Swept away: use of general medical and mental health services among veterans displaced by Hurricane Katrina.

OBJECTIVE: This study examined national patterns of outpatient service use by veterans from regions affected by Hurricane Katrina. METHODS: Analyses tracked use of general medical and mental/substance use services in September and October through December 2005 in New Orleans and Biloxi-Gulfport compared to a cohort receiving care during the same months in the previous 2 years. RESULTS: In adjusted models, veterans from New Orleans and Biloxi-Gulfport were, respectively, 73% and 41% less likely in September 2005 to use any outpatient services as were cohorts from 2003-2004. Particularly in New Orleans, the relative decline in service use was substantially greater for specialty mental health and substance use services than for general medical services. CONCLUSIONS: Although many veterans were able to obtain care after Hurricane Katrina, there was a substantial disruption in delivery of Veterans Administration services, with disproportionate declines in mental health and substance use care.

A randomized trial of telemedicine-based collaborative care for depression.

BACKGROUND: Evidence-based practices designed for large urban clinics are not necessarily portable into smaller isolated clinics. Implementing practice-based collaborative care for depression in smaller primary care clinics presents unique challenges because it is often not feasible to employ on-site psychiatrists. OBJECTIVE: The purpose of the Telemedicine Enhanced Antidepressant Management (TEAM) study was to evaluate a telemedicine-based collaborative care model adapted for small clinics without on-site psychiatrists. DESIGN: Matched sites were randomized to the intervention or usual care. PARTICIPANTS: Small VA Community-based outpatient clinics with no on-site psychiatrists, but access to telepsychiatrists. In 2003-2004, 395 primary care patients with PHQ9 depression severity scores > or = 12 were enrolled, and followed for 12 months. Patients with serious mental illness and current substance dependence were excluded. MEASURES: Medication adherence, treatment response, remission, health status, health-related quality of life, and treatment satisfaction. RESULTS: The sample comprised mostly elderly, white, males with substantial physical and behavioral health comorbidity. At baseline, subjects had moderate depression severity (Hopkins Symptom Checklist, SCL-20 = 1.8), 3.7 prior depression episodes, and 67% had received prior depression treatment. Multivariate analyses indicated that intervention patients were more likely to be adherent at both 6 (odds ratio [OR] = 2.1, p = .04) and 12 months (OR = 2.7, p = .01). Intervention patients were more likely to respond by 6 months (OR = 2.0, p = .02), and remit by 12 months (OR = 2.4, p = .02). Intervention patients reported larger gains in mental health status and health-related quality of life, and reported higher satisfaction. CONCLUSIONS: Collaborative care can be successfully adapted for primary care clinics without on-site psychiatrists using telemedicine technologies.

Analysis of the Appropriateness of Off-Label Antipsychotic Use for Mental Health Indications in a Veteran Population.

STUDY OBJECTIVE: A substantial proportion of antipsychotic (AP) use in veterans is for nonapproved indications (i.e., off-label prescribing). Not all off-label use is necessarily detrimental to patients, however, and in certain situations, off-label prescribing could be considered justifiable. The objective of this study was to determine the extent to which off-label AP prescribing in a veteran population was potentially appropriate. DESIGN: Expert panel and retrospective analysis. DATA SOURCE: Veterans Health Administration (VHA) Corporate Data Warehouse. PATIENTS: A total of 69,823 veterans who had at least one pharmacy record for an AP medication during fiscal years 2005-2012. MEASUREMENTS AND MAIN RESULTS: An expert panel was convened to determine if agreement exists on the appropriateness of AP use in various scenarios. The panel consisted of 10 experts in the field of psychiatry: nine physicians with various specialties, and one pharmacist. We used a modified RAND appropriateness method approach to identify potentially appropriate, uncertain, and inappropriate cases of AP use. The use of six second-generation APs was examined individually, and the use of first-generation APs was examined as a class. Based on data previously collected quantifying VHA AP use, the panel was given disease state scenarios for the most commonly occurring off-label diagnoses for AP prescriptions. Disease states were coupled with scenario modifiers that the expert panel considered potentially significant clinical factors. Among the four disease states-anxiety, dementia, insomnia, and posttraumatic stress disorder-29 scenarios were investigated for each AP. None of the scenarios were judged by the expert panel to be appropriate for the use of APs. Of the 203 scenarios for all APs, 60% were judged to be inappropriate by the expert panel, and the remaining 40% were considered uncertain. Of the AP medications, risperidone (72%) and olanzapine (62%) were the most likely to be seen as uncertain, whereas first-generation APs (86%) were the most likely to be considered inappropriate in a given scenario. Widespread off-label use of APs outside of the approved indications of treatment of schizophrenia and bipolar disorder, or adjunctive treatment of major depressive disorder, may not be an appropriate treatment option. According to this expert panel, no examined situations were considered appropriate for the use of APs. CONCLUSION: The consensus of our expert panel was that off-label AP use is uncertain at best and more likely, even in complicated cases, inappropriate. These findings strengthen the case for stronger control of APs in integrated health care settings such as the VHA, as well as better education and information for practitioners who provide care for patients with anxiety, dementia, insomnia, or posttraumatic stress disorder.

Design and implementation of the telemedicine-enhanced antidepressant management study.

