Social Factors Predict Treatment Engagement in Veterans with PTSD or SUD.

Veterans with PTSD and SUDs often fail to initiate, or prematurely discontinue, mental health treatment in Veteran Affairs Medical Centers (VAMC). While much is known about clinical characteristics and demographic factors impacting treatment engagement in this population, less is known about the role of social factors. This retrospective study examines primary care-based screening assessment and specialty mental healthcare appointment data in a VAMC, to test whether social factors predict treatment initiation and appointment attendance. Findings reveal veterans were more likely to initiate treatment when (a) those with SUDs (n = 235) reported more frequent negative exchanges with others and (b) those with PTSD (n = 2107) reported more perceived support or being partnered. Those with PTSD who were partnered had higher appointment attendance rates. Findings suggest social factors are relevant to treatment initiation among veterans with PTSD and SUDs and that close others may be helpful in facilitating referrals.

Internet-based family training with telephone coaching to promote mental health treatment initiation among veterans with posttraumatic stress disorder: A pilot study.

Posttraumatic stress disorder (PTSD) is common among military veterans, yet many affected veterans do not seek treatment. Family members of these veterans often experience compromised well-being and a desire for the veteran to receive mental health care. The Veterans Affairs (VA)-Community Reinforcement and Family Training (VA-CRAFT) for PTSD is an internet-based intervention intended to teach veterans' family members skills to encourage veterans to initiate mental health care. This study assessed the feasibility, acceptability, and potential efficacy of VA-CRAFT with telephone coaching in a sample of 12 spouses and intimate partners of veterans with PTSD. Participants completed the intervention over 12 weeks and were assessed pre- and posttreatment. For feasibility, 75.0% (n = 9) of participants completed the intervention and reported few difficulties and ease of use. Supporting acceptability, all nine completers had mostly favorable impressions of the intervention and perceived it as helpful. Finally, six (50.0%) participants got the PTSD-affected veteran to engage in mental health care; however, aside from potentially increasing treatment talk frequency, outcome expectancy, and self-efficacy, ds = 0.60-1.08, no apparent improvements were observed for any well-being outcomes, ds = 0.01-0.40. Although the findings are promising, given the study limitations, future research is required to evaluate this approach in a full-scale randomized controlled trial.

Coaching Into Care: Veterans Affairs Telephone-Based Service for Concerned Family Members of Military Veterans.

Many veterans who need mental health treatment are reluctant to seek care, and their family members often do not know how to encourage them to do so. In 2011, a telephone-based service called Coaching Into Care (CIC) was developed to address this concern. Callers are provided with educational resources and referrals; in more complicated cases, callers are provided with up to 6 months of telephone-based coaching. This coaching of family members has been associated with an increase in veterans accessing mental health care. This program may serve as a model for community efforts to engage individuals in needed mental health care.

Recent advances in the understanding of relationship communication during military deployment.

In recent decades, there has been a dramatic increase in the ability of service members and their intimate partners to communicate while the service member is deployed to a combat zone. Communication among partners is a crucial aspect of intimate relationships that has been demonstrated to be highly associated with couples' satisfaction. In addition, it is often cited by unhappy partners as a primary relationship problem. This special section of the Journal of Family Psychology presents five articles investigating deployment communication among service members and their intimate partners. The studies address the content and goals of deployment communication, the relations of communication to relationship satisfaction, as well as a new measure of deployment communication for potential use in future studies. A greater understanding of communication among partners of military couples during a combat deployment could likely benefit our understanding of relationship communication in a broader range of couples. (PsycINFO Database Record

Deployment communication: Underlying processes and outcomes.

This concurrent embedded mixed methods study explored important aspects of communication occurring between military service members and their intimate partners during a combat deployment to Iraq or Afghanistan. Fifty-eight participants (32 military veterans and 26 non-veteran partners) participated in an interview using standardized self-report measures assessing the current level of relationship satisfaction, trauma symptoms of the veteran, and the veterans' trauma exposure. Participants also participated in a semistructured interview focused on combat deployment and reintegration experiences. The findings suggested that communication between service members and their intimate partners during deployment is important to maintaining an emotional connection, preventing distancing to ease the transition back, obtaining assurance regarding the safety of the deployed partner, and meeting current needs to be emotionally engaged with their partner. Access to the methods of deployment communication, however, was reported to be highly variable within and across deployments. Planned withholding of unpleasant or distressing information from one's partner appeared to be common and may represent a choice by participants to improve their well-being and outcomes. Recommendations for clinical interventions include preventive programs to help couples discuss their expectations for communication during the deployment. Future research might focus on the development of measures of preferences in deployment communication, as well as the degree of impact of communication on service member duty performance, individual psychological outcomes, and couple-based outcomes. (PsycINFO Database Record

Social support predicts self-care confidence in patients with heart failure.

