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.

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.

Coaching third parties for suicide prevention.

Objective: Concerned allies often call crisis lines and other call centers about their loved ones' mental health. Callers to Coaching Into Care, a non-crisis call center, often report concerns about suicide risk in Veterans yet little is known about how best to support those callers. We conducted a documentation review to understand standard operating procedures, barriers, and opportunities for risk reduction. Method: Across 1,581 unique callers with an initial call over a 6 month period, 225 callers (14.2%) were identified for contact note review and coding. Results: Calls were frequently characterized by current suicidal ideation (62.7%), suicide attempts (24.0%), and access to lethal means (35.6%), although use of lethal means safety interventions was infrequently documented (12.9%). The majority of callers were coded as open to intervention (83.4%). After coaching, 16% of Veterans who were previously not connected to mental health care had connected to care in the community or VA. Conclusions: There was substantial heterogeneity in assessments and interventions used, particularly related to documentation of access to lethal means; however, there is an opportunity to provide risk reduction education and communication skill building for family and friends of Veterans. Those closest to Veterans report being open to learning new ways to engage with Veterans around safety and mental wellness.

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.

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.

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.

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.

The family forum: directions for the implementation of family psychoeducation for severe mental illness.

It is well documented that family psychoeducation decreases relapse rates of individuals with schizophrenia. Despite the evidence, surveys indicate that families have minimal contact with their relative's treatment team, let alone participate in the evidence-based practice of family psychoeducation. The Department of Veterans Affairs (VA) sponsored a conference, the Family Forum, to assess the state of the art regarding family psychoeducation and to form a consensus regarding the next steps to increase family involvement. The forum reached consensus on these issues: family psychoeducation treatment models should be optimized by efforts to identify the factors mediating their success in order to maximize dissemination; leadership support, training in family psychoeducation models for managers and clinicians, and adequate resources are necessary to successfully implement family psychoeducation; because family psychoeducation may not be appropriate, indicated, or acceptable for all families, additional complementary strategies are needed that involve families in the mental health care of the patient; and work is required to develop and validate instruments that appropriately assess the intervention process and consumer and family outcomes. A treatment heuristic for working with families of persons with severe mental illness is also offered and provides a match of interventions at varying levels of intensity, tailored to family and consumer needs and circumstances. The article describes opportunities for the research and clinical communities to expand the proportion of families served.

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

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.

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

Psychiatric comorbidity and greater hospitalization risk, longer length of stay, and higher hospitalization costs in older adults with heart failure.

OBJECTIVES: To explore associations between psychiatric comorbidity and rehospitalization risk, length of hospitalization, and costs. DESIGN: Cross-sectional study of 1-year hospital administrative data. SETTING: Claims-based study of older adults hospitalized in the United States. PARTICIPANTS: Twenty-one thousand four hundred twenty-nine patients from a 5% national random sample of U.S. Medicare beneficiaries aged 65 and older, with at least one acute care hospitalization in 1999 with a Diagnostic-Related Group of congestive heart failure. MEASUREMENTS: The number of hospitalizations, mean length of hospital stay, and total hospitalization costs in calendar year 1999. RESULTS: Overall, 15.8% of patients hospitalized for heart failure (HF) had a coded psychiatric comorbidity; the most commonly coded comorbid psychiatric disorder was depression (8.5% of the sample). Most forms of psychiatric comorbidity were associated with greater inpatient utilization, including risk of additional hospitalizations, days of stay, and hospitalization charges. Additional hospitalization costs associated with psychiatric comorbidity ranged up to $7,763, and additional days length of stay ranged up to 1.4 days. CONCLUSION: Psychiatric comorbidity appears in a significant minority of patients hospitalized for HF and may affect their clinical and economic outcomes. The associations between psychiatric comorbidity and use of inpatient care are likely to be an underestimate, because psychiatric illness is known to be underdetected in older adults and in hospitalized medical patients.

Relative contributions of relationship distress and depression to communication patterns in couples.

Researchers have long been interested in the relationship between marital distress and depression. Empirical findings from investigations into the relative contributions of marital distress and depression to marital communication have been inconsistent, and some communication behaviors, such as the demand/withdraw interaction pattern, have yet to be examined. The ability of depression to predict major types of communication (positive communication, negative communication, problem-solving, and demand/withdraw) was analyzed after controlling for the shared variance between marital distress and depression. Across two studies of couples beginning therapy and one study of couples beginning an enhancement program, results failed to provide support for a unique contribution of depression to couples' communication behaviors.

Affectivity in the problem-solving interactions of schizophrenia patients and their family members.

This study sought to examine the relationship between symptomatology and the affect expressed between individuals with schizophrenia and their family members. It was hypothesized that, because of their impact on patient social behavior and potential burden on relatives, greater negative symptoms would be associated with less emotional expression in patients but would be related to the greater expression of negative emotions in their relatives within a problem-solving discussion. Informed by research on the structure of emotion, a broad assessment of affect, including Negativity, Positivity, and Disengagement, was utilized to examine affect expressed by patients with schizophrenic disorders (N=91) and their family members during videotaped problem-solving discussions. Although individuals with schizophrenia were comparable to their family members in displays of Negativity, patients displayed less Positivity and greater Disengagement. Greater negative symptoms (in particular blunted or flat affect) were related to a general diminution of affective expression in the schizophrenia group. However, negative symptoms were unrelated to the emotional expression of family members. Other symptoms such as thought disorder and mood symptoms of anxiety, depression, and hostility were not related to displays of affect by either patients or their family members. The findings indicate the importance of examining domains of affect other than negativity and demonstrate that negative symptoms are related to interpersonal displays of affect in schizophrenia. Additionally, these results suggest that schizophrenic symptoms, by themselves, may contribute little to the conflict between patients and their family members.

An assessment of suicide in an urban VA Medical Center.

This study characterizes those patients of an urban VA Medical Center (VAMC) who had committed suicide. A cause-of-death search of the 1,075 veterans from the VAMC's case rolls who died during 1998 was conducted. For confirmed and suspected suicides, a chart review was conducted, noting psychiatric history and recent contact with the VAMC. Nineteen patients were either confirmed or suspected suicides. Few of these patients had made recent contact with the VAMC, although the majority of them had received psychiatric services from the VA at some time. The proportion of deaths due to suicide was similar in African American and White patients. Rates of suicide were elevated, primarily because of the high proportion of patients receiving psychiatric treatment. Elderly suicides were less likely to have had psychiatric services or previous psychiatric diagnoses than were younger suicides. Patients with past contact with psychiatric services may be especially at risk of suicide, particularly as contact with these services diminishes. Elderly patients in medical settings with undiagnosed or undertreated psychiatric disorders are also likely to have elevated risk for suicide. These findings demonstrate the importance of acknowledging that risk factors for suicide are specific to sites or populations; this information can be used in allocating resources for developing site-specific strategies for prevention.

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).

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.

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.

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.