My Space, Your Space, Our Space: Exploring the Potential of Collaborative Group Facilitation Between Therapists and Peer Workers in Mental Health Settings.

This paper explores the potential of collaborative group facilitation between therapists and peer workers in mental health. A case study of co-practice between a music therapist and a peer worker is used to illustrate how lived experience expertise can enrich and complement therapeutic groups. The paper aims to begin a discussion around collaborative group facilitation within mental health practice and to advocate for continued development of collaborative practice between peer workers and therapists. Experiences of collaboration are explored through the case study provided using a synthesis of the authors' reflections and dialogue. The importance of role negotiation, role definition, and open communication around changing roles and boundaries are discussed as key considerations for beginning collaborations, as well as the establishment and maintenance of a foundation of trust and support within the working relationship.

Treatment of military-related post-traumatic stress disorder: challenges, innovations, and the way forward.

Post-traumatic stress disorder (PTSD) is one of the common mental disorders in military and veteran populations. Considerable research and clinical opinion has been focused on understanding the relationship between PTSD and military service and the implications for prevention, treatment, and management. This paper examines factors associated with the development of PTSD in this population, considers issues relating to engagement in treatment, and discusses the empirical support for best practice evidence-based treatment. The paper goes on to explore the challenges in those areas, with particular reference to treatment engagement and barriers to care, as well as treatment non-response. The final section addresses innovative solutions to these challenges through improvements in agreed terminology and definitions, strategies to increase engagement, early identification approaches, understanding predictors of treatment outcome, and innovations in treatment. Treatment innovations include enhancing existing treatments, emerging non-trauma-focused interventions, novel pharmacotherapy, personalized medicine approaches, advancing functional outcomes, family intervention and support, and attention to physical health.

Suicide in Military and Veteran Populations: A View Across the Five Eyes Nations.

OBJECTIVE: This commentary highlights challenges and opportunities in suicide prevention across the military and veteran populations of the Five Eyes nations. METHODS: Trends in suicides and suicidality in military and veteran populations are outlined, as well as identified risk and protective factors, and approaches to suicide prevention. RESULTS: Suicide risk is higher in veterans compared to current serving and community samples. Despite extensive research, the causation, prediction, and prevention of suicide, is still not well understood. We propose areas for further attention in prevention strategies. CONCLUSION: Suicide and suicidality are issues of concern in military and veteran populations. Suicide prevention requires commitment to continuous improvement through research, analysis, and incorporation of evolving best practice.

Predictors of Retirement Voluntariness Using Canadian Longitudinal Study on Aging Data.

Objectives: Involuntary exit from the labor force can lead to poor health and well-being outcomes. Therefore, the purpose of this research is to better understand the factors that contribute to perceived retirement voluntariness. Methods: We conducted descriptive and multivariable logistic regression analyses using a sample of recent retirees (n = 2080) from the Canadian Longitudinal Study on Aging (CLSA). Results: More than one-quarter (28%) of older workers perceived their retirement to be involuntary. Among 37 possible predictors, 14 directly predicted retirement voluntariness and many more indirectly predicted retirement voluntariness. Only four direct predictors were common to both women and men, retiring because of organizational restructuring/job elimination; disability, health, or stress; financial possibility; and having wanted to stop working. Discussion: Findings suggest the need for employment support, health promotion, work disability prevention, financial education, and support that is sensitive to the differences between women and men to prevent involuntary retirement.

Pathways to mental health care in active military populations across the Five-Eyes nations: An integrated perspective.

Military service is associated with increased risk of mental health problems. Previous reviews have pointed to under-utilization of mental health services in military populations. Building on the most recent systematic review, our narrative, critical review takes a complementary approach and considers research across the Five-Eyes nations from the past six years to update and broaden the discussion on pathways to mental healthcare in military populations. We find that at a broad population level, there is improvement in several indicators of mental health care access, with greater gains in initial engagement, time to first treatment contact, and subjective satisfaction with care, and smaller gains in objective indicators of adequacy of care. Among individual-level barriers to care-seeking, there is progress in improving recognition of need for care and reducing stigma concerns. Among organizational-level barriers, there are advances in availability of services and cultural acceptance of care-seeking. Other barriers, such as concerns around confidentiality, career impact, and deployability persist, however, and may account for some remaining unmet need. To address these barriers, new initiatives that are more evidence-based, theoretically-driven, and culturally-sensitive, are therefore needed, and must be rigorously evaluated to ensure they bring about additional improvements in pathways to care.

