Co-occurring alcohol use disorder and obesity in U.S. military veterans: Prevalence, risk factors, and clinical features.

Obesity and alcohol use disorder (AUD) are two of the most prevalent and costly clinical conditions among U.S. military veterans, and these conditions often co-occur. However, little is known about the clinical correlates of co-occurring obesity and AUD, which is critical to informing effective interventions. The current study analyzed data from a nationally representative sample of 4069 (3463 males, 479 females) veterans, who completed an online survey. The Alcohol Use Disorder Identification Test was used to identify veterans who screened positive for probable AUD (pAUD) and self-reported height and weight was used to calculate body mass index and identify veterans with obesity. Multinomial logistic regression was used to examine differences between four groups: controls (no current AUD or obesity), pAUD only, obesity only, and pAUD + obesity. A total of 1390 (36.1%) veterans had obesity, 10.5% (n = 359) had pAUD, and 3.7% (n = 124) had pAUD and obesity. Relative to veterans without AUD, Veterans with pAUD were less likely to have normal/lean weight (14.6% versus 21.4%) and more likely to have overweight (49.6% versus 41.7%). Veterans with pAUD + obesity were nearly twice as likely than veterans with pAUD to report three or more adverse childhood experiences. The results of this study help inform the clinical presentation and needs of veterans with co-occurring obesity and AUD. They also underscore the importance of regularly monitoring weight among veterans with AUD, and considering the role of childhood adversity as a risk factor for co-occurring AUD and obesity.

A randomized controlled trial of cognitive behavioral therapy compared with diabetes education for diabetic peripheral neuropathic pain.

A randomized controlled trial compared cognitive behavioral therapy (CBT) and diabetes education (ED) as an adjunctive treatment for diabetic peripheral neuropathic pain (DPNP). We examined change from baseline to 12- and 36-week follow-up in overall pain intensity (NRS), neuropathic pain intensity/quality, pain interference, and mental health functioning, among others. Although CBT participants demonstrated improvement in pain intensity NRS, there were no between-condition differences at either follow-up. CBT reduced neuropathic pain intensity at 12-weeks more than ED. At 36-weeks, CBT was superior to ED for improving pain interference and mental health functioning. Results provide evidence of benefit of CBT for DPNP.ClinicalTrials.gov Identifier: NCT00830011.

The acceptability and feasibility of screening, brief intervention, and referral to treatment for pain management among new England veterans with chronic pain: A pilot study.

OBJECTIVES: Musculoskeletal disorders often lead to chronic pain in Veterans. Chronic pain puts sufferers at risk for substance misuse, and early intervention is needed for both conditions. This pilot study tested the feasibility and acceptability of a Screening, Brief Intervention, and Referral to Treatment for Pain Management intervention (SBIRT-PM) to help engage Veterans seeking disability compensation for painful musculoskeletal disorders in multimodal pain treatment and to reduce risky substance use, when indicated. METHODS: This pilot study enrolled 40 Veterans from 8 medical centers across New England in up to 4 sessions of telephone-based counseling using a motivational interviewing framework. Counseling provided education about, and facilitated engagement in, multimodal pain treatments. Study eligibility required Veterans be engaged in no more than 2 Veteran Affairs (VA) pain treatment modalities, and study participation involved a 12-week postassessment and semistructured interview about the counseling process. RESULTS: Majorities of enrolled Veterans screened positive for comorbid depression and problematic substance use. Regarding the offered counseling, 80% of participants engaged in at least one session, with a mean of 3 sessions completed. Ninety percent of participants completed the postassessment. Numerically, most measures improved slightly from baseline to week 12. In semistructured interviews, participants described satisfaction with learning about new pain care services, obtaining assistance connecting to services, and receiving support from their counselors. DISCUSSION: It was feasible to deliver SBIRT-PM to Veterans across New England to promote engagement in multimodal pain treatment and to track study outcomes over 12 weeks. Preliminary results suggest SBIRT-PM was well-received and has promise for the targeted outcomes.

Race, Ethnicity, and Clinical Features of Alcohol Use Disorder Among US Military Veterans: Results From the National Health and Resilience in Veterans Study.

