Veteran Beliefs About the Causes of Gulf War Illness and Expectations for Improvement.

BACKGROUND: Individuals' beliefs about the etiology of persistent physical symptoms (PPS) are linked to differences in coping style. However, it is unclear which attributions are related to greater expectations for improvement. METHOD AND RESULTS: A cross-sectional regression analysis (N = 262) indicated that Veterans with Gulf War Illness (GWI) who attributed their GWI to behavior, (e.g., diet and exercise), had greater expectations for improvement (p = .001) than those who attributed their GWI to deployment, physical, or psychological causes (p values > .05). CONCLUSIONS: Findings support the possible clinical utility of exploring perceived contributing factors of PPS, which may increase perceptions that improvement of PPS is possible. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02161133.

Improving care for veterans' environmental exposure concerns: applications of the consolidated framework for implementation research in program evaluation.

BACKGROUND: Healthcare systems, like the US Department of Veterans Affairs (VA), need policies and procedures for delivering care to special populations including those with environmental exposure concerns. Despite being common and pervasive, especially among Veterans, environmental exposures are largely overlooked by healthcare providers. To successfully implement care for Veterans with military environmental exposure concerns, an understanding of contextual factors impeding care on the provider (e.g., knowledge and beliefs) and organizational (e.g., leadership's priorities) level is needed. Our goal was to conduct an operational needs assessment of providers to examine provider educational needs regarding Veterans' military environmental exposure concerns. METHODS: In 2020, we surveyed 2,775 VA medical and behavioral health providers. Our cross-sectional assessment was informed by the Consolidated Framework for Implementation Research (CFIR) and assessed barriers and facilitators to the uptake and application of knowledge regarding interdisciplinary care for environmental exposure concerns. The web-based survey was emailed to providers across the United States representing a variety of disciplines and practice settings to reflect the interdisciplinary approach to care for environmental exposures. We used bivariate statistics to investigate the intervention setting, inner setting, and individual characteristics of providers regarding care for environmental exposure concerns. RESULTS: Approximately one-third of VA medical and behavioral health clinicians report low to no knowledge of environmental exposure concerns. We find 88% of medical and 91% of behavioral health providers report they are ready to learn more about environmental exposures. Half of medical and behavioral health providers report they have access to information on environmental exposures and less than half report care for environmental exposures is a priority where they practice. CONCLUSIONS: Our findings suggest interdisciplinary providers' knowledge of and discussion with Veterans about environmental exposures may be influenced by contextual factors at the organizational level. Considering individual-level factors and organizational culture is important to consider when supporting care for environmental exposures. Since this needs assessment, VA established targeted programs to improve care related to military environmental exposures in response to legislation; future exploration of these same variables or contextual factors is warranted.

Assessing Change in Participation in Clinical Evaluations of Deployed Veterans with Medically Unexplained Symptoms.

Many deployed veterans experience issues reintegrating into civilian life. Addressing this in a clinical setting can prove challenging; however, assessing participation, defined as involvement in a life situation by the World Health Organization's International Classification of Functioning, Disability and Health, may be helpful. The Community Reintegration of Injured Service Members-Computer Adaptive Test (CRIS-CAT) is a measure of participation developed and validated in veteran populations. The War Related and Illness and Injury Study Center, which provides comprehensive evaluations to veterans with medically unexplained deployment-related concerns, used the CRIS-CAT as part of their social work evaluations during these visits and follow-up telephone calls. This retrospective review of clinical data examines the link between participation as assessed by the CRIS-CAT and factors that are mutable (such as relationships with others) and immutable (personal characteristics) as assessed in the social work evaluation over 12 months. The findings indicate that these veteran patients did not experience change in their participation as measured by the CRIS-CAT. Multivariable regression models demonstrated relationships only between change in CRIS-CAT scales and baseline scores and race. Article concludes by discussing lessons learned from this evaluation of the utility of the CRIS-CAT in clinical care and in longitudinal evaluation.

The common-sense model and mental illness outcomes: A meta-analysis.

