The Impact of the Covid-19-Related Transition to Telehealth on Visit Adherence in Mental Health Care: An Interrupted Time Series Study.

Covid-19 has led to an unprecedented shift to telemental health (TMH) in mental healthcare. This study examines the impact of this transition on visit adherence for mental health services in an integrated behavioral health department. Monthly visit data for 12,245 patients from January, 2019 to January, 2021 was extracted from the electronic medical record. Interrupted time series (ITS) analysis examined the impact of the Covid-19 transition to TMH on immediate level and trend changes in the percentage of cancelled visits and no shows in the 10 months following the transition. ITS also compared changes across the three largest services types: adult, pediatric, and substance use. Following the TMH-transition, completed visits increased by 10% amounting to an additional 3644 visits. In April, 2020, immediately following the TMH-transition, no shows increased by 1.4%, (95% CI 0.1, 2.7, p < 0.05) and cancellations fell by 13.5% (95% CI - 17.9, - 9.0, p < 0.001). Across the 10-month post-TMH period, 18.2% of visits were cancelled, compared to 28.3% across the 14-month pre-TMH period. The proportion of no-shows remained the same. The pattern was similar for pediatric and adult sub-clinics, but no significant changes in cancellations or no shows were observed in the substance use sub-clinic. TMH during the Covid-19 pandemic is associated with improved visit adherence over time and may be a promising model for improving the efficiency of mental health care delivery once it is safe to resume in person care.

Sources of moral injury among war veterans: A qualitative evaluation.

OBJECTIVE: Service members deployed to war are at risk for moral injury, but the potential sources of moral injury are poorly understood. The aim of this qualitative study was to explore the types of events that veterans perceive as morally injurious and to use those events to develop a categorization scheme for combat-related morally injurious events. METHOD: Six focus groups with US war veterans were conducted. RESULTS: Analysis based on Grounded Theory yielded two categories (and eight subcategories) of events that putatively cause moral injury. The two categories were defined by the focal attribution of responsibility for the event: Personal Responsibility (veteran's reported distress is related to his own behavior) versus Responsibility of Others (veteran's distress is related to actions taken by others). Examples of each type of morally injurious event are provided. CONCLUSIONS: Implications for the further development of the moral injury construct and treatment are discussed.

Evaluation of the impact of a digital care navigator on increasing patient registration with digital mental health interventions in routine care.

Background: Less than half of adults with mental health disorders in the United States receive appropriate or timely care. Digital Mental Health Interventions (DMHIs) have the potential to bridge this gap. However, real-world adoption of DMHIs is impeded by patient and provider-level technological barriers. Care navigators have the potential to address these challenges by providing technical support and enhancing patients' experience with DMHIs. Objective: This study explores the effect of a digital care navigator (DCN) on patient registration latency and rates of DMHIs implemented as part of a digital-first behavioral health care model integrated within routine care at a large multispecialty group medical practice. Methods: Data were collected from electronic medical records and DMHI registration data were obtained from the DMHI vendors. Descriptive statistics were used to describe the DCN's efforts to help patients register with their DMHIs. Moods median tests evaluated differences in registration latency and weekly registration rate pre- and post- DCN implementation. Change in registration likelihood as a function of DCN outreach latency was investigated using a Kaplan-Meier plot. Results: During the first eight months, the DCN made 1306 phone calls to 680 unique patients, successfully connecting with 66 %. DCN implementation also increased the median registration rate from 61.9 % to 76.9 %. Results showed that the expediency by which the DCN outreached patients directly impacted registration rate such that of those who were outreached by the DCN on the day of their referral to a DMHI, 96.86 % registered. This number was reduced to 76.15 % if the DCN reached them 1-day following referral, and 41.39 % 5-days after their referral. Conclusions: Use of a DCN shows promise for enhancing patient registration rates with DMHIs in routine healthcare settings.

Prospective investigation of mental health following sexual assault.

BACKGROUND: Comorbidity in psychological disorders is common following exposure to a traumatic event. Relatively little is known about the manner in which changes in the symptoms of a given type of psychological disorder in the acute period following a trauma impact changes in symptoms of another disorder. This study investigated the relationship between changes in posttraumatic stress disorder (PTSD), depression, and anxiety symptoms in the first 12 weeks following sexual assault. METHODS: Participants were 126 women who had been sexually assaulted in the previous 4 weeks. RESULTS: Lower level mediation analyses revealed that changes in PTSD symptoms had a greater impact on changes in depression and anxiety than vice versa. CONCLUSIONS: The finding highlights the role of PTSD symptoms in influencing subsequent change in other psychological symptoms. These findings are discussed in the context of models detailing the trajectory of psychological disorders following trauma, and clinical implications are considered.

