Therapeutic Risk Management for Violence: Safety Planning for Other-directed Violence.

Therapeutic management of risk for other-directed violence (ODV) involves screening, assessment, and clinically appropriate intervention. In this 5-part series, effective screening and assessment for ODV have been described as a combination of clinical interviewing and the use of structured tools to inform clinical impressions of both acute and chronic risk for violence. Once risk of violence is identified, therapeutic management of the risk throughout the course of treatment is best achieved by determining the function of the violent ideation and behavior. This can be achieved through the use of functional chain analysis. Chain analysis not only serves the purpose of providing insight into the contingencies of violent behavior but also helps to identify target areas of intervention where other skills, strategies, and means to access resources for support can be applied. In this fifth and final column of the series, we describe an intervention with all of these outcomes as its goals. A safety plan for ODV assists both clients and mental health professionals in disrupting patterns of violent ideation or behavior that would otherwise continue causing not only harm to others but prolonged negative consequences for those engaging in such behaviors.

Therapeutic Risk Management for Violence: Chain Analysis of Other-directed Violent Ideation and Behavior.

Violence risk assessment is a requisite component of mental health treatment. Adhering to standards of care and ethical and legal requirements necessitates a cogent process for conducting, and then documenting, other-directed violence (ODV) risk screening, assessment, and management. In this 5-part series, we describe a model for achieving therapeutic risk management of the potentially violent patient, with essential elements involving: clinical interview augmented by structured screening or assessment tools; risk stratification in terms of temporality and severity; chain analysis to intervene on the functions of ODV ideation and behavior; and a personalized safety plan to mitigate/manage risk. In this fourth column of the series, we describe chain analysis as a critical tool for assessing and intervening on ODV ideation and behavior. We identify the pathways of reinforcement that can cause ODV to persist, and how to navigate potential barriers to completing ODV chains. Using a case example, we demonstrate how to apply chain analysis to ODV ideation and behavior and offer interventional strategies that can be used to disrupt the chain and ultimately reduce the risk for violence.

Rivastigmine Transdermal Patch Treatment for Moderate to Severe Cognitive Impairment in Veterans with Traumatic Brain Injury (RiVET Study): A Randomized Clinical Trial.

Cognitive impairment is common in veterans with histories of traumatic brain injury (TBI). Cholinergic deficits have been hypothesized as contributors to this impairment. We report the effects of cholinesterase inhibitor rivastigmine transdermal patch treatment in veterans with TBI and post-traumatic memory impairment. Our objective was to evaluate the efficacy and safety of a 9.5 mg/24 h (10 cm2) rivastigmine patch in veterans of military conflicts with persistent moderate to severe memory impairment at least 12 weeks after TBI. This randomized, outpatient, double-blind, placebo-controlled 12-week trial with an exploratory double-blind phase of an additional 14 weeks was conducted at 5 VA Medical Centers, among veterans with closed, non-penetrating TBI who met or exceeded modified American Congress of Rehabilitation Medicine criteria for mild TBI with verbal memory deficits, as assessed by the Hopkins Verbal Learning Test, Revised (HVLT-R). Patients were randomized 1:1 to rivastigmine or matching placebo patches after a 1-week single-blind, placebo run-in phase. At randomization, patients received 4.6 mg/24 h rivastigmine patches or matching placebo increased to a 9.5 mg/24 h patch after 4 weeks. The primary efficacy outcome measure was the proportion of participants who had at least a five-word improvement on the HVLT-R Total Recall Index (Trials 1-3). A total of 3671 participants were pre-screened, of whom 257 (7.0%) were screened; 96 (37%) randomized, and 94 included in study analyses. Responder rates were 40.8% (20 of 49) and 51.1% (23 of 45) in the rivastigmine and placebo groups, respectively (p = 0.41). A mixed-effect model including treatment, time, and treatment-by-time interaction indicated no significant difference in treatment effect over time between the groups (p = 0.24). Overall, there were no significant differences in changes for all secondary outcomes between the rivastigmine and placebo groups. The most commonly observed adverse events were application site reactions. This trial provides the largest sample to date of veterans with TBI and post-traumatic memory deficits enrolled in a pharmacological trial. Trial Registration: clinicaltrials.gov Identifier: NCT01670526.