Psychotherapists can improve their patients' outcomes during and after therapy by improving patients' self-management. Patients who do not effectively manage their mental illness generally have worse outcomes. Leventhal's Common-Sense Model of Self-Regulation theorizes that patients' perceptions of their illness (illness representations) guide their self-management, influencing health outcomes. The present study quantified the relations between illness representations, self-management and outcomes for mental illnesses. We conducted a meta-analysis and included articles if they reported (1) on adults with mental illnesses and (2) the correlation between mental illness representations and mental illness outcomes. Twenty-five articles were included which represented 28 independent samples. The pattern of correlations among illness representations (identity, consequences, timeline, control, coherence and emotional representations), self-management strategies (attendance, engagement and adherence to treatment) and mental illness outcomes (symptom severity and quality of life) was consistent with analyses from previous studies of mental and physical illnesses. The results found threat-related illness representations mostly had a large relationship with worse mental illness outcomes and self-management. Protective illness representations had a small-to-large relationship with better mental illness outcomes and self-management. The results suggest patients' perceptions of their mental illness may be a critical indicator of their mental illness outcomes, including symptom severity and quality of life. This theory-driven meta-analysis supports calls for the inclusion of illness representations in psychotherapy for mental illness.

Understanding Veterans' Causal Attributions of Physical Symptoms.

BACKGROUND: Illness beliefs are significant contributors to health outcomes. Beliefs about the cause of physical symptoms are considered particularly important among those with medically unexplained symptoms and illnesses (MUS); yet little is known about causal beliefs among those with the most severe MUS (i.e., Veterans). The goal of the current study was to examine Veteran's causal attributions of their physical symptoms. METHOD: A total of 91 combat Veterans with MUS were surveyed using a mixed-methods design about the cause of their physical symptoms, physical symptom severity, and PTSD symptoms. Causal attributions of physical symptoms were analyzed through thematic response analysis and grouped into categories. Chi-square analysis was used to assess the distribution of causal attribution types across Veterans with varying physical symptom severity and PTSD symptom severity. RESULTS: Veterans with MUS reported an average of 7.9 physical symptoms, and attributed the cause of their symptoms to seven different categories ("Do not Know," "Stress/Mental Health," "Deployment/Environment," "Functional/Symptom," "Medically Explained," "Medically Unexplained Syndrome," and "Lifestyle"). Exploratory chi-square analysis revealed significant differences in causal attributions across physical symptom severity and severity of PTSD symptoms. Veterans with more severe PTSD and Veterans with more severe physical symptoms were more likely to attribute their MUS to stress/mental health or to a medically unexplained syndrome compared with those with low/no PTSD symptoms and physical symptom severity. Veterans with minimal PTSD and Veterans with minimal physical symptom severity were more likely to attribute the cause of their MUS to lifestyle choices (e.g., exercise/diet) compared with those with high PTSD and physical symptom severity. CONCLUSION: Veterans with MUS endorse multiple, varied causal attributions for their physical symptoms, suggesting more complex causal beliefs than typically assumed. This has important implications for patient-provider communication and development of concordance around MUS treatment.

Interrelationships between symptom burden and health functioning and health care utilization among veterans with persistent physical symptoms.

BACKGROUND: Between 10 and 50% of primary care patients present with persistent physical symptoms (PPS). Patients with PPS tend to utilize excessive or inappropriate health care services, while being stuck in a deleterious cycle of inactivity, deconditioning, and further worsening of symptoms and disability. Since military deployment (relative to non-deployment) is associated with greater likelihood of PPS, we examined the interrelationships of health care utilization, symptom burden and functioning among a sample of recently deployed Veterans with new onset persistent physical symptoms. METHODS: This study analyzed a cohort of 790 U.S. soldiers who recently returned from deployment to Iraq or Afghanistan. Data for this analysis were obtained at pre- and post-deployment. We used moderation analyses to evaluate interactions between physical symptom burden and physical and mental health functioning and four types of health care utilization one-year after deployment, after adjusting for key baseline measures. RESULTS: Moderation analyses revealed significant triple interactions between physical symptom burden and health functioning and: primary care (F = 3.63 [2, 303], R2Δ = .02, p = 0.03), specialty care (F = 6.81 [2, 303] R2Δ =0.03, p < .001), allied therapy care (F = 3.76 [2, 302], R2Δ = .02, p = 0.02), but not mental health care (F = 1.82 [1, 303], R2Δ = .01, p = .16), one-year after deployment. CONCLUSIONS: Among U.S. Veterans with newly emerging persistent physical symptoms one-year after deployment, increased physical symptom burden coupled with decreased physical and increased mental health functioning was associated with increased medical care use in the year after deployment. These findings support whole health initiatives aimed at improving health function/well-being, rather than merely symptom alleviation.