Using Client Narratives to Identify Predictors of Outcome in Written Exposure Therapy and Cognitive Processing Therapy.

Written exposure therapy (WET) is a brief, five-session treatment for posttraumatic stress disorder (PTSD) that aims to improve access to care. WET has been demonstrated to be an efficacious PTSD treatment with lower rates of dropout and noninferior PTSD symptom outcome compared to cognitive processing therapy (CPT), a 12-session, gold-standard treatment. To identify predictors of treatment outcome in both WET and CPT, the current study examined the content of participants' written narratives. Participants were 123 adults with PTSD who were randomly assigned to receive WET (n = 61) or CPT (n = 62). The Change and Growth Experiences Scale (CHANGE) coding system was used to code all available narratives in both treatment conditions for variables hypothesized to be relevant to therapeutic change. Linear regression analyses revealed that in WET, higher average levels of accommodated (healthy, balanced) beliefs and an increase in accommodated beliefs from the first to the final impact statement predicted better PTSD symptom outcome at 12 weeks postrandomization. In CPT, higher average levels of overgeneralized and accommodated beliefs and lower levels of avoidance expressed in the narratives predicted better PTSD outcome. There were no significant predictors of outcome in analyses of change from the first to final impact statement in CPT. These findings add to research identifying predictors of change in WET and CPT by highlighting the importance of low avoidance in CPT and of trauma-related cognitions in both CPT and WET, even though WET is a brief written intervention that does not explicitly target cognitive change.

Associations between psychiatric morbidity and COVID-19 vaccine hesitancy: An analysis of electronic health records and patient survey.

Psychiatric illness confers significant risk for severe COVID-19 morbidity and mortality; identifying psychiatric risk factors for vaccine hesitancy is critical to mitigating risk in this population. This study examined the prevalence of vaccine hesitancy among those with psychiatric illness and the associations between psychiatric morbidity and vaccine hesitancy. Data came from electronic health records and a patient survey obtained from 14,365 patients at a group medical practice between February and May 2021. Logistic regression was used to calculate odds for vaccine hesitancy adjusted for sociodemographic characteristics and physical comorbidity. Of 14,365 participants 1,761 (12.3%) participants reported vaccine hesitancy. Vaccine hesitancy was significantly more prevalent among participants with substance use (29.6%), attention deficit and hyperactivity (23.3%), posttraumatic stress (23.1%), bipolar (18.0%), generalized anxiety (16.5%), major depressive (16.1%), and other anxiety (15.5%) disorders, tobacco use (18.6%), and those previously infected with COVID-19 (19.8%) compared to participants without . After adjusting for sociodemographic characteristics and physical comorbidities, substance use disorders and tobacco use were significantly associated with increased odds for vaccine hesitancy and bipolar disorder was significantly inversely associated with vaccine hesitancy. Interventions to improve uptake in these populations may be warranted.

Predictors of Dropout in Cognitive Processing Therapy for PTSD: An Examination of Trauma Narrative Content.

Dropout rates in trauma-focused treatments for adult posttraumatic stress disorder (PTSD) are high. Most research has focused on demographic and pretreatment predictors of dropout, but findings have been inconsistent. We examined predictors of dropout in cognitive processing therapy (CPT) by coding the content of trauma narratives written in early sessions of CPT. Data are from a randomized controlled noninferiority trial of CPT and written exposure therapy (WET) in which CPT showed significantly higher dropout rates than WET (39.7% CPT vs. 6.4% WET). Participants were 51 adults with a primary diagnosis of PTSD who were receiving CPT and completed at least one of three narratives in the early sessions of CPT. Sixteen (31%) in this subsample were classified as dropouts and 35 as completers. An additional 9 participants dropped out but could not be included because they did not complete any narratives. Of the 11 participants who provided a reason for dropout, 82% reported that CPT was too distressing. The CHANGE coding system was used to code narratives for pathological trauma responses (cognitions, emotions, physiological responses) and maladaptive modes of processing (avoidance, ruminative processing, overgeneralization), each on a scale from 0 (absent) to 3 (high). Binary logistic regressions showed that, averaging across all available narratives, more negative emotions described during or around the time of the trauma predicted less dropout. More ruminative processing in the present time frame predicted lower rates of dropout, whereas more overgeneralized beliefs predicted higher rates. In the first impact statement alone, more negative emotions in the present time frame predicted lower dropout rates, but when emotional reactions had a physiological impact, dropout was higher. These findings suggest clinicians might attend to clients' written trauma narratives in CPT in order to identify indicators of dropout risk and to help increase engagement.

