Ketamine versus ECT for Nonpsychotic Treatment-Resistant Major Depression.

BACKGROUND: Electroconvulsive therapy (ECT) and subanesthetic intravenous ketamine are both currently used for treatment-resistant major depression, but the comparative effectiveness of the two treatments remains uncertain. METHODS: We conducted an open-label, randomized, noninferiority trial involving patients referred to ECT clinics for treatment-resistant major depression. Patients with treatment-resistant major depression without psychosis were recruited and assigned in a 1:1 ratio to receive ketamine or ECT. During an initial 3-week treatment phase, patients received either ECT three times per week or ketamine (0.5 mg per kilogram of body weight over 40 minutes) twice per week. The primary outcome was a response to treatment (i.e., a decrease of ≥50% from baseline in the score on the 16-item Quick Inventory of Depressive Symptomatology-Self-Report; scores range from 0 to 27, with higher scores indicating greater depression). The noninferiority margin was -10 percentage points. Secondary outcomes included scores on memory tests and patient-reported quality of life. After the initial treatment phase, the patients who had a response were followed over a 6-month period. RESULTS: A total of 403 patients underwent randomization at five clinical sites; 200 patients were assigned to the ketamine group and 203 to the ECT group. After 38 patients had withdrawn before initiation of the assigned treatment, ketamine was administered to 195 patients and ECT to 170 patients. A total of 55.4% of the patients in the ketamine group and 41.2% of those in the ECT group had a response (difference, 14.2 percentage points; 95% confidence interval, 3.9 to 24.2; P<0.001 for the noninferiority of ketamine to ECT). ECT appeared to be associated with a decrease in memory recall after 3 weeks of treatment (mean [±SE] decrease in the T-score for delayed recall on the Hopkins Verbal Learning Test-Revised, -0.9±1.1 in the ketamine group vs. -9.7±1.2 in the ECT group; scores range from -300 to 200, with higher scores indicating better function) with gradual recovery during follow-up. Improvement in patient-reported quality-of-life was similar in the two trial groups. ECT was associated with musculoskeletal adverse effects, whereas ketamine was associated with dissociation. CONCLUSIONS: Ketamine was noninferior to ECT as therapy for treatment-resistant major depression without psychosis. (Funded by the Patient-Centered Outcomes Research Institute; ELEKT-D ClinicalTrials.gov number, NCT03113968.).

A Scoping Review of Recommendations and Training to Respond to Patient Microaggressions.

OBJECTIVE: Patient microaggressions affect practitioners in all fields of healthcare and especially psychiatry. In multiple studies, healthcare professionals reported high rates of patient microaggressions and discrimination. To date, this is the first scoping review of recommendations and trainings on patient microaggressions. METHOD: A scoping review of articles indexed in PubMed, PsycINFO, Medline, ERIC, and MedEdPORTAL was conducted from July 2020 to August 2020 to identify recommendations and solutions for healthcare professionals on responding to patient microaggressions. RESULTS: The review identified 27 studies that provide recommendations and trainings for healthcare professionals to address patient microaggressions. Twenty studies outlined recommendations for healthcare professionals and systems on how to respond to patient offenses. These 20 studies were grouped into establishing a supportive culture, addressing the microaggression, supporting the targets of microaggressions, discriminatory requests, and institutional responses. Six articles described trainings that equip providers with tools to address patient microaggressions, including the ERASE framework ("Expect/Recognize/Address/Support/Establish, Encourage"); Stop, Talk, and Roll; interrupting microaggressions; XYZ ("I felt X when Y because Z"); the ACTION model ("Ask/Come/Tell/Impact/Own/Next"); and the OWTFD tool ("Observe/Why/Think/Feel/Desire"). CONCLUSION: Recommendations and trainings for the response to microaggressions are emerging, and results of trainings are encouraging. However, more work is needed to evaluate the effectiveness of these trainings in clinical settings and longitudinally.

Veterans Administration Readjustment Counseling Service Counselors' Training Needs: Results of a National Needs Assessment.

