Role of Institutional Support for Evidence-Based Psychotherapy in Satisfaction and Burnout Among Veterans Affairs Therapists.

OBJECTIVE: Burnout is widespread among psychotherapists and leads to negative mental and other health outcomes, absenteeism, and turnover. Job resources, including institutional support for evidence-based practices, can buffer against burnout and may improve satisfaction among therapists. The Veterans Health Administration (VHA) is the nation's largest integrated health system and employs 23,000 therapists, including psychologists, social workers, and counselors. The authors assessed associations between perceived institutional support for evidence-based treatment and satisfaction and burnout among VHA therapists. METHODS: This analysis used data from the VHA's national 2018 Mental Health Provider Survey. Responding therapists (N=5,341) answered questions about the quality of mental health care and job satisfaction. Multilevel logistic regression models were used to predict burnout and satisfaction. The authors tested availability of evidence-based treatment and measurement-based care (MBC) as predictors; analyses were adjusted for therapist workload, demographic characteristics, and potential clustering by facility. RESULTS: VHA therapists had less burnout and more job satisfaction when they perceived receiving institutional support for evidence-based psychotherapy (EBP) and MBC, irrespective of whether the analyses were adjusted for workload. Less difficulty in scheduling EBP was significantly associated with decreased likelihood of burnout (OR=0.83, p<0.001) and increased satisfaction (OR=1.09, p=0.008). Less difficulty ending psychotherapy was significantly associated with decreased likelihood of burnout (OR=0.89, p=0.002) and increased satisfaction (OR=1.12, p=0.004). CONCLUSIONS: Support for evidence-based practices, including EBP and MBC, was closely linked to VHA therapists' satisfaction and burnout. Expanding support for therapists to provide evidence-based treatment may benefit therapists, patients, and the health care system.

Guideline adherence for mentally ill reproductive-aged women on treatment with valproic acid: a retrospective chart review.

OBJECTIVE: Valproic acid (VPA) use during pregnancy increases fetal risk of major congenital malformations and cognitive impairment. Given these risks, several medical societies have put forth guidelines suggesting to either limit the use of VPA or take certain precautions, such as making sure effective contraception practices and/or appropriate folic acid supplementation are in place, when treating reproductive-aged women. Our study aimed to review and assess adherence to these guidelines. METHODS: Using electronic medical record (EMR) and administrative claims data over a 19-month period (January 1, 2013-July 31, 2014), a retrospective chart review was conducted of all reproductive-aged female patients at a major medical center in the Midwest who were prescribed VPA as treatment for their psychiatric illness (n = 190; aged from 15 to 49 years). Psychiatric diagnoses were determined via ICD-9 billing codes. We assessed 3 variables of interest as an index of adherence to guidelines: chart documentation of provider-patient discussion regarding potential teratogenicity associated with VPA use, prescription of contraceptives, and co-prescription of folic acid. RESULTS: EMR documentation of provider-patient discussions regarding possible teratogenicity of VPA was rare (13.2%), as was documentation of contraception use (30%) and co-prescription of folate (7.9%). Neither patient demographic characteristics nor diagnoses were associated with outcomes. Among those not receiving treatment in the inpatient setting, patients who were seen by outpatient psychiatry or neurology clinics (rather than other outpatient settings) were more likely to have documented discussions about teratogenicity (23% and 30%, respectively; P = .003), and patients receiving neurologic care were more likely to be prescribed folate than those seen by other providers (26%, P = .004). Women who had contact with inpatient psychiatric services were less likely to be taking contraception (n = 12 [20%], P = .041). Only 22% of women under 34 years of age were documented as using contraception (P = .03). CONCLUSIONS: Adherence to standard guidelines is low even at an academic tertiary care center. To the extent that there is any documentation or co-prescription of folate, it varies by provider specialty.

Help-seeking from clergy and spiritual counselors among veterans with depression and PTSD in primary care.

Little is known about the prevalence or predictors of seeking help for depression and PTSD from spiritual counselors and clergy. We describe openness to and actual help-seeking from spiritual counselors among primary care patients with depression. We screened consecutive VA primary care patients for depression; 761 Veterans with probable major depression participated in telephone surveys (at baseline, 7 months, and 18 months). Participants were asked about (1) openness to seeking help for emotional problems from spiritual counselors/clergy and (2) actual contact with spiritual counselors/clergy in the past 6 months. At baseline, almost half of the participants, 359 (47.2%), endorsed being "very" or "somewhat likely" to seek help for emotional problems from spiritual counselors; 498 (65.4%) were open to a primary care provider, 486 (63.9%) to a psychiatrist, and 409 (66.5%) to another type of mental health provider. Ninety-one participants (12%) reported actual spiritual counselor/clergy consultation. Ninety-five (10.3%) participants reported that their VA providers had recently asked them about spiritual support; the majority of these found this discussion helpful. Participants with current PTSD symptoms, and those with a mental health visit in the past 6 months, were more likely to report openness to and actual help-seeking from clergy. Veterans with depression and PTSD are amenable to receiving help from spiritual counselors/clergy and other providers. Integration of spiritual counselors/clergy into care teams may be helpful to Veterans with PTSD. Training of such providers to address PTSD specifically may also be desirable.