Coping with Medically Unexplained Physical Symptoms: the Role of Illness Beliefs and Behaviors.

BACKGROUND: Medically unexplained syndromes (MUS) are both prevalent and disabling. While illness beliefs and behaviors are thought to maintain MUS-related disability, little is known about which specific behavioral responses to MUS are related to disability or the way in which beliefs and behaviors interact to impact functioning. The purpose of the present study was to examine the relationship between illness beliefs and disability among patients with MUS, and assess the extent to which behaviors mediate this relationship. METHODS: The study examined data from the baseline assessment of a multi-site randomized controlled trial (RCT). Participants were 248 veterans with MUS. Illness beliefs, behavioral responses to illness, and disability were assessed through self-report questionnaire. Data were analyzed using mediation analysis. RESULTS: Threat-related beliefs predicted greater disability through decreased activity and increased practical support seeking. Protective beliefs predicted less disability through reductions in all-or-nothing behavior and limiting behavior. CONCLUSIONS: These outcomes suggest that all-or-nothing behavior, limiting behavior, and practical support seeking are important in the perpetuation of disability among those with MUS. This has implications for improving MUS treatment by highlighting potential treatment targets. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02161133.

Helpful ways providers can communicate about persistent medically unexplained physical symptoms.

BACKGROUND: Communication between patients and providers about persistent "medically unexplained" physical symptoms (MUS) is characterized by discordance. While the difficulties are well documented, few studies have examined effective communication. We sought to determine what veterans with Gulf War Illness (GWI) perceive as the most helpful communication from their providers. Veterans with GWI, a type of MUS, have historically had complex relationships with medical providers. Determining effective communication for patients with particularly complex relationships may help identify the most critical communication elements for all patients with MUS. METHODS: Two hundred and-ten veterans with GWI were asked, in a written questionnaire, what was the most useful thing a medical provider had told them about their GWI. Responses were coded into three categories with 10 codes. RESULTS: The most prevalent helpful communication reported by patients was when the provider offered acknowledgement and validation (N = 70). Specific recommendations for managing GWI or its symptoms (N = 48) were also commonly reported to be helpful. In contrast, about a third of the responses indicated that nothing about the communication was helpful (N = 63). There were not differences in severity of symptoms, disability or healthcare utilization between patients who found acknowledgement and validation, specific recommendations or nothing helpful. CONCLUSIONS: Previous research has documented the discord between patients and providers regarding MUS. This study suggests that most patients are able to identify something helpful a provider has said, particularly acknowledgement and validation and specific treatment recommendations. The findings also highlight missed communication opportunities with a third of patients not finding anything helpful.

Cultural incongruity predicts adjustment to college for student veterans.

Little is known about what predicts student service members' and veterans' (SSM/V) adjustment to college. In qualitative research, SSM/V report feeling they do not belong and are misunderstood by college communities, a phenomenon that counseling psychologists call cultural incongruity. The goal of the current study was to quantitatively examine the relationship between cultural incongruity and adjustment to college. We surveyed 814 SSM/V about their adjustment to college using the Student Adaptation to College Questionnaire. Cultural incongruity was operationalized in two ways: feelings of not belonging were measured via direct report and the association with adjustment to college assessed with regression. Feelings of being misunderstood about academic barriers were assessed by comparing SSM/V's perceptions of academic barriers and SSM/V's perceptions of how others view the SSM/V's academic barriers and the association with adjustment was assessed using polynomial regression and response surface analysis. Cultural incongruity predicted adjustment to college. After controlling for other known predictors, feelings of not belonging accounted for 18% of the variance in adjustment to college. Polynomial regression showed that feeling understood about academic barriers protected against the negative impact of the barrier on adjustment to college. Cultural incongruity predicts adjustment to college for SSM/V. Helping SSM/V feel their unique barriers to college adjustment are understood may blunt the impact of these barriers. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Empirical Evaluation of Veterans' Perceived Non-Concordance with Providers Regarding Medically Unexplained Symptoms.