BACKGROUND AND OBJECTIVES: Alcohol use disorder (AUD) is highly prevalent in US military veterans, though little is known about whether the psychiatric comorbidities and functional outcomes (ie, clinical features) of AUD differ across race/ethnic groups. We aimed to identify differences in the clinical features of veterans with AUD by race/ethnicity. METHODS: In a sample of veterans with AUD (n = 1212) from the nationally representative National Health and Resilience in Veterans Study, we compared the clinical features associated with AUD across racial/ethnic groups using analysis of covariance and logistic regression. RESULTS: Black veterans (n = 60, 34.0%) were less likely to screen positive for lifetime AUD compared with white (n = 1099, 42.7%) and Hispanic (n = 53, 41.5%) veterans. Among those with lifetime AUD, Hispanic veterans were more likely than white veterans to have lifetime and current mood or anxiety disorders (adjusted odds ratio range [AORR] = 2.21-2.52, P < .05). Black veterans were more likely than white veterans to have current mood and anxiety disorders (AORR = 2.01-3.07, P < .05). Hispanic veterans reported poorer functioning and quality of life than white and black veterans (Cohen's d range = 0.12-0.37, P < .05). DISCUSSION AND CONCLUSIONS: Black and Hispanic veterans with lifetime AUD may experience a higher disease burden relative to white veterans. Results underscore the importance of race/ethnicity-sensitive assessment, monitoring, and treatment of AUD for veterans. SCIENTIFIC SIGNIFICANCE: This is the first known study to examine differences by race/ethnicity in the clinical features of Veterans with AUD in a nationally representative sample. Findings suggest higher disease burden for racial/ethnic minority veterans. (Am J Addict 2021;30:26-33).

Substance Use Disorder Detection Rates Among Providers of General Medical Inpatients.

BACKGROUND: The prevalence of substance use disorders is higher among medical inpatients than in the general population, placing inpatient providers in a prime position to detect these patients and intervene. OBJECTIVE: To assess provider detection rates of substance use disorders among medical inpatients and to identify patient characteristics associated with detection. DESIGN: Data drawn from a cluster randomized controlled trial that tested the effectiveness of three distinct implementation strategies for providers to screen patients for substance use disorders and deliver a brief intervention (Clinical Trials.gov : NCT01825057). PARTICIPANTS: A total of 1076 patients receiving care from 13 general medical inpatient units in a large teaching hospital participated in this study. MAIN MEASURES: Data sources included patient self-reported questionnaires, a diagnostic interview for substance use disorders, and patient medical records. Provider detection was determined by diagnoses documented in medical records. KEY RESULTS: Provider detection rates were highest for nicotine use disorder (72.2%) and lowest for cannabis use disorder (26.4%). Detection of alcohol use disorder was more likely among male compared to female patients (OR (95% CI) = 4.0 (1.9, 4.8)). When compared to White patients, alcohol (OR (95% CI) = 0.4 (0.2, 0.6)) and opioid (OR (95% CI) = 0.2 (0.1, 0.7)) use disorders were less likely to be detected among Black patients, while alcohol (OR (95% CI) = 0.3 (0.0, 2.0)) and cocaine (OR (95% CI) = 0.3 (0.1, 0.9)) use disorders were less likely to be detected among Hispanic patients. Providers were more likely to detect nicotine, alcohol, opioid, and other drug use disorders among patients with higher addiction severity (OR (95% CI) = 1.20 (1.08-1.34), 1.62 (1.48, 1.78), 1.46 (1.07, 1.98), 1.38 (1.00, 1.90), respectively). CONCLUSIONS: Findings indicate patient characteristics, including gender, race, and addiction severity impact rates of provider detection. Instituting formal screening for all substances may increase provider detection and inform treatment decisions.

A randomized controlled pilot study evaluating Worry Less, Live More: The Mindful Way Through Anxiety Workbook.

Effective interventions for generalized anxiety exist, but barriers to treatment prevent their broad dissemination. Commercially available self-help materials may help bridge this gap, but few have been empirically evaluated. This study compared self-reported change in generalized anxiety symptomology and associated problems between community members with excessive worry who were randomly assigned to receive the Worry Less, Live More: The Mindful Way through Anxiety Workbook (n = 35) and those in a delayed condition (n = 29). Participants in the workbook condition reported significantly greater reductions between baseline and 11-week follow-up in self-reported worry (η2 =.15), general anxiety/tension (η2 =.13), and anxiety (η2 =.24) than those in the delayed condition, although no statistically significant differences across condition on changes in depression, functional impairment or acceptance were detected. This pilot study provides support for continued research examining the efficacy of acceptance-based behavioral therapy delivered in a self-help format.

The relationship between substance use, experiential avoidance, and personally meaningful experiences.

