The Proposal Preparation Program: A Group Mentoring, Faculty Development Model to Facilitate the Submission and Funding of NIH Grant Applications.

This article describes the University of Minnesota Medical School Proposal Preparation Program (P3). P3 is designed to develop grant-writing skills for assistant professors preparing their first K- or R-series application to the National Institutes of Health (NIH). Three 4-month P3 cycles are conducted annually. For each cycle, a cohort of around 10 assistant professor participants and 5 regular faculty mentors meet for ten ~2-hour group sessions. Participants receive iterative oral and written feedback on their proposals in development within a small, interdisciplinary, group mentoring setting providing structure, accountability, guidance, and support. Between sessions, 1 peer and 1 mentor are assigned (on a rotating basis) to critique each participant's developing application. The sessions include a brief mentor-led presentation on a particular grant section followed by discussion of each participant's application conducted by the assigned reviewers. The cycle concludes with a mock NIH review session, in which each participant is matched with a University of Minnesota faculty content expert who critiques their completed application using NIH guidelines. In a survey sent to all past P3 participants as of 2018 (n = 194), 88% of respondents reported having submitted their P3-developed NIH grant, and 35% of these submitters reported funding success. A separate analysis of institutional data for all past P3 participants as of 2016 (n = 165) showed that 73% submitted at least 1 NIH proposal since completing P3 and that 43% of these had acquired NIH funding, for a combined total of $193 million in funding awarded. The estimated rate at which participants obtained funding for their P3-developed grant application (~35%) exceeds the national annual NIH grant funding rates (~20%) by approximately 50%. This article provides the practical information needed for other institutions to implement a P3-like program and presents a cost-benefit analysis showing the advantages of doing so.

Using consumer-wearable technology for remote assessment of physiological response to stress in the naturalistic environment.

Psychosocial stress is a major risk factor for morbidity and mortality related to a wide range of health conditions and has a significant negative impact on public health. Quantifying exposure to stress in the naturalistic environment can help to better understand its health effects and identify strategies for timely intervention. The objective of the current project was to develop and test the infrastructure and methods necessary for using wearable technology to quantify individual response to stressful situations and to determine if popular and accessible fitness trackers such as Fitbit® equipped with an optical heart rate (HR) monitor could be used to detect physiological response to psychosocial stress in everyday life. The participants in this study were University of Minnesota students (n = 18) that owned a Fitbit® tracker and had at least one upcoming examination. Continuous HR and activity measurements were obtained during a 7-day observation period containing examinations self-reported by the participants. Participants responded to six ecological momentary assessment surveys per day (~ 2 hour intervals) to indicate occurrence of stressful events. We compared HR during stressful events (e.g., exams) to baseline HR during periods indicated as non-stressful using mixed effects modeling. Our results show that HR was elevated by 8.9 beats per minute during exams and by 3.2 beats per minute during non-exam stressors. These results are consistent with prior laboratory findings and indicate that consumer wearable fitness trackers could serve as a valuable source of information on exposure to psychosocial stressors encountered in the naturalistic environment.

Veterans' service utilization and associated costs following participation in dialectical behavior therapy: a preliminary investigation.

CONTEXT: Dialectical Behavior Therapy (DBT) is an evidence-based therapy developed for the treatment of suicidal behaviors and disorders characterized by emotional and behavioral dyscontrol that is effective in veteran populations. The impact of DBT on veterans' Veterans Affairs (VA) service utilization and cost is unknown. EVIDENCE ACQUISITION: This study evaluated the impact of DBT in a VA outpatient mental health setting on VA service utilization and cost of services. Veterans treated for symptoms of Borderline Personality Disorder, who had completed at least 6 months of the DBT program were sampled (N = 41). Use of physical and mental health services during the years prior and following DBT was assessed using medical record information. RESULTS: There was a significant decrease in mental health service utilization. Psychiatric hospitalization dropped in half, and for those with a hospitalization, length of stay decreased significantly. Direct costs associated with all health care were significantly reduced. CONCLUSION: Changes in service utilization resulted in a significant reduction in direct costs of providing care to veterans with symptoms of Borderline Personality Disorder. Additional research is needed to compare the reduction in overall costs to the cost of implementing DBT and to compare these changes to a control group.

