Chronic pain and problematic substance use for veterans during COVID-19: the moderating role of psychological flexibility.

Background: Chronic pain and problematic substance use are commonly co-occurring and highly detrimental issues that are especially prevalent in U.S. veteran populations. Although COVID-19 made clinical management of these conditions potentially difficult, some research suggests that certain veterans with these conditions did not experience this period as negatively as others. It is thus important to consider whether resilience factors, such as the increasingly-studied process of psychological flexibility, might have led to better outcomes for veterans managing pain and problematic substance use during this time of global crisis. Methods: This planned sub-analysis of a larger cross-sectional, anonymous, and nationally-distributed survey (N = 409) was collected during the first year of the COVID-19 pandemic. Veteran participants completed a short screener and battery of online surveys assessing pain severity and interference, substance use, psychological flexibility, mental health functioning, and pandemic-related quality of life. Results: For veterans with chronic pain and problematic substance use, the pandemic resulted in a significant lowering of their quality of life related to meeting basic needs, emotional health, and physical health compared to veterans with problematic substance use but no chronic pain diagnosis. However, moderation analyses revealed that veterans with these comorbid conditions experienced less negative impacts from the pandemic on quality of life and mental health when they reported greater psychological flexibility. For veterans with problematic substance use only, psychological flexibility was also related to better mental health functioning, but did not significantly correlate with their quality of life. Conclusion: Results highlight how COVID-19 differentially impacted veterans with both problematic substance use and chronic pain, such that this group reported particularly negative impacts of the pandemic on multiple areas of quality of life. However, our findings further emphasize that psychological flexibility, a modifiable resiliency process, also buffered against some of the negative impacts of the pandemic on mental health and quality of life. Given this, future research into the impact of natural crises and healthcare management should investigate how psychological flexibility can be targeted to help increase resiliency for veterans with chronic pain and problematic substance use.

An Avatar-Led Web-Based and SMS Text Message Smoking Cessation Program for Socioeconomically Disadvantaged Veterans: Pilot Randomized Controlled Trial.

BACKGROUND: Despite the declining prevalence of cigarette smoking in the United States, socioeconomically disadvantaged veterans receiving care from the Veterans Health Administration have a high prevalence of smoking. Currently, available treatment options for these veterans focus on tobacco users who are ready to quit and have limited reach. Consequently, there is a great need for accessible, effective smoking cessation interventions for veterans at all levels of readiness to quit smoking. OBJECTIVE: To address these needs, we developed Vet Flexiquit, a web-based Acceptance and Commitment Therapy program for veterans, and evaluated its acceptability (primary aim), efficacy, and impact on theory-based change processes relative to the National Cancer Institute's SmokefreeVET program in a pilot randomized controlled trial. METHODS: Participants (N=49) were randomized 1:1 to receive either the Vet Flexiquit (n=25) or SmokefreeVET (n=24) web program