Background: High rates of substance use among college students have been associated with a wide range of detrimental consequences. Psychological inflexibility, characterized by both experiential avoidance and a disconnection with personally meaningful values, is proposed to contribute to the development and maintenance of substance misuse. Objectives: This study explored the unique contribution of experiential avoidance and four different values dimensions (i.e., importance, consistency, effort, and intrinsic motivation) on substance use and related problems accounting for the known predictors of gender and drinking motives. Method: Zero-inflated regression was used to analyze predictors of substance use and related problems among 233 college students. Results: Controlling for gender and drinking motives, stronger values importance was predictive of lower rates of alcohol use problems. Less behavioral consistency with values predicted marijuana abstinence, less frequent use of marijuana, and less frequent use of illicit drugs. Although there was little evidence for a unique association between experiential avoidance and substance use or substance-related problems in this sample, coping and enhancement motives predicted alcohol use problems and illicit drug use. Conclusion/Importance: These findings offer preliminary support for prevention and intervention efforts aimed at enhancing engagement in values activities and reducing substance use as a form of affect regulation in this population.

Predictors of Participation in a Nonpharmacological Intervention for Chronic Back Pain.

Objective: Cognitive behavioral therapy for chronic pain (CBT-CP) has been identified as an evidence-based adjunct or alternative to opioid pain care. However, little is known about which patients participate in CBT-CP. This study examined predictors of enrollment in a noninferiority trial of in-person vs technology-based CBT-CP for patients with chronic back pain. Setting: A single Veterans Health Affairs (VHA) medical center. Subjects: Veterans with chronic back pain. Design and Methods: For eligible participants (N = 290), individual factors (demographics, distance from a VHA medical center, pain intensity, receipt of opioid prescription, and recruitment method) collected at trial screening were examined to identify predictors of enrollment (i.e., signed consent form). Of those who enrolled, duration of participation in the treatment portion of the study was examined. Results: Among eligible patients, 54% declined enrollment due to lack of interest. Regression analyses revealed that patients not in receipt of an opioid were more likely to enroll. The probability of being in the trial long enough to receive a "dose" of treatment (3 visits or more) was 0.76 (0.04). Conclusions: Overall, enrollment rates were low. However, most patients who enrolled in the study (102 of 134 signed consent) were retained and received a treatment dose. Patients not receiving opioids were more likely to enroll, suggesting that patients who are prescribed opioids, an important group for treatment outreach, are likely underengaged. Identifying predictors of enrollment in CBT-CP may help increase recruitment efficiency and assist in targeting patients who may benefit but are not currently interested in treatment.

Work outcomes after benefits counseling among veterans applying for service connection for a psychiatric condition.

OBJECTIVE: This study's objective was to determine the efficacy of benefits counseling in a clinical trial. There has been concern that disability payments for psychiatric disorders reduce incentives for employment and rehabilitation. Benefits counseling, with education about opportunities to work and the financial implications of work on receipt of disability benefits, may counter these disincentives. METHODS: This single-blind, six-month randomized clinical trial enrolled 84 veterans who had applied for service-connected compensation for a psychiatric condition. Veterans were randomly assigned to either four sessions of benefits counseling or of a control condition involving orientation to the U.S Department of Veterans Affairs health care system and services. Days of paid work and work-related activities were assessed at follow-up visits by using a timeline follow-back calendar. RESULTS: Veterans assigned to benefits counseling worked for pay for significantly more days than did veterans in the control group (effect size=.69, p<.05), reflecting an average of three more days of paid employment during the 28 days preceding the six-month follow-up. Benefits counseling was associated with increased use of mental health services, but this correlation did not mediate the effect of benefits counseling on working. CONCLUSIONS: Barriers to employment associated with disability payments are remediable with basic counseling. More research is needed to understand the active ingredient of this counseling and to strengthen the intervention.

Financial motivation to work among people with psychiatric disorders.

BACKGROUND: Supported employment is an effective intervention for people with serious mental illnesses (SMI) but is underutilized. Clients' desire to work might be heightened by programs that provide counseling about managing one's funds, since money management helps people become more aware of the advantages of having money. AIM: To analyze the thoughts of recently homeless or hospitalized persons with SMI concerning their personal finances and employment. METHODS: We interviewed 49 people with SMI about their finances, reviewed transcripts and analyzed their baseline characteristics. RESULTS: Twenty of the 49 participants spontaneously expressed a desire to work in order to earn more money. Those who expressed a desire to work managed their money significantly better than those who did not. CONCLUSION: Discussion of finances, such as that fostered by money management programs, may promote engagement in vocational rehabilitation and working for pay.

Pathways to assignment of payees.