Best practices: The electronic medical record is an invaluable clinical tool: let's start using it.

This column describes the potential of an enhanced electronic medical record (EMR) to advance best practices by displaying patient history, measuring progress, and facilitating clinical research. To create a graphical, single-page display of patient history, the authors examined data in the Minneapolis Department of Veterans Affairs EMR system, including 1.8 million encounters for 50,000 mental health patients. The prototype dashboard presents information on a patient's current and past providers, diagnoses, therapeutic interventions, prescriptions, dosages, and outcomes. To provide needed outcome data to monitor patient progress, the authors tested two questions with 212 patients. Patient and clinician responses to the questions provide reliable and clinically useful data that can be used in the EMR to track patient change over time. Use of EMRs can bridge gaps between science and practice to inform diagnosis and treatment decisions and permit more accurate prognoses.

Service utilization following participation in cognitive processing therapy or prolonged exposure therapy for post-traumatic stress disorder.

This study evaluated the impact of a course of prolonged exposure or cognitive processing therapy on mental health and medical service utilization and health care service costs provided by the Department of Veterans Affairs (VA). Data on VA health service utilization and health care costs were obtained from national VA databases for 70 veterans who completed prolonged exposure or cognitive processing therapy at a Midwestern VA medical center. Utilization of services and cost data were examined for the year before and after treatment. Results demonstrated a significant decrease in the use of individual and group psychotherapy. Direct costs associated with mental health care decreased by 39.4%. Primary care and emergency department services remained unchanged.

Psychiatric morbidity and parental substance use disorder.

OBJECTIVE: To assess psychiatric morbidity associated with having no, one, or two parents with Substance Use Disorder (SUD), among patients receiving SUD care. DESIGN: Two measures of psychiatric morbidity included (a) current psychopathology and (b) lifetime use of psychiatric treatment. SETTINGS: Alcohol-drug treatment programs were located in two university medical centers. SUBJECTS: Four hundred ninety-five voluntary patients aged 18 and older and non-adopted. RESULTS: Parental SUD was directly related to (a) more current psychiatric symptoms, both self-rated and psychiatrist-rated and (b) greater likelihood of ever having ever received psychiatric treatment. Among those who had ever received psychiatric care, the number of psychotropic medications was related to parental SUD. Number of admissions, venues, visits/days, and cost of psychiatric care were not associated with parental SUD. CONCLUSIONS: Extent of parental SUD was related to increased psychiatric morbidity.

Use of administrative data to identify health plan members with unrecognized bipolar disorder: a retrospective cohort study.

OBJECTIVE: This retrospective cohort study used an algorithmic case-finding system on claims data from nationwide commercial health plans to validate previously identified predictors of unrecognized bipolar disorder among adults. STUDY DESIGN: Retrospective cohort design. METHODS: Using logistic regression, 2 claims data sets were evaluated to explore potential predictors; the first included claims for all healthcare encounters (all-encounters data set); the second excluded mental health provider claims (carve-out data set). A total of 280,244 members aged 18 to 64 years were included from 2 commercial health plans. RESULTS: Claims related to attention deficit-hyperactivity disorder, depression, depression treated with antipsychotics, use of 3 (of 5) classes of psychotherapeutic drugs, younger age, and sex were all significant predictors of a subsequent diagnosis of bipolar disorder. In the all-encounters data set, a predicted value of 5% or greater yielded a sensitivity of 9.8% and a specificity of 99.9%; a predicted threshold of 3% increased sensitivity to 20.7%; area under the receiver operating characteristic curve (AUC) was 0.82. Performance of the model was acceptable in the carve-out data set, with AUC 0.69. CONCLUSIONS: The case-finding system described here, which compares favorably with other screening tests used in primary care, may have significant value in helping physicians to identify patients with unrecognized bipolar disorder.