Classifying heterogeneous presentations of PTSD via the default mode, central executive, and salience networks with machine learning.

Intrinsic connectivity networks (ICNs), including the default mode network (DMN), the central executive network (CEN), and the salience network (SN) have been shown to be aberrant in patients with posttraumatic stress disorder (PTSD). The purpose of the current study was to a) compare ICN functional connectivity between PTSD, dissociative subtype PTSD (PTSD+DS) and healthy individuals; and b) to examine the use of multivariate machine learning algorithms in classifying PTSD, PTSD+DS, and healthy individuals based on ICN functional activation. Our neuroimaging dataset consisted of resting-state fMRI scans from 186 participants [PTSD (n = 81); PTSD + DS (n = 49); and healthy controls (n = 56)]. We performed group-level independent component analyses to evaluate functional connectivity differences within each ICN. Multiclass Gaussian Process Classification algorithms within PRoNTo software were then used to predict the diagnosis of PTSD, PTSD+DS, and healthy individuals based on ICN functional activation. When comparing the functional connectivity of ICNs between PTSD, PTSD+DS and healthy controls, we found differential patterns of connectivity to brain regions involved in emotion regulation, in addition to limbic structures and areas involved in self-referential processing, interoception, bodily self-consciousness, and depersonalization/derealization. Machine learning algorithms were able to predict with high accuracy the classification of PTSD, PTSD+DS, and healthy individuals based on ICN functional activation. Our results suggest that alterations within intrinsic connectivity networks may underlie unique psychopathology and symptom presentation among PTSD subtypes. Furthermore, the current findings substantiate the use of machine learning algorithms for classifying subtypes of PTSD illness based on ICNs.

Canada's Veterans independence program: a pioneer of "aging at home".

The Veterans Independence Program (VIP) was developed in the late 1970s to promote the independence and aging at home of Second World War veterans. This paper describes VIP's origins, core services and its service-delivery approach. It also summarizes program expenditures and client trends, presents the results of research studies of program impact and effectiveness and discusses lessons learned and best practices.

Increasing value for money in the Canadian healthcare system: new findings and the case for integrated care for seniors.

Given the recent economic climate and increasing costs in the Canadian healthcare system, we must ensure that we are getting the best value for money possible. This article presents new findings and a broad weight of evidence to make the case that it is possible to obtain better value for money in our healthcare system by adopting models of integrated care delivery for seniors and others with ongoing care needs.

Predictors of general medical and psychological treatment use among a national sample of peacekeeping veterans with health problems.

We investigated general medical and psychological treatment use predictors among peacekeeping veterans with health problems, aiming to find those characteristics most associated with treatment use intensity (i.e., visit counts). One thousand one hundred and thirty-two male Canadian Forces peacekeeping veterans registered with Veterans Affairs for health problems were randomly recruited for a prospective national survey. Regression analyses for treatment use intensity controlled for age, total time deployed and health problems (covariates), and examined the incremental contribution of depression and post-traumatic stress disorder (PTSD) severity on health service use intensity. Results revealed that after controlling for covariates, the depression and PTSD model was associated with increased medical and psychological treatment use intensity. Medical use intensity was significantly predicted by married status, greater depression and health problems; psychological treatment use intensity was predicted by younger age, greater PTSD severity and health problems. This study highlights the importance of an integrated primary care-mental health service delivery model for veterans.

Association of PTSD and depression with medical and specialist care utilization in modern peacekeeping veterans in Canada with health-related disabilities.