Medically unexplained symptoms (MUS) are common among veterans and are difficult to treat. Optimal treatment entails continued care from providers, including primary care and counseling psychologists. Non-concordance between veterans' and providers' views of MUS may contribute to poor veteran satisfaction with care and possibly disengagement with care (e.g., non-adherence to treatment recommendations, including counseling and graded exercise). The current study surveyed 243 veterans with MUS post-deployment and evaluated the degree of non-concordance perceived by veterans with their primary care providers regarding their MUS and the effect of perceived non-concordance on treatment behaviors and outcomes. Many veterans in the current sample perceived non-concordance with their provider regarding their MUS (19% reporting quite a bit or complete disagreement). Perceived non-concordance (regarding MUS overall and specific causal perceptions) predicted important outcomes of interest, particularly veterans' satisfaction with their provider. Perceived concordance with primary care doctors may be required for sufficient adherence to MUS treatment recommendations, such as seeking and maintaining psychological counseling. Research should evaluate the effect of perceived concordance with the counseling psychologist on adherence to and outcomes from counseling for MUS.

Medically Unexplained Physical Symptoms: What They Are and Why Counseling Psychologists Should Care about Them.

Medically unexplained symptoms and syndromes (MUS) affect the health of 20%-30% of patients seen in primary care. Optimally, treatment for these patients requires an interdisciplinary team consisting of both primary care and mental health providers. By developing an expertise in MUS, counseling psychologists can improve the care of patients with MUS who are already in their practice, expand the number of patients they help, and enhance the integration of counseling psychology into the broader medical community. Additionally, counseling psychologists' expertise in culture, attunement to therapeutic processes, and our focus on prioritizing patients' perspectives and quality of life can fill the gap in research on MUS and bringing increased attention to counseling psychologists' unique contributions to health service delivery.

Longitudinal relationship between onset of physical symptoms and functional impairment.

Patients with chronic physical symptoms (e.g., chronic pain) often have significant functional impairment (i.e., disability). The fear avoidance model is the dominant theoretical model of how the relationship between chronic physical symptoms and functional impairment develops and proposes a cyclical/bidirectional relationship. There has never been a definitive test of the proposed bi-directional relationship. The current study followed 767 Operation Enduring Freedom/Operation Iraqi Freedom soldiers from pre-deployment, when they were relatively healthy, to 1 year after deployment, when it was anticipated that symptoms would increase or develop. Over the four assessment time points, physical symptom severity consistently predicted worse functional impairment at the subsequent time point. Functional impairment did not show a consistent relationship with worsening of physical symptom severity. These findings suggest that changes to functional impairment do not have a short-term impact on physical symptom severity.

Chronic multisymptom illness among female Veterans deployed to Iraq and Afghanistan.

BACKGROUND: Chronic multisymptom illness (CMI) may be more prevalent among female Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn (OEF/OIF/OND) deployed Veterans due to deployment-related experiences. OBJECTIVES: To investigate CMI-related diagnoses among female OEF/OIF/OND Veterans. RESEARCH DESIGN: We estimated the prevalence of the International Classification of Disease-9th edition-Clinical Modification coded CMI-related diagnoses of chronic fatigue syndrome, fibromyalgia (FM), and irritable bowel syndrome (IBS) among female OEF/OIF/OND Veterans with Veterans Health Administration (VHA) visits, FY2002-2012 (n=78,435). We described the characteristics of female Veterans with and without CMI-related diagnoses and VHA settings of first CMI-related diagnoses. RESULTS: The prevalence of CMI-related diagnoses among female OEF/OIF/OND Veterans was 6397 (8.2%), over twice as high as the prevalence 95,424 (3.9%) among the totality of female Veterans currently accessing VHA (P<0.01). There were statistically significant differences in age, education, marital status, military component, service branch, and proportions of those with depression and/or post-traumatic stress disorder diagnoses across females with and without CMI-related diagnoses. Diagnoses were mainly from primary care, women's health, and physical medicine and rehabilitation clinics. CONCLUSIONS: CMI-related diagnoses were more prevalent among female OEF/OIF/OND Veterans compared with all female Veterans who currently access VHA. Future studies of the role of mental health diagnoses as confounders or mediators of the association of OEF/OIF/OND deployment and CMI are warranted. These and other factors associated with CMI may provide a basis for enhanced screening to facilitate recognition of these conditions. Further work should evaluate models of care and healthcare utilization related to CMI in female Veterans.