BACKGROUND: Self-care for patients with heart failure includes engaging in behaviours that maintain medical stability and manage problematic symptoms, as well as the confidence in one's ability to carry out such behaviours. Given the social context of self-care behaviours in heart failure, there has been increasing interest in social support as a predictor of self-care. AIM: The goal of the present study was to examine the role of social support in self-care across time for persons with heart failure. METHODS: Using data from an observational study of patients with chronic heart failure ( n = 280), we examined the role of three types of support - instrumental support, emotional support and assistance with self-care - in the longitudinal course of self-care maintenance, management and confidence. Self-report questionnaire data were collected at baseline and at three and six months later. RESULTS: We found that instrumental and emotional support predicted better self-care confidence on average and that self-care confidence improved at a faster rate for those with less instrumental support. Emotional support was positively associated with self-care management and self-care confidence, and assistance with self-care was positively associated with self-care maintenance. CONCLUSION: These findings highlight the contribution of social support to self-care in heart failure and provide guidance for future family-based interventions to improve self-care.

Health-related social control among older men with depressive symptomatology.

OBJECTIVES: Social control attempts, or attempts by social network members to influence a person's behavior, significantly predict men's health behaviors and psychological well-being. Despite the fact that depression is associated with compromised interpersonal functioning and poor health behaviors, the association between social control processes and depression has not been studied. Thus, this pilot study explored differential vulnerability to spouses' social control attempts among older, male primary care patients with varying levels of depression symptom severity and the degree to which these attempts predicted patients' behavioral and affective responses. METHOD: Participants included 88 older men referred by their primary care providers for a behavioral health assessment at a Veterans Affairs Medical Center. Data on sociodemographics, depressive symptomatology, health behaviors, spouses' positive and negative social control attempts, and patients' behavioral and affective responses to attempts were collected by telephone. RESULTS: The sample was primarily Caucasian (mean age = 65.3 (SD = 8.1) years). Patients' higher depressive symptoms were significantly associated with positive and negative affective responses to their spouses' social control attempts. The frequency of control attempts and patients' behavioral responses, however, were unrelated to patients' depressive symptoms. Multiple regression models revealed that while spouses' control attempts were unrelated to patients' positive behavioral responses, more frequent negative attempts predicted greater negative behavioral responses (e.g., ignoring spouses' attempts). Moreover, negative control attempts predicted greater negative affective responses (e.g., resentment, sadness). CONCLUSION: The findings highlight the value of identifying effective social control strategies that maximize positive behavioral change, emotional responses, and health outcomes among older men with depressive symptoms.

Veteran preferences for romantic partner involvement in depression treatment.

OBJECTIVE: The objective was to examine Veterans' preferences for romantic partner involvement in depression treatment and patient characteristics that are associated with the likelihood of preferred involvement. METHOD: One hundred seventy-nine Veterans who met criteria for major or minor depression reported if they wanted their partners to give them medication reminders, accompany them to appointments, and speak with their treatment provider. RESULTS: Greater depression severity and wanting a partner to be less critical and more encouraging were associated with greater preferences for involvement. CONCLUSION: Veterans may view their partners' involvement in depression treatment as one opportunity for partners to decrease blame or understand more about their problems.

The role of depression in medication adherence among heart failure patients.

The purpose of the study was to explore the association between depression and medication adherence in heart failure (HF) patients. Studies have shown that people with depression are likely to be nonadherent to their prescribed medication treatment. But other studies suggest that nonadherence may be overestimated by people with depression. A total of 244 adults with Stage C HF completed the study. Self-reported medication adherence was obtained using the Basel Assessment of Adherence Scale (BAAS); objective data on medication adherence were collected using the electronic Medication Event Monitoring System (MEMS). Depression was measured via self-report with the Patient Health Questionnaire (PHQ-9). There was a significant difference between depressed and nondepressed participants in self-reported medication nonadherence (p = .008), but not in objectively measured medication nonadherence (p = .72). The depressed sample was 2.3 times more likely to self-report poor medication adherence than those who were nondepressed (p = .006).