Acceptability of cognitive anxiety sensitivity treatment among veterans with mTBI.

OBJECTIVE: Anxiety sensitivity (AS) is a transdiagnostic risk factor for persistent physical and psychological symptoms relevant to veterans, such as postconcussive symptoms following mild traumatic brain injury (mTBI). The Cognitive Anxiety Sensitivity Treatment (CAST) computerized intervention has been shown to reduce AS but has not been widely used among veterans. The purpose of this study was to assess the acceptability and feasibility of CAST among veterans with elevated AS and mTBI eligible to receive Veterans Health Administration (VHA) care. DESIGN: Twenty-two veterans with mTBI, elevated cognitive AS, and history of deployment to Iraq and/or Afghanistan completed a single assessment and intervention session. Acceptability was assessed with the Client Satisfaction Quesitonnaire-8 (CSQ-8) and a qualitative interview. Measures of feasibility included study enrollment, ease of participation, and intervention completion. AS was assessed pre- and post-CAST completion. RESULTS: Consistent with interview responses, 77.3% of participants' CSQ-8 scores indicated that veterans found the intervention acceptable. Technological issues, such as internet connectivity, decreased feasibility of consistently delivering the intervention in the research setting readily available to the study team. Decreases on pre-to-post intervention AS outcomes were observed. CONCLUSIONS: Acceptability of the CAST intervention in this sample was generally supported. Feasibility of implementing CAST in this study was limited by technological issues. Data did not indicate a critical need to revise content of the CAST intervention. Identified strategies for increasing the feasibility of future research and clinical implementation of CAST are discussed. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Therapeutic Risk Management for Violence: Stratifying Risk and Characterizing Violence.

Violence risk assessment is a requisite component of mental health treatment. Adhering to standards of care and ethical and legal requirements necessitates a cogent process for conducting, and then documenting, other-directed violence risk screening, assessment, and management. In this 5-part series, we describe a model for achieving therapeutic risk management of the potentially violent patient, with essential elements involving: clinical interview augmented by structured screening or assessment tools; risk stratification in terms of temporality and severity; chain analysis to intervene on the functions of violent ideation and behavior; and personalized safety plans to mitigate/manage risk. This third column in the series describes other-directed violence risk stratification in terms of both severity and temporality, as well an approach for characterizing (ie, predatory/planned or impulsive/reactive) the violence risk posed by an individual.

Therapeutic Risk Management for Violence: Augmenting Clinical Risk Assessment With Structured Instruments.

Violence risk assessment is a requisite component of mental health treatment. Adhering to standards of care and ethical and legal requirements necessitates a cogent process for conducting, and then documenting, other-directed violence risk screening, assessment, and management. In this 5-part series, we describe a model for achieving therapeutic risk management of the potentially violent patient, with essential elements involving: clinical interview augmented by structured screening or assessment tools; risk stratification in terms of temporality and severity; chain analysis to intervene on the functions of violent ideation and behavior; and a personalized safety plan to mitigate/manage risk. This second column in the series describes the advantages of, and offers suggestions for, incorporating structured tools into violence risk assessment.

Mobile App for Mental Health Monitoring and Clinical Outreach in Veterans: Mixed Methods Feasibility and Acceptability Study.