The Department of Veteran Affairs established Readjustment Counseling Service (RCS) to meet the mental health needs of active-duty service members, veterans, and their families. A diverse therapeutic skill set is needed to serve this complex population. To assess training needs, a national mixed-methods needs assessment consisting of a survey for RCS counselors and focus groups among counselors, RCS educational trainers, and national leadership was conducted. Survey results (n = 681) showed that RCS counselors were most interested in trainings on moral injury, acceptance and commitment therapy, and military sexual trauma (MST). Desired trainings aligned with populations served. Themes from focus groups revealed the need for foundational trainings so that all RCS counselors are adept in treating MST, moral injury, and posttraumatic disorder and proficient in caring for couples. Additionally, counselors desired advanced trainings tailored to individual counselors' needs. RCS counselors identified multiple trainings to help them treat those they serve.

Making an Impact: Evaluation of an Enduring Online Training Empowering Clinicians to Respond to Hate Speech.

Mental health clinicians frequently experience hate speech during patient care, resulting in an ethical dilemma. This study evaluated a 1-hour webinar discussing the ethics of working with Veterans who use hate speech, motivations and intentions of hate speech, and guidance on how to respond. The webinar was offered through the virtual Community-Based Outpatient Clinic Mental Health Grand Rounds session at the Veterans Health Administration (VHA). Rural mental health clinicians were the target audience; however, all VHA clinicians could attend. Participants were VHA clinicians who completed the evaluation for the training and received one continuing education unit for this training (n = 668). They were highly satisfied with the training and would recommend it to others. They also reported the intention to talk with coworkers and trainees about responding to hate speech and requested additional training. The recorded training can be viewed for free at https://www.mirecc.va.gov/visn16/working-with-patients-who-use-hate-speech.asp.

Wellness for Warriors: Developing and Disseminating a Veteran-centric Wellness Guide.

BACKGROUND: Evidence-based self-help wellness interventions have several benefits, including low cost, brevity, and lack of need for a health care professional. Veterans, in particular, may benefit from a self-guided resource, given a culture of self-reliance, mental health help-seeking stigma, and a high need for mental health care. Despite the high need, few self-help resources are designed for veterans. OBJECTIVES: The goal of this project was to create the Veteran Wellness Guide, a self-guided resource comprising SMART goal setting and evidence-based interventions for veterans (e.g., self-kindness, gratitude, diaphragmatic breathing, mindfulness). METHODS: First, a Veteran Engagement Group reviewed the guide and provided feedback on veteran-centric content and design. After the authors revised the guide, a subset of the group approved changes. Additional veterans used it for 2 weeks and provided feedback. RESULTS: Veterans reported the guide as being highly useful, were willing to recommend it to other veterans, and identified a need for it in the veteran community. Veterans and Veterans Health Administration clinicians and leadership helped to craft a dissemination plan to reach veterans whether they receive care through the Veterans Health Administration or the community. CONCLUSIONS: Partnering with veterans in the creation of the wellness guide led to a veteran-centric product tailored to meet the unique wellness needs of veterans. The guide has been nationally disseminated and downloaded over 3000 times and can be downloaded for free from our website.

A high-need, high-impact educational session on firearms and death by suicide.

BACKGROUND: The suicide rate among Veterans is 1.5 times greater than that for civilians, partly a result of the high use of firearms as the means for suicide. One effective strategy to reduce Veteran suicide by firearms is to provide counseling on firearm safety as a method of means reduction. However, many clinicians do not discuss firearm safety with Veterans. AIMS: This study evaluates a one-hour educational seminar for clinicians on lethal means safety. MATERIALS AND METHODS: One hundred and ninety clinicians from the Veterans Health Administration, including social workers, psychologists, psychiatrists, and nurses, participated in the training. The seminar was streamed during the South Central Mental Health Illness Research, Education and Clinical Center's Community-Based Outpatient Clinic Mental Health Grand Rounds, for which participants were eligible for continuing education units. Data were collected immediately after the training and four months later. RESULTS: After completing the training, participants believed that it was important to speak with Veterans about firearm safety and felt knowledgeable and empowered to do so. Four months after the seminar, participants had counseled, on average, over half of Veterans treated about lethal means safety. DISCUSSION: Participants reported the value of normalizing discussions about firearm safety with their Veterans and focusing on the safety aspect while discussing firearms. CONCLUSIONS: This webinar was effective in providing clinicians the skills to talk with Veterans about firearm safety and continued to impact their practice four months after training. The training is available for free on our website at https://www.mirecc.va.gov/visn16/public-health-approach-to-firearms-and-death-by-suicide.asp.