Integrated care: treatment initiation following positive depression screens.

BACKGROUND: Primary Care-Mental Health Integration (PC-MHI) may improve mental health services access and continuity of care. OBJECTIVE: To assess whether receipt of integrated PC-MHI services on the date of an initial positive depression screen influences receipt of depression treatment among primary care (PC) patients in the Veterans Health Administration. DESIGN: Retrospective cohort study. SUBJECTS: Thirty-six thousand, two hundred and sixty-three PC patients with positive depression screens between October 1, 2009 and September 30, 2010. MAIN MEASURES: Subjects were assessed for depression diagnosis and initiation of antidepressants or psychotherapy on the screening day, within 12 weeks, and within 6 months. Among individuals with PC encounters on the screening day, setting of services received that day was categorized as PC only, PC-MHI, or Specialty Mental Health (SMH). Using multivariable generalized estimating equations (GEE) logistic regression, we assessed likelihood of treatment initiation, adjusting for demographic and clinical measures, including depression screening score. KEY RESULTS: Patients who received same-day PC-MHI services were more likely to initiate psychotherapy (OR: 8.16; 95 % CI: 6.54-10.17) and antidepressant medications (OR: 2.33, 95 % CI: 2.10-2.58) within 12 weeks than were those who received only PC services on the screening day. CONCLUSIONS: Receipt of same-day PC-MHI may facilitate timely receipt of depression treatment.

Are primary care mental health services associated with differences in specialty mental health clinic use?

OBJECTIVES: The aim of this study was to determine whether implementation of primary care mental health services is associated with differences in specialty mental health clinic use within the Veterans Health Administration (VHA). METHODS: The authors compared over a one-year period the new use of specialty mental health clinics and psychiatric diagnosis patterns among patients of 118 primary care facilities that offered integrated mental health care with 142 facilities without this service, with adjustment for other facility characteristics. RESULTS: Patients at both types of primary care facilities (those with integrated mental health care and those without) initiated specialty mental health treatment at similar rates (5.6% versus 5.8%) and averaged similar total specialty mental health clinic visits (7.0 versus 6.3). There were no significant differences in diagnosis patterns. CONCLUSIONS: Initial national implementation of mental health care in primary care within the VHA was not associated with substantial differences in new specialty mental health clinic use or diagnostic case mix among primary care patients.

Initiation of Primary Care-Mental Health Integration programs in the VA Health System: associations with psychiatric diagnoses in primary care.

BACKGROUND: Providing collaborative mental health treatment within primary care settings improves depression outcomes and may improve detection of mental disorders. Few studies have assessed the effect of collaborative mental health treatment programs on diagnosis of mental disorders in primary care populations. In 2008, many Department of Veterans Affairs (VA) facilities implemented collaborative care programs, as part of the VA's Primary Care-Mental Health Integration (PC-MHI) program. OBJECTIVES: To assess the prevalence of diagnosed mental health conditions among primary care patient populations in association with PC-MHI programs, overall and for patient subpopulations that may be less likely to receive mental health treatment. RESEARCH DESIGN: Using a difference-in-differences analysis, we evaluated whether the rates of psychiatric diagnoses among primary care patient populations at 294 VA facilities changed from fiscal year (FY)07 to FY08, and whether trends differed at facilities with PC-MHI encounters in FY08. Subgroup analyses examined whether trends differed by patient age and race/ethnicity. SUBJECTS, MEASURES, AND RESULTS: From FY07 to FY08, the prevalence of diagnosed depression, anxiety, post-traumatic stress disorder, and alcohol abuse increased more in the 137 facilities with PC-MHI program encounters than in the 157 facilities without these encounters. Increases were more likely among patients who were younger (18-64) and white. CONCLUSIONS: Initiation of PC-MHI programs was associated with elevated diagnosis patterns, which may enhance recognition of mental health needs among primary care patients. Increases in diagnosis prevalence were not uniform across patient subgroups. Further research is needed on treatment processes and outcomes for individuals receiving services in PC-MHI programs.