BACKGROUND: Advances in mobile health (mHealth) technology have made it possible for patients and health care providers to monitor and track behavioral health symptoms in real time. Ideally, mHealth apps include both passive and interactive monitoring and demonstrate high levels of patient engagement. Digital phenotyping, the measurement of individual technology usage, provides insight into individual behaviors associated with mental health. OBJECTIVE: Researchers at a Veterans Affairs Medical Center and Cogito Corporation sought to explore the feasibility and acceptability of an mHealth app, the Cogito Companion. METHODS: A mixed methodological approach was used to investigate the feasibility and acceptability of the app. Veterans completed clinical interviews and self-report measures, at baseline and at a 3-month follow-up. During the data collection period, participants were provided access to the Cogito Companion smartphone app. The mobile app gathered passive and active behavioral health indicators. Data collected (eg, vocal features and digital phenotyping of everyday social signals) are analyzed in real time. Passive data collected include location via global positioning system (GPS), phone calls, and SMS text message metadata. Four primary model scores were identified as being predictive of the presence or absence of depression or posttraumatic stress disorder (PTSD). Veterans Affairs clinicians monitored a provider dashboard and conducted clinical outreach when indicated. RESULTS: Findings suggest that use of the Cogito Companion app was feasible and acceptable. Veterans (n=83) were interested in and used the app; however, active use declined over time. Nonetheless, data were passively collected, and outreach occurred throughout the study period. On the Client Satisfaction Questionnaire-8, 79% (53/67) of the sample reported scores demonstrating acceptability of the app (mean 26.2, SD 4.3). Many veterans reported liking specific app features (day-to-day monitoring) and the sense of connection they felt with the study clinicians who conducted outreach. Only a small percentage (4/67, 6%) reported concerns regarding personal privacy. CONCLUSIONS: Feasibility and acceptability of the Cogito Corporation platform to monitor mental health symptoms, behaviors, and facilitate follow-up in a sample of veterans were supported. Clinically, platforms such as the Cogito Companion system may serve as useful methods to promote monitoring, thereby facilitating early identification of risk and mitigating negative psychiatric outcomes, such as suicide.

Therapeutic Risk Management for Violence: Clinical Risk Assessment.

Violence risk assessment is a requisite component of mental health treatment. Adhering to standards of care and ethical and legal requirements necessitates a cogent process for conducting (and documenting) screening, assessment, and management of other-directed violence risk. In this 5-part series, we describe a model for achieving therapeutic risk management of the potentially violent patient, with essential elements involving a clinical interview augmented by structured screening or assessment tools; risk stratification in terms of temporality and severity; chain analysis to intervene on the functions of violent ideation and behavior; and development of a personalized safety plan. This first column of the series focuses on essential aspects of the clinical interview.

Community Reintegration Problems Among Veterans and Active Duty Service Members With Traumatic Brain Injury.

OBJECTIVES: To examine community reintegration problems among Veterans and military service members with mild or moderate/severe traumatic brain injury (TBI) at 1 year postinjury and to identify unique predictors that may contribute to these difficulties. SETTING: VA Polytrauma Rehabilitation Centers. PARTICIPANTS: Participants were 154 inpatients enrolled in the VA TBI Model Systems Program with available injury severity data (mild = 28.6%; moderate/severe = 71.4%) and 1-year postinjury outcome data. DESIGN: Prospective, longitudinal cohort. MAIN MEASURES: Community reintegration outcomes included independent driving, employability, and general community participation. Additional measures assessed depression, posttraumatic stress, and cognitive and motor functioning. RESULTS: In the mild TBI (mTBI) group, posttraumatic stress disorder and depressive symptoms were associated with lower levels of various community reintegration outcomes. In the moderate/severe TBI group, cognition and motor skills were significantly associated with lower levels of community participation, independent driving, and employability. CONCLUSION: Community reintegration is problematic for Veterans and active duty service members with a history of TBI. Unique comorbidities across injury severity groups inhibit full reintegration into the community. These findings highlight the ongoing rehabilitation needs of persons with TBI, specifically evidence-based mental healthcare, in comprehensive rehabilitation programs consistent with a chronic disease management model.

Pain and psychiatric comorbidities among two groups of Iraq and Afghanistan era Veterans.