Using the common sense model of self-regulation to understand the relationship between symptom reporting and trait negative affect.

BACKGROUND/PURPOSE: Based on the Common Sense Model of Self-Regulation, we examined if the relationship of trait NA to physical symptom reporting was moderated by life events and illness representations. METHODS: This relationship was examined using a cross-sectional dataset of 554 elderly adults. RESULTS: A significant three-way interaction demonstrated that individuals who reported the greatest severity of physical symptoms were higher in trait NA, and reported more life events and a chronic illness history. CONCLUSIONS: The results of this study are consistent with the hypothesis that individual high on trait NA who have a history of a chronic illness have illness representations with both disease specific physical symptoms and symptoms from other causes, such as emotional distress. This may complicate the care of medical conditions for these patients.

Developing Evidence to Support Policy: Protocol for the StrAtegic PoLicy EvIdence-Based Evaluation CeNTer (SALIENT).

BACKGROUND: All federal agencies are required to support appropriation requests with evidence and evaluation (US Public Law 115-435; the Evidence Act). The StrAtegic PoLicy EvIdence-Based Evaluation CeNTer (SALIENT) is 1 of 6 centers that help the Department of Veterans Affairs (VA) meet this requirement. OBJECTIVE: Working with the existing VA evaluation structure, SALIENT evaluations will contribute to (1) optimize policies and programs for veteran populations; (2) improve outcomes regarding health, equity, cost, and provider well-being; (3) advance the science of dissemination and knowledge translation; and (4) expand the implementation and dissemination science workforce. METHODS: We leverage the Lean Sprint methodology (iterative, incremental, rule-governed approach to clearly defined, and time-boxed work) and 3 cores to develop our evaluation plans collaboratively with operational partners and key stakeholders including veterans, policy experts, and clinicians. The Operations Core will work with evaluation teams to develop timelines, facilitate work, monitor progress, and guide quality improvement within SALIENT. The Methods Core will work with evaluation teams to identify the most appropriate qualitative, quantitative, and mixed methods approaches to address each evaluation, ensure that the analyses are conducted appropriately, and troubleshoot when problems with data acquisition and analysis arise. The Knowledge Translation (KT) Core will target key partners and decision makers using a needs-based market segmentation approach to ensure that needs are incorporated in the dissemination of knowledge. The KT Core will create communications briefs, playbooks, and other materials targeted at these market segments to facilitate implementation of evidence-based practices and maximize the impact of evaluation results. RESULTS: The SALIENT team has developed a center infrastructure to support high-priority evaluations, often to be responsive to shifting operational needs and priorities. Our team has engaged in our core missions and operations to rapidly evaluate a high-priority areas, develop a comprehensive Lean Sprint systems redesign approach to training, and accelerate rapid knowledge translation. CONCLUSIONS: With an array of interdisciplinary expertise, operational partnerships, and integrated resources, SALIENT has an established and evolving infrastructure to rapidly develop and implement high-impact evaluations. Projects are developed with sustained efficiency approaches that can pivot to new priorities as needed and effectively translate knowledge for key stakeholders and policy makers, while creating a learning health system infrastructure to foster the next generation of evaluation and implementation scientists. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/59830.

What pre-deployment and early post-deployment factors predict health function after combat deployment?: a prospective longitudinal study of Operation Enduring Freedom (OEF)/Operation Iraqi Freedom (OIF) soldiers.