What is the best measure of daytime sleepiness in adults with heart failure?

PURPOSE: To identify the best screening measure of daytime sleepiness in adults with heart failure (HF). DATA SOURCES: A total of 280 adults with HF completed the Epworth Sleepiness Scale, the Stanford Sleepiness Scale, and a single Likert item measuring daytime sleepiness. The sensitivity and specificity of these self-report measures were assessed in relation to a measure of daytime dysfunction from poor sleep quality. CONCLUSIONS: Only 16% of the sample reported significant daytime dysfunction because of poor sleep quality. Those reporting daytime dysfunction were likely to be younger (p < .001), to be unmarried (p = .002), to have New York Heart Association (NYHA) functional class IV HF (p = .015), and to report low income (p = .006) and fewer hours of sleep (p = .015). The measure of daytime sleepiness that was most sensitive to daytime dysfunction was a single Likert item measured on a 10-point (1-10) scale. Patients with a score ≥4 were 2.4 times more likely to have daytime dysfunction than those with a score <4. IMPLICATIONS FOR PRACTICE: Complaints of daytime dysfunction because of poor sleep are not common in adults with HF. Routine use of a single question about daytime sleepiness can help nurse practitioners to identify those HF patients with significant sleep issues that may require further screening.

Predictors of objectively measured medication nonadherence in adults with heart failure.

BACKGROUND: Medication nonadherence rates are high. The factors predicting nonadherence in heart failure remain unclear. METHODS AND RESULTS: A sample of 202 adults with heart failure was enrolled from the northeastern United States and followed for 6 months. Specific aims were to describe the types of objectively measured medication adherence (eg, taking, timing, dosing, drug holidays) and to identify contributors to nonadherence 6 months after enrollment. Latent growth mixture modeling was used to identify distinct trajectories of adherence. Indicators of the 5 World Health Organization dimensions of adherence (socioeconomic, condition, therapy, patient, and healthcare system) were tested to identify contributors to nonadherence. Two distinct trajectories were identified and labeled persistent adherence (77.8%) and steep decline (22.3%). Three contributors to the steep decline in adherence were identified. Participants with lapses in attention (adjusted OR, 2.65; P=0.023), those with excessive daytime sleepiness (OR, 2.51; P=0.037), and those with ≥2 medication dosings per day (OR, 2.59; P=0.016) were more likely to have a steep decline in adherence over time than to have persistent adherence. CONCLUSIONS: Two distinct patterns of adherence were identified. Three potentially modifiable contributors to nonadherence have been identified.

Double jeopardy: the influence of excessive daytime sleepiness and impaired cognition on health-related quality of life in adults with heart failure.

AIMS: To determine how excessive daytime sleepiness (EDS) and impaired cognition contribute to health-related quality of life (HRQL) in heart failure (HF). METHODS AND RESULTS: Adults with chronic HF were enrolled into a prospective cohort study. Data were obtained from 280 subjects enrolled from three sites in the northeastern USA; 242 completed the 6-month study. At baseline, cohorts with and without EDS were identified using the Epworth Sleepiness Scale. Each EDS group was further subdivided into those with and without impaired cognition using a battery of five neuropsychological tests. Two disease-specific measures, the Kansas City Cardiomyopathy Questionnaire (KCCQ) and the Functional Outcomes of Sleep Questionnaire (FOSQ), were used to measure HRQL. General linear modelling of square-transformed variables was used to test the hypothesis that cohort membership was a significant predictor of HRQL. At 6 months the remaining sample was 62.5 [standard deviation (SD) 12] years old, mostly male (63%), white (65%), and functionally compromised [72% New York Heart Association (NYHA) class III/IV]. The cohort with both EDS and impaired cognition had the lowest KCCQ overall summary score (60.5 ± 22.5) compared with the cohort without EDS or impaired cognition (74.6 ± 17.4, P ≤ 0.001). A similar effect was seen on the FOSQ (16.0 ± 2.8 vs. 18.5 ± 2.2, P < 0.001). CONCLUSION: Impaired cognition alone did not explain poor HRQL, but the addition of EDS poses a significant risk for poor HRQL. Interventions designed to influence EDS may improve HRQL in this population.