Virtual Synchronous Motivational Interviewing Training for Geographically Dispersed Interprofessional Learners.

INTRODUCTION: Behavioral health and other preventable factors account for nearly half of all premature deaths in the United States. Motivational interviewing (MI) is effective for engaging ambivalent patients in behavior change. However, many clinicians report barriers to receiving MI training, including time, cost, and travel. This study examined the effect of a 2-day virtual MI training built around didactic and real-play learning activities. METHODS: Thirty interprofessional clinicians from eight Veterans Affairs medical centers and their community-based outpatient clinics across 4 US states attended a 2-day virtual MI training. Participants completed a posttraining evaluation and a 3-month posttraining evaluation. RESULTS: Participants reported that they learned new knowledge and skills, and they would be able to apply these to their practice (M > 4).They reported high satisfaction with the training and platform and found the technology easy to use (M > 4). In the 3-month posttraining survey, participants reported that they were using MI in their practice (M = 4.19) and that they would like additional support, such as additional reading (n = 8). DISCUSSION: This study demonstrates the effect of a 2-day virtual MI training built around didactic and real-play learning activities. Virtual training particularly enhances training opportunities in rural settings. Our training removed travel and payment as barriers to participation.

Obsessive-Compulsive Disorder in Older Adults: A Comprehensive Literature Review.

We reviewed English-language articles concerning obsessive-compulsive disorder (OCD) in older adults. PubMed was searched using key words that included obsessive-compulsive disorder, geriatric, elderly, aging, and older. Of the 644 articles identified, we included 78 that were relevant to the topic. Articles that were excluded as irrelevant included studies that were not focused on OCD in older adults, animal studies, and older case reports if we identified similar more recent case reports. The literature contains very little information about the epidemiology, diagnosis, psychopathology, and treatment of OCD in older adults. Even though the diagnostic criteria for OCD are the same for older and younger adults, different manifestations and progression in older patients have been reported. While the domains and severity of symptoms of OCD do not change with age, pathologic doubt may worsen. The Yale-Brown Obsessive Compulsive Scale is used for diagnosing and evaluating illness severity, and the Obsessive-Compulsive Inventory-Revised is another valuable tool for use in older adults. Psychotherapy, specifically exposure and response prevention, is the first-line treatment for OCD because of minimal adverse effects and reported benefit. Although the US Food and Drug Administration has not approved any medications specifically for OCD in older adults, pharmacotherapy is a consideration if psychotherapy is not successful. Selective serotonin reuptake inhibitors have the fewest side effects, while the cardiovascular and anticholinergic side effects of tricyclic antidepressants are especially worrisome in older adults. OCD in older adults has received little attention, and further studies are needed.

Transforming Veterans Health Administration Mental Health Clinician Education and Practices: 20 Years of Educational Initiatives by a Center of Excellence.

Twenty years ago, the US Congress articulated a need to decrease the time it takes clinical best practices to move from the literature to daily clinical practice. The Veterans Affairs South Central Mental Illness Research, Education, and Clinical Center was one of several centers of excellence established to address this need. It is also unique in that it focuses on rural and underserved veterans. This article summarizes the education accomplishments of the South Central Mental Illness Research, Education, and Clinical Center thus far in providing educational resources and trainings to frontline Veterans Affairs mental health staff with the goal of bringing best practices to routine clinical care, thus improving mental health services. We describe the use of implementation science to support dissemination of information, such as the monthly mental health grand rounds, especially for rural staff to receive continuing education, and the adoption of evidence-based psychotherapy trainings. The Clinical Educator Grants program allows clinicians to share their clinical expertise through development of practical tools for practice gaps they identify. We describe some future directions to meet the evolving needs of Veterans Affairs and community clinicians to provide the best possible care to Veterans. Take-away messages are that, for trainings to be successful, an implementation plan is critical and that an effective educational program requires funding and leadership commitment.