This study aimed to (1) identify the prevalence and severity of pain and psychiatric comorbidities among personnel who had been deployed during Operation Iraqi Freedom (OIF), Operation Enduring Freedom (OEF), and Operation New Dawn (OND) and (2) assess whether the Department of Veterans Affairs (VA) Polytrauma System of Care and an OIF/OEF/OND registry reflect real differences among patients. Participants (N = 359) were recruited from two VA hospitals. They completed a clinical interview, structured diagnostic interview, and self-report measures. Results indicated pain was the most common complaint, with 87 percent experiencing pain during the prior week and 56 percent reporting moderate or severe pain. Eighty percent of participants met criteria for at least one of seven assessed comorbid problems (moderate or severe pain, postconcussional disorder, posttraumatic stress disorder [PTSD], anxiety disorder, mood disorder, substance use disorder, psychosis), and 59 percent met criteria for two or more problems. PTSD and postconcussional disorder rarely occurred in the absence of pain or other comorbidities (0.3% and 0%, respectively). The Polytrauma group had more comorbid psychiatric conditions (χ(2) = 48.67, p < 0.05) and reported greater severity of symptoms (p < 0.05) than the Registry group. This study confirmed the high prevalence of pain and concurrent mental health problems among personnel returning from military deployment.

Development of a traumatic brain injury model system within the Department of Veterans Affairs Polytrauma System of Care.

BACKGROUND: In 2008, the Department of Veterans Affairs Polytrauma Rehabilitation Centers partnered with the National Institute on Disability and Rehabilitation Research to establish a Model Systems program of research that would closely emulate the civilian Traumatic Brain Injury (TBI) Model Systems Centers Program established in 1987. OBJECTIVE: To describe the development of a TBI Model Systems program within the Department of Veterans Affairs Polytrauma System of Care. METHODS: Enrollment criteria and data collection/data quality efforts for the newly established Department of Veterans Affairs sites are reviewed. RESULTS: Significant progress has been made in the establishment of a Model Systems program for the Polytrauma System of Care. Data collection has moved forward and program-specific modifications have been implemented. CONCLUSION: The Veterans Affairs TBI Model System program is established and growing, with many projects underway and a strong working relationship with the civilian TBI Model System programs.

Access to the US Department of Veterans Affairs health system: self-reported barriers to care among returnees of Operations Enduring Freedom and Iraqi Freedom.

BACKGROUND: The U.S. Department of Veterans Affairs (VA) implemented the Polytrauma System of Care to meet the health care needs of military and veterans with multiple injuries returning from combat operations in Afghanistan and Iraq. Studies are needed to systematically assess barriers to use of comprehensive and exclusive VA healthcare services from the perspective of veterans with polytrauma and with other complex health outcomes following their service in Afghanistan and Iraq. These perspectives can inform policy with regard to the optimal delivery of care to returning veterans. METHODS: We studied combat veterans (n = 359) from two polytrauma rehabilitation centers using structured clinical interviews and qualitative open-ended questions, augmented with data collected from electronic health records. Our outcomes included several measures of exclusive utilization of VA care with our primary exposure as reported access barriers to care. RESULTS: Nearly two thirds of the veterans reported one or more barriers to their exclusive use of VA healthcare services. These barriers predicted differences in exclusive use of VA healthcare services. Experiencing any barriers doubled the returnees' odds of not using VA exclusively, the geographic distance to VA barrier resulted in a 7 fold increase in the returnees odds of not using VA, and reporting a wait time barrier doubled the returnee's odds of not using VA. There were no striking differences in access barriers for veterans with polytrauma compared to other returning veterans, suggesting the barriers may be uniform barriers that predict differences in using the VA exclusively for health care. CONCLUSIONS: This study provides an initial description of utilization of VA polytrauma rehabilitation and other medical care for veteran returnees from all military services who were involved in combat operations in Afghanistan or Iraq. Our findings indicate that these veterans reported important stigmatization and barriers to receiving services exclusively from the VA, including mutable health delivery system factors.