OBJECTIVE: We examined the relative associations between posttraumatic stress disorder (PTSD) and depression severity with medical and specialist care use in modern peacekeeping veterans with health-related disabilities. METHOD: The participants consisted of 1016 male veterans who served in the Canadian Forces from 1990 to 1999, selected from a larger random sample of 1968 veterans who voluntarily completed an anonymous general health survey conducted by Veterans Affairs Canada in 1999. Survey instruments included the PTSD Checklist-Military Version (PCL-M), Center for Epidemiological Studies-Depression Scale, and questionnaires of health problems and service use, sociodemographic characteristics, and military history. RESULTS: Among peacekeeping veterans with health disabilities, "probable" PTSD (PCL-M score > or = 50) was associated with significantly more medical service use (primary and specialty care combined), with a mean of 16.4 times (SD = 17.4) compared with 6.0 times (SD = 6.6), p < .001, for veterans without PTSD. We found that in multivariate analyses, general medical care intensity (i.e., number of visits) was related to increased health problems, greater probable PTSD diagnosis, and greater depression symptom severity. We also found that depression severity accounted for health care use intensity and that PTSD only added a small amount of incremental variance above that. CONCLUSIONS: The observed association between PTSD (diagnosis and severity) and medical care utilization stresses the importance of PTSD screening in primary care settings, especially in patients with a history of military service. This association is also useful for clinicians and hospital administrators in understanding potential medical and psychiatric needs for military veterans.

Disability correlates in Canadian Armed Forces Regular Force Veterans.

PURPOSE: This study was undertaken to inform disability mitigation for military veterans by identifying personal, environmental, and health factors associated with activity limitations. METHOD: A sample of 3154 Canadian Armed Forces Regular Force Veterans who were released during 1998-2007 participated in the 2010 Survey on Transition to Civilian Life. Associations between personal and environmental factors, health conditions and activity limitations were explored using ordinal logistic regression. RESULTS: The prevalence of activity reduction in life domains was higher than the Canadian general population (49% versus 21%), as was needing assistance with at least one activity of daily living (17% versus 5%). Prior to adjusting for health conditions, disability odds were elevated for increased age, females, non-degree post-secondary graduation, low income, junior non-commissioned members, deployment, low social support, low mastery, high life stress, and weak sense of community belonging. Reduced odds were found for private/recruit ranks. Disability odds were highest for chronic pain (10.9), any mental health condition (2.7), and musculoskeletal conditions (2.6), and there was a synergistic additive effect of physical and mental health co-occurrence. CONCLUSIONS: Disability, measured as activity limitation, was associated with a range of personal and environmental factors and health conditions, indicating multifactorial and multidisciplinary approaches to disability mitigation.

The Overseas Service Veteran (OSV) At Home Pilot: how choice of care may affect use of nursing home beds and waiting lists.

In 1999 Veterans Affairs Canada (VAC) implemented the Overseas Service Veterans (OSV) At Home Pilot Project in response to the problem that a growing number of clients were on waiting lists for beds in long-term care facilities. The At Home pilot offered certain clients on waiting lists, who met nursing-level care and military-service requirements, access to home care and treatment services for which they had previously been ineligible. A review of the pilot showed that a large majority of clients preferred to remain at home, with support, rather than accept a long-term care placement, even when a bed became available. The pilot has helped reduce waiting times for nursing home beds and may have important implications for reducing costs and the demand for long-term care beds.

Out of the shadows: mental health of Canadian armed forces veterans.

In the past 15 years in Canada, as in other nations, the mental health of veterans has emerged as a key concern for both government and the public. As mental health service enhancement unfolded, the need for wider population studies became apparent. This paper describes the renewal of services and key findings from national surveys of serving personnel and veterans.

Postmilitary adjustment to civilian life: potential risks and protective factors.