How clients come to be assigned representative payees and/or conservators to manage their funds is not well understood. We compared clients assigned a payee during a clinical trial of a money management-based intervention to those not assigned payees and examined antecedents to payee assignment. One year after randomization, significantly more clients assigned to the advisor teller money manager (ATM) money management intervention were assigned payees than participants in the control condition (10 of 47 vs. 2 of 43; p = .02); those assigned payees had lower baseline GAF scores and participated more in study therapies. Several ATM clients were assigned payees after third parties paid more attention to clients' finances, and others after having negotiated storage of their funds with the ATM money manager during the study. Assignment of payees appears to be influenced by whether third parties critically attend to how clients' manage funds and by clients' receptiveness to having a payee.

Recovery and money management.

OBJECTIVE: Social recovery and external money management are important approaches in contemporary mental health care, but little research has been done on the relationship between the two or on application of recovery principles to money management for people at risk of being assigned a representative payee or conservator. METHOD: Out of 49 total qualitative interviews, 25 transcripts with persons receiving Social Security insurance or Social Security disability insurance who were at risk of being assigned a money manager were analyzed to assess the presence of recognized recovery themes. RESULTS: The recovery principles of self-direction and responsibility were strong themes in participant comments related to money management. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Money management interventions should incorporate peoples' recovery-related motivations to acquire financial management skills as a means to direct and assume responsibility for one's finances. Staff involved in money management should receive training to support client's recovery-related goals.

Timeline historical review of income and financial transactions: a reliable assessment of personal finances.

The need for accurate and reliable information about income and resources available to individuals with psychiatric disabilities is critical for the assessment of need and evaluation of programs designed to alleviate financial hardship or affect finance allocation. Measurement of finances is ubiquitous in studies of economics, poverty, and social services. However, evidence has demonstrated that these measures often contain error. We compare the 1-week test-retest reliability of income and finance data from 24 adult psychiatric outpatients using assessment-as-usual (AAU) and a new instrument, the Timeline Historical Review of Income and Financial Transactions (THRIFT). Reliability estimates obtained with the THRIFT for Income (0.77), Expenses (0.91), and Debt (0.99) domains were significantly better than those obtained with AAU. Reliability estimates for Balance did not differ. THRIFT reduced measurement error and provided more reliable information than AAU for assessment of personal finances in psychiatric patients receiving Social Security benefits. The instrument also may be useful with other low-income groups.

Build a better mouse: directly-observed issues in computer use for adults with SMI.

Integrating information technology into healthcare has the potential to bring treatment to hard-to-reach people. Individuals with serious mental illness (SMI), however, may derive limited benefit from these advances in care because of lack of computer ownership and experience. To date, conclusions about the computer skills and attitudes of adults with SMI have been based primarily on self-report. In the current study, 28 psychiatric outpatients with co-occurring cocaine use were interviewed about their computer use and opinions, and 25 were then directly observed using task analysis and think aloud methods as they navigated a multi-component health informational website. Participants reported low rates of computer ownership and use, and negative attitudes towards computers. Self-reported computer skills were higher than demonstrated in the task analysis. However, some participants spontaneously expressed more positive attitudes and greater computer self-efficacy after navigating the website. Implications for increasing access to computer-based health information are discussed.

Subjective Experiences of Clients in a Voluntary Money Management Program.

A large proportion of people diagnosed with mental illnesses have difficulty managing their money, and therefore many psychiatric treatments involve providing money management assistance. However, little is known about the subjective experience of having a money manager, and extant literature is restricted to people forced to work with a representative payee or conservator. In this study, fifteen people were interviewed about their experience receiving a voluntary money management intervention designed to minimize substance use. Clients emphasized the importance of trusting the money manager, financial mindfulness (an enhanced awareness of the financial transactions in clients' day-to-day lives), agency over their own affairs, and addiction. In contrast to evaluations of people assigned representative payees and/or conservators, there was little mention of feeling coerced. These findings suggest that money management programs can address client concerns by building trust, relating budgeting to clients' day-to-day lives, and encouraging clients' control over their own affairs.

Associations between impulsivity and high risk sexual behaviors in dually diagnosed outpatients.

BACKGROUND/OBJECTIVES: It is unknown whether impulsivity is associated with risky sexual behavior in dually diagnosed clients. METHODS: Impulsivity in 51 sexually-active, dually diagnosed clients was assessed by the Barrett Impulsivity Scale, Delayed Discounting Questionnaire, and Wisconsin Card-Sorting Task, and a path analysis of relationship to self-reported risk behaviors was conducted. RESULTS: Recent cocaine use was correlated with risky sexual behaviors and a preference for immediate over larger, delayed rewards trended towards a correlation. CONCLUSION AND SCIENTIFIC SIGNIFICANCE: The association between impulsivity and risky sexual behavior among substance users appears to extend to the dually diagnosed. Implications for HIV prevention are discussed.