproblematic, show a considerable decrease in drinking, with slightly greater improvement evidenced in problem drinkers and higher engagement in treatment seen in those assigned to IC.