BACKGROUND: Adjustment to civilian life in Canadian veterans after release from military service has not been well studied. OBJECTIVES: The objectives of this study were: (1) to explore dimensions of postmilitary adjustment to civilian life and (2) to identify demographic and military service characteristics associated with difficult adjustment. DESIGN: Data were analyzed from a national sample of 3,154 veterans released from the regular Canadian Forces during 1998 to 2007 in a cross-sectional survey conducted in 2010 called the Survey on Transition to Civilian Life. METHODS: The prevalence of difficult adjustment to civilian life for selected characteristics was analyzed descriptively, and confidence intervals were calculated at the 95% level. Multivariable logistic regression analysis was used to identify characteristics available at the time of release that were associated with difficult adjustment. RESULTS: The prevalence of difficult adjustment to civilian life was 25%. Statistically significant differences were found across indicators of health, disability, and determinants of health. In multivariable regression, lower rank and medical, involuntary, mid-career, and Army release were associated with difficult adjustment, whereas sex, marital status, and number of deployments were not. LIMITATIONS: Findings cannot be generalized to all veterans because many characteristics were self-reported, important characteristics may have been omitted, and causality and association among health, disability, and determinants of health characteristics could not be determined. CONCLUSIONS: Postmilitary adjustment to civilian life appears to be multidimensional, suggesting the need for multidisciplinary collaboration between physical therapists and other service providers to mitigate difficult transition. Potential risk and protective factors were identified that can inform interventions, outreach strategies, and screening activities, as well as further research.

Health-related quality of life of Canadian Forces veterans after transition to civilian life.

OBJECTIVES: Describe health-related quality of life (HRQoL) of former Canadian Forces (CF) men and women in uniform (Veterans) after transition to civilian life, and compare to age- and sex-adjusted Canadian norms. METHODS: The 2010 Survey on Transition to Civilian Life was a national computer-assisted telephone survey of CF Regular Force personnel who released during 1998-2007. HRQoL was assessed using the SF-12 Physical (PCS) and Mental (MCS) Component Summary scores. Descriptive analysis of HRQoL was conducted for socio-demographic, health, disability and determinants of health characteristics. RESULTS: Mean age was 46 years (range 20-67). Compared to age- and sex-adjusted Canadian averages, PCS (47.3) was low and MCS was similar (52.0). PCS and MCS were variably below average for middle age groups and lowest for non-commissioned ranks, widowed/divorced/separated, 10-19 years of service, physical and mental health conditions, disability, dissatisfaction with finances, seeking work/not working, low social support and difficulty adjusting to civilian life. Among Veterans Affairs Canada clients, 83% had below-average physical PCS, 49% had below-average MCS, and mean PCS (38.2) was significantly lower than mean MCS (48.3). CONCLUSIONS: HRQoL varied across a range of biopsychosocial factors, suggesting possible protective factors and vulnerable subgroups that may benefit from targeted interventions. These findings will be of interest to agencies supporting Veterans in transition to civilian life and to researchers developing hypotheses to better understand well-being in Canadian Veterans.

Work reintegration for veterans with mental disorders: a systematic literature review to inform research.

BACKGROUND: Some veterans, and especially those with mental disorders, have difficulty reintegrating into the civilian workforce. PURPOSE: The objectives of this study were to describe the scope of the existing literature on mental disorders and unemployment and to identify factors potentially associated with reintegration of workers with mental disorders into the workforce. DATA SOURCES: The following databases were searched from their respective inception dates: MEDLINE, EMBASE, Cumulative Index Nursing Allied Health (CINAHL), and PsycINFO. STUDY SELECTION: In-scope studies had quantitative measures of employment and study populations with well-described mental disorders (eg, anxiety, depression, posttraumatic stress disorder, substance-use disorders). DATA EXTRACTION: A systematic and comprehensive search of the relevant published literature up to July 2009 was conducted that identified a total of 5,195 articles. From that list, 81 in-scope studies were identified. An update to July 2012 identified 1,267 new articles, resulting in an additional 16 in-scope articles. DATA SYNTHESIS: Three major categories emerged from the in-scope articles: return to work, supported employment, and reintegration. The literature on return to work and supported employment is well summarized by existing reviews. The reintegration literature included 32 in-scope articles; only 10 of these were conducted in populations of veterans. LIMITATIONS: Studies of reintegration to work were not similar enough to synthesize, and it was inappropriate to pool results for this category of literature. CONCLUSIONS: Comprehensive literature review found limited knowledge about how to integrate people with mental disorders into a new workplace after a prolonged absence (>1 year). Even more limited knowledge was found for veterans. The results informed the next steps for our research team to enhance successful reintegration of veterans with mental disorders into the civilian workplace.