Determinants of excessive daytime sleepiness and fatigue in adults with heart failure.

Little is known about excessive daytime sleepiness (EDS) in heart failure (HF). The aim of this cross-sectional descriptive study was to describe the prevalence of EDS and factors associated with it in HF. A secondary purpose was to explore the correlates of fatigue. We enrolled a consecutive sample of 280 adults with a confirmed diagnosis of chronic HF from three outpatient settings in the northeastern United States. Patients with major depressive illness were excluded. Clinical, sociodemographic, behavioral, and perceptual factors were explored as possible correlates of EDS. Using an Epworth Sleepiness Scale score > 10, the prevalence of EDS was 23.6%. Significant determinants of EDS were worse sleep quality (p = .048), worse functional class (p = .004), not taking a diuretic (p = .005), and lack of physical activity (p = .04). Only sleep quality was associated with fatigue (p < .001). Sleep-disordered breathing was not significantly associated with EDS or with fatigue. These factors may be amenable to intervention.

Modifiable factors associated with sleep dysfunction in adults with heart failure.

BACKGROUND: Sleep dysfunction contributes to poor quality of life in adults with heart failure (HF). The purpose of this study was to identify factors associated with sleep dysfunction that may be modifiable. METHODS: Data were collected from 266 subjects enrolled from three sites in the U.S. Sleep dysfunction was measured over the past month with the Pittsburgh sleep quality index, using a score > 10 to indicate sleep dysfunction. Potentially modifiable clinical, behavioral, and psychological factors thought to be associated with sleep dysfunction were analyzed with hierarchical logistic regression analysis. RESULTS: When covariates of age, gender, race, data collection site, and New York Heart Association (NYHA) functional class were entered on the first step, only NYHA was a significant correlate of sleep dysfunction. When the clinical, behavioral, and psychological factors were entered, correlates of sleep dysfunction were the number of drugs known to cause daytime somnolence (OR = 2.08), depression (OR = 1.83), worse overall perceived health (OR = 1.64), and better sleep hygiene (OR = 1.40). Although most (54%) subjects had sleep disordered breathing (SDB), SDB was not a significant predictor of sleep dysfunction. DISCUSSION: Factors associated with sleep dysfunction in HF include medications with sleepiness as a side-effect, depression, poorer health perceptions, and better sleep hygiene. Sleep dysfunction may motivate HF patients to address sleep hygiene. Eliminating medications with sleepiness as a side-effect, treating depression and perceptions of poor health may improve sleep quality in HF patients.

Excessive daytime sleepiness is associated with poor medication adherence in adults with heart failure.

BACKGROUND: A relationship between excessive daytime sleepiness (EDS) and poor treatment adherence has been suspected but not confirmed. We hypothesized that medication adherence would be poorer in adults with heart failure (HF) and EDS and that cognitive status would be the mechanism of effect. METHODS AND RESULTS: A sample of 280 adults with chronic HF were enrolled into a prospective cohort comparison study. We identified a cohort with EDS and a control group without EDS and further divided both groups into those with and without mild cognitive decline. Data on medication adherence were obtained at baseline and 3 and 6 months by using the Basel Assessment of Adherence Scale. Regression analysis was used to clarify the contribution of EDS and cognition to medication adherence and to assess relationships over 6 months after adjusting for age, enrollment site, gender, race, functional class, depression, and premorbid intellect. At baseline, 62% of subjects were nonadherent to their medication regime. Nonadherence was significantly more common in those with EDS, regardless of cognitive status (P = .035). The odds of nonadherence increased by 11% for each unit increase in EDS (adjusted odds ratio 1.11; 95% confidence interval 1.05-1.19; P = .001). In longitudinal models, there was a 10% increase in the odds of nonadherence for each unit increase in EDS (P = .008). The only cognition measure significantly associated with medication adherence was attention (P = .047). CONCLUSIONS: Adults with HF and EDS are more likely to have problems adhering to their medication regimen than those without EDS, regardless of their cognitive status. Identifying and correcting factors that interfere with sleep may improve medication adherence.

Primary care-mental health integration in healthcare in the Department of Veterans Affairs.