BACKGROUND: Physical and mental function are strong indicators of disability and mortality. OEF/OIF Veterans returning from deployment have been found to have poorer function than soldiers who have not deployed; however the reasons for this are unknown. METHODS: A prospective cohort of 790 soldiers was assessed both pre- and immediately after deployment to determine predictors of physical and mental function after war. RESULTS: On average, OEF/OIF Veterans showed significant declines in both physical (t=6.65, p<.0001) and mental function (t=7.11, p<.0001). After controlling for pre-deployment function, poorer physical function after deployment was associated with older age, more physical symptoms, blunted systolic blood pressure reactivity and being injured. After controlling for pre-deployment function, poorer mental function after deployment was associated with younger age, lower social desirability, lower social support, greater physical symptoms and greater PTSD symptoms. CONCLUSIONS: Combat deployment was associated with an immediate decline in both mental and physical function. The relationship of combat deployment to function is complex and influenced by demographic, psychosocial, physiological and experiential factors. Social support and physical symptoms emerged as potentially modifiable factors.

Treatment and life goals among veterans with Gulf War illness.

Medically unexplained syndromes (MUS), also termed persistent physical symptoms, are both prevalent and disabling. Yet treatments for MUS are marked by high rates of patient dissatisfaction, as well as disagreement between patients and providers on the management of persistent physical symptoms. A better understanding of patient-generated goals could increase collaborative goal setting and promote person-centered care, a critical component of MUS treatment; yet research in this area is lacking. This paper aimed to develop a typology of treatment and life goals among Gulf War veterans with a medically unexplained syndrome (Gulf War Illness). We examined participants' responses to open-ended questions about treatment and life goals using Braun and Clarke's thematic analysis methodology. Results showed that treatment goals could be categorized into four overarching themes: 1) Get better/healthier, 2) Improve quality of life, 3) Improve or seek additional treatment, and 4) Don't know/Don't have any. Life goals were categorized into six overarching themes: 1) Live a fulfilling life, 2) Live a happy life, 3) Live a healthy life, 4) Be productive/financially successful, 5) Manage GWI, and 6) Don't know/Don't have any. Treatment goals were largely focused on getting better/healthier (e.g., improving symptoms), whereas life goals focused on living a fulfilling life. Implications for the treatment of Gulf War Illness and patient-provider communication are discussed. ClinicalTrials.gov Identifier: NCT02161133.

Associations between risky alcohol use, disability, and problem-solving impairment among Veterans with Gulf War Illness: Secondary data analysis of a randomized clinical trial.

OBJECTIVE: Gulf War Illness (GWI) and alcohol use are both major sources of disability among Gulf War Veterans. The goal of this secondary data analysis was to examine associations between risky alcohol use, problem-solving impairment, and disability among Veterans in a randomized clinical trial of problem-solving treatment (PST) for GWI. We examined cross-sectional associations and conducted longitudinal analyses to test if alcohol use moderated treatment outcome of PST. METHODS: Participants were 268 United States military Veterans with GWI randomized to PST or a control intervention. Participants were assessed at four timepoints. Measures included the World Health Organization Disability Assessment Schedule 2.0 (WHO-DAS 2.0), Problem Solving Inventory (PSI), and Alcohol Use Disorders Identification Test-Concise (AUDIT-C). We conducted multivariate regression (cross-sectional) and mixed model analyses (longitudinal) with separate models for WHO-DAS 2.0 and PSI. All models included AUDIT-C and household income. This analysis was pre-registered on the Open Science Framework. RESULTS: Cross-sectional analyses revealed a significant negative association with small effect size between AUDIT-C and WHO-DAS 2.0 (p = 0.006; f2 = 0.05); worse disability was associated with less risky alcohol use. There was no evidence that risky alcohol use moderated effects of PST on disability or PSI. CONCLUSION: If replicated, the cross-sectional findings suggest high levels of disability may deter heavy drinking among Veterans with GWI. We did not find evidence that risky alcohol use moderated treatment outcome of PST for GWI. More research is needed to identify moderators of GWI interventions and to understand risky drinking among Veterans with complex health problems.