Michigan assessment-screening test for alcohol and drugs (MAST/AD): evaluation in a clinical sample.

In this study, we sought to evaluate a modification of the Michigan Alcohol Screening Test designed to include problems associated with other drug abuse/dependence besides alcohol. Scores of the lifetime Michigan Assessment-Screening Test/Alcohol-Drug (MAST/AD) were compared to other lifetime measures of substance abuse and dependence and to psychiatric scales reflecting current or recent symptoms. Two university medical centers with alcohol-drug programs located within departments of psychiatry hosted 520 patients with alcohol-drug-related diagnoses. Patients completed their own MAST/AD using a paper-and-pencil format. Based on interviews with the patient, a research associate rated the patients' substance-related problems on the Minnesota Substance Abuse Problem Scale (M-SAPS) and obtained information on lifetime treatment for substance abuse. An addictions psychiatrist determined abuse or dependence and made a current diagnosis of alcohol abuse/dependence only, drug abuse/dependence only, and alcohol plus drug abuse/dependence. The MAST/AD was highly correlated with the M-SAPS and several other measures of substance abuse morbidity. Patients with alcohol-only and drug-only diagnoses did not differ from one another on the MAST/AD, although both groups had lower scores than those with alcohol plus drug diagnoses. Current psychosocial morbidity as assessed by the patient and the psychiatrist was associated with the MAST/AD, although less strongly than with lifetime substance abuse measures. The lifetime MAST/AD demonstrates reliability as a severity measure for alcohol and/or drug abuse. With minor modification, this standard measure can be expanded from alcohol diagnoses to all substance diagnoses. This study in a clinical population did not demonstrate its utility as a screening instrument; additional work is needed to reveal its utility for this purpose.

The influence of patients' compensation-seeking status on the perceptions of veterans affairs clinicians.

The study compared clinicians' perceptions of three groups of veterans with posttraumatic stress disorder (PTSD): those seeking compensation for PTSD, those not seeking compensation, and those certified as permanently disabled and thus not needing to reapply for benefits. The study subjects were 50 clinicians working in specialized PTSD programs of the Department of Veterans Affairs. The clinicians had a more negative view of the treatment engagement of veterans who were seeking compensation and of clinical work with these patients than they did in the case of the other two groups. The longer clinicians had been working with veterans who had PTSD, the more extreme were these negative perceptions. Most clinicians expressed a belief that the pursuit of service connection for PTSD has a negative impact on the therapeutic relationship and on clinical work in general.

Perceived barriers to VA mental health care among Upper Midwest American Indian veterans: description and associations.

OBJECTIVES: This community-based study was undertaken to understand why Native-American veterans in the Upper Midwest choose not to use VA mental health services despite high rates of certain psychiatric disorders. RESEARCH DESIGN: A sample consisting of 543 Native-American veterans was obtained using a focused-intensive nonprobability sampling method, structured to over-sample urban and female veterans. Data sources included (1) interview (ie, an open-ended query regarding barriers to VA mental health care), (2) questionnaire (demography, psychiatric rating scales), and (3) computer-based diagnostic questionnaire, the Quick Diagnostic Interview Schedule, and a treatment questionnaire. RESULTS: These data confirmed that Native-American veterans were less apt to employ VA mental health services as compared with other professional and nonprofessional mental health services. Perceived barriers to VA mental health care were coded using a schema developed among Native American and Hispanic VA workers. Types of perceived barriers were qualitatively similar to those obtained from the VA workers, ie, barriers in the VA system, among Native-American veterans themselves, in VA staff members, and among Native American families and communities. Demographic and clinical characteristics among these 543 veterans were not associated with presence-versus-absence of barrier reporting. Among those who did report any barriers, veterans who used more traditional-alternative-complementary (TAC) care reported more barriers than did other veterans. Secondary analysis of those who reported barriers and used TAC revealed that this group had high current rates of Mood Disorder and PTSD symptoms, and high lifetime rates of PTSD and Mood Disorder. Although this latter group had tended to use VA mental health services in the past, they had generally not used them in the last year.