OBJECTIVE: Evidence-based practices designed for large urban clinics are not necessarily transportable into small rural practices. Implementing collaborative care for depression in small rural primary care clinics presents unique challenges because it is typically not feasible to employ on-site mental health specialists. The purpose of the Telemedicine-Enhanced Antidepressant Management (TEAM) study was to evaluate a collaborative care model adapted for small rural clinics using telemedicine technologies. The purpose of this paper is to describe the TEAM study design. METHOD: The TEAM study was conducted in small rural Veterans Administration community-based outpatient clinics with interactive video equipment available for mental health, but no on-site psychiatrists/psychologists. The study attempted to enroll all patients whose depression could be appropriately treated in primary care. RESULTS: The clinical characteristics of the 395 study participants differed significantly from most previous trials of collaborative care. At baseline, 41% were already receiving primary care depression treatment. Study participants averaged 5.5 chronic physical health illnesses and 56.5% had a comorbid anxiety disorder. Over half (57.2%) reported that pain impaired their functioning extremely or quite a bit. CONCLUSIONS: Despite small patient populations in rural clinics, enough patients with depression can be successfully enrolled to evaluate telemedicine-based collaborative care.

How mental health providers spend their time: a survey of 10 Veterans Health Administration mental health services.

BACKGROUND: Allocation of provider time across clinical, administrative, educational, and research activities may influence job satisfaction, productivity, and quality of care, yet we know little about what determines time allocation. AIMS: To investigate factors associated with time allocation, we surveyed all mental health providers in one Veterans Health Administration (VHA) network. We hypothesized that both facility characteristics (academic affiliation, type of organization of services, serving as a hub for treatment of severely mentally ill, facility size) and individual provider characteristics (discipline, length of time in job, having an academic appointment) would influence time allocation. METHODS: Eligible providers were psychiatrists, psychologists, social workers, physician assistants, registered or licensed practical nurses or other providers (psychology technicians, addiction therapists, nursing assistants, rehabilitation, recreational, occupational therapists) who were providing care in mental health services. A brief self-report survey was collected from all eligible providers at ten VHA facilities in late 1998 (N = 997). Data regarding facility characteristics were obtained by site visits and interviews with managers. Multilevel modeling was used to examine factors associated with three dependent variables: (i) total time allocation by activity (clinical, administrative, educational, research); (ii) clinical time allocation by treatment setting (inpatient vs. outpatient); and (iii) clinical time allocation by type of care (mental vs. physical). Licensed Practical Nurses (LPNs) were used as the reference group for all analyses because LPNs were expected to spend the majority of their time on clinical activities. RESULTS: Overall, providers spent most of their time on clinical activities (77%), followed by administrative (11%), and educational (10%). Surprisingly, research activities accounted for only 2% of their time. Multilevel analysis indicated none of the facility-level variables were significant in explaining facility variance in time allocation, but individual characteristics were associated with time allocation. The model for predicting time allocation by inpatient or outpatient settings explained 16-18% of the variance in the dependent variable. In all models, provider discipline and length of time in job played an important role. Having an academic appointment was important only in the model examining total time allocation by activity type. DISCUSSION: These simple models explained only a small amount of variance in the three dependent variables which were intended to capture issues related to time allocation; and the low number of facilities limited our power to examine effects of facility-level factors. Our models performed better in predicting allocation of clinical time to treatment setting and type of treatment than in predicting overall time allocation. Discipline and length of time in job were significant across all models. In contrast, having an academic appointment was associated with allocating significantly less time to clinical activities and more time to administrative activities but not to any significant difference in time spent in either research or education. IMPLICATIONS: While a gold standard of optimal time allocation does not exist, it is striking that research, a stated mission of the VHA, accounted for so little of providers' time. The lack of involvement of clinicians in research has implications for recruitment and retention of high-quality mental health providers in this network and for the education of future providers. Without involvement of clinicians, research conducted in the network by nonclinicians may be less relevant to "real-world" clinical issues. Reductions of funds available to mental health, coupled with increased clinical demands, may have prompted this pattern of time allocation, and these findings attest to the challenges faced by large institutions that are charged with balancing many often seemingly competing missions.

Reasons for antidepressant nonadherence among veterans treated in primary care clinics.

OBJECTIVE: To examine the experiences of veterans (mostly middle-aged and elderly men) prescribed antidepressants, specifically with regard to different types of nonadherence, reasons for nonadherence, and side effects. METHOD: A mixed-methods analysis of Department of Veterans Affairs primary care patients (N = 395) with depression (9-item depression scale of the Patient Health Questionnaire criteria) enrolled in a randomized collaborative care trial was conducted. Adherence was measured from patient self-report and pharmacy data. Qualitative interviews elicited in-depth information regarding adherence. The study was conducted from April 2003 to September 2005. RESULTS: The intervention significantly improved self-reported adherence at 6 months (OR = 2.1; 95% CI, 1.0-4.4; P = .04) and 12 months (OR = 2.7; 95% CI, 1.4-5.4; P < .01), as well as medication possession at 12 months (OR = 1.82; 95% CI, 1.0-3.2; P = .04). The most common type of nonadherence at 6 months was discontinuation (12.2%), followed by not taking as prescribed (10.9%) and never took (4.8%). For patients discontinuing their antidepressant in the first 6 months, the most common and important reason was that it was not helping. Only 19.4% of patients with self-reported adherence ≥ 80% responded to treatment by 6 months. Side effects were also a commonly reported reason for discontinuation at 6 months, with 82% reporting experiencing side effects. One-third (31.4%) reported difficulty with sexual activity at 6 months, with 66.1% reporting that it was severe. Qualitative interviews supported the finding that side effects, and generally not feeling like oneself, are important adherence barriers. CONCLUSIONS: In this sample of mostly middle-aged and elderly men with depression, treatment nonresponse and side effects were the rule rather than the exception. These findings suggest that nonadherence may have resulted primarily from patients' negative experiences with antidepressants rather than structural barriers or noncompliant behaviors. TRIAL REGISTRATION: Clinicaltrials.gov Identifier: NCT00105690.