The temporal relationship between posttraumatic stress disorder and problem alcohol use following traumatic injury.

Chronic alcohol abuse is a major public health concern following trauma exposure; however, little is known about the temporal association between posttraumatic stress disorder (PTSD) symptoms and problem alcohol use. The current study examined the temporal relationship between PTSD symptom clusters (re-experiencing, effortful avoidance, emotional numbing, and hyperarousal) and problem alcohol use following trauma exposure. This study was a longitudinal survey of randomly selected traumatic injury patients interviewed at baseline, 3 months, 12 months, and 24 months following injury. Participants were 1,139 injury patients recruited upon admission from 4 Level 1 trauma centers across Australia. Participants were assessed using the Clinician Administered PTSD Scale and Alcohol Use Disorders Identification Test. Results indicated that high levels of re-experiencing, effortful avoidance, and hyperarousal symptoms at 12 months were associated with greater increases (or smaller decreases) in problem alcohol use between 12 and 24 months. Findings also suggested that high levels of problem alcohol use at 12 months were associated with greater increases (or smaller decreases) in emotional numbing symptoms between 12 and 24 months. These findings highlight the critical importance of the chronic period following trauma exposure in the relationship between PTSD symptoms and problem alcohol use.

Perceived military organizational support and peacekeeper distress: a longitudinal investigation.

Many professions vital to the safety of society require workers to face high magnitude and potentially traumatizing events. Because this routine exposure can cause high levels of stress in workers, it is important to investigate factors that contribute to both risk of posttraumatic stress disorder (PTSD), and healthy responses to stress. Although some research has found social support to mitigate the effects of posttraumatic stress symptoms, scant research has investigated organizational support. The aim of the present study is to investigate the temporal relationship between stress symptoms and perceived organizational support in a sample of 1,039 service members deployed to the peacekeeping mission to Kosovo. Participants completed self-report measures of stress symptoms and perceived organizational support at 4 study time points. Bivariate latent difference score structural equation modeling was utilized to examine the temporal relationship among stress and perceived organizational support. In general, across the 4 time points, latent PCL scores evidenced a salient and negative relationship to subsequent POS latent difference scores. However, no significant relationship was found between latent POS variables and subsequent PCL latent difference scores. Findings suggest that prior stress symptoms are influencing service member's perceptions of the supportiveness of their organization such that increased prior stress is associated with worsening perceptions of support. These results illustrate that targeting stress directly may potentiate the positive influence of organizational support and that institutional support programs should be adapted to better account for the negative biases increased distress may encourage.

The distinctiveness of prolonged grief and posttraumatic stress disorder in adults bereaved by the attacks of September 11th.

BACKGROUND: Prolonged Grief Disorder (PGD) is a new diagnosis proposed for inclusion in the DSM-V. Although some studies have shown the distinctiveness of PGD and posttraumatic stress disorder (PTSD), this relationship has yet to be tested within a context of sudden, violent loss. METHOD: We conducted an exploratory factor analysis (EFA) using self-report data collected from a sample of 587 bereaved adults who lost friends and relatives in the attacks of September 11th. Participants completed a 9-item PGD screening measure and the 17-item PTSD Checklist. RESULTS: A five factor solution representing two distinct constructs emerged from our analysis. Although two PGD items loaded onto factors containing PTSD symptoms, these items assessed non-specific symptomatology (i.e., generalized negative affect). Thus, overall, our results support the distinctiveness of PGD and PTSD within a context of sudden, violent loss. LIMITATIONS: Data were collected using self-report. The representativeness of our sample is uncertain. CONCLUSIONS: These findings provide a stringent test of construct validity and suggest that PGD warrants inclusion in the diagnostic nosology. Adding PGD to the DSM-V will help clinicians better assess and treat psychopathology resulting from grief.