The U.S. Department of Veterans Affairs (VA) has been undergoing tremendous transformation in the past 15 years with regard to the delivery of health care. This special issue describes one aspect of this transformation of the largest health system in the U.S.; the system-wide efforts to integrate mental health treatment into the primary care setting in VA. This primary care-mental health integration (PC-MHI) is being accomplished through the central VA system support and implementation of three primary models developed in the field: the White River Colocated models, the Behavioral Health Laboratory, and TIDES (Translating Initiatives in Depression into Effective Solutions). The papers in this special issue describe the development of these models, local and regional efforts to prepare medical centers to adapt and implement PC-MHI, and the impact of the integration on mental health care in these settings. These efforts could represent a national model of PC-MHI implementation for health care systems throughout the U.S.

Family problems among recently returned military veterans referred for a mental health evaluation.

CONTEXT: Existing evidence suggests that military veterans with mental health disorders have poorer family functioning, although little research has focused on this topic. OBJECTIVE: To test whether psychiatric symptoms are associated with family reintegration problems in recently returned military veterans. DESIGN: Cross-sectional survey of a clinical population. Respondents who were referred to behavioral health evaluation from April 2006 through August 2007 were considered for the survey. SETTING: Philadelphia Veterans Affairs Medical Center, Pa. PARTICIPANTS: 199 military veterans who served in Iraq or Afghanistan after 2001 and were referred for behavioral health evaluation from primary care (mean age = 32.7 years, SD = 9.1). MAIN OUTCOME MEASURES: Measures included the Mini-International Neuropsychiatric Interview for psychiatric diagnoses, the 9-item Patient Health Questionnaire for depression diagnosis and severity, and screening measures of alcohol abuse and illicit substance use. A measure of military family readjustment problems and a screening measure of domestic abuse were developed for this study. RESULTS: Three fourths of the married/cohabiting veterans reported some type of family problem in the past week, such as feeling like a guest in their household (40.7%), reporting their children acting afraid or not being warm toward them (25.0%), or being unsure about their family role (37.2%). Among veterans with current or recently separated partners, 53.7% reported conflicts involving "shouting, pushing, or shoving," and 27.6% reported that this partner was "afraid of them." Depression and posttraumatic stress disorder symptoms were both associated with higher rates of family reintegration problems. CONCLUSIONS: Mental health problems may complicate veterans' readjustment and reintegration into family life. The findings suggest an opportunity to improve the treatment of psychiatric disorders by addressing family problems.

Social support and self-care of patients with heart failure.

BACKGROUND: Social support can influence treatment adherence of patients with chronic illnesses, which may explain the positive effects of social support on heart failure (HF) outcomes. PURPOSE: To investigate the effects of social support among patients with HF, we examined whether aspects of social support were associated with self-care, including medication adherence, dietary adherence, and HF symptom monitoring functions. METHODS: We recruited 74 patients with HF from cardiology clinics of a Veterans Affairs Medical Center and a university-affiliated hospital, and tested the relationships between social support and the patients' self-care. RESULTS: Consistent with previous research in older adults, family members, especially spouses, were often involved in the medical care of patients with chronic HF and provided a range of levels of support to patients. Self-care was generally poor, as measured across several self-care domains. Perceived social support was moderately associated with relatively better self-reported medication and dietary adherence, and other aspects of self-care such as daily weighing. CONCLUSIONS: These findings suggest that a relatively higher level of self-care is an important correlate of social support and may explain how social support influences HF outcomes. This study also suggests that family members should play a greater part in clinical care focused on improving self-care.

Clinical exacerbations as a surrogate end point in heart failure research.

BACKGROUND: We examined the utility of an index of clinical exacerbations of heart failure (HF) as a surrogate measure of outcome for use in modestly sized clinical trials and observational studies. METHODS: Electronic records of 189 outpatients with HF in a US Veterans Affairs Medical Center were examined over a 2- to 3-year period. Data collected included patient characteristics, clinical exacerbations of HF, hospitalizations, and deaths. Subsets of patient were also assessed for HF-related level of functioning. RESULTS: Episodes of clinical exacerbation could be detected reliably (kappa = .83). An index of episodes (number of episodes divided by the time in years) was associated with lower quality of life, higher functional class, increased rate of HF hospitalization, poorer exercise tolerance, and up to 30% increased risk of mortality across 2 years. CONCLUSIONS: The index of HF exacerbations is potentially a useful surrogate end point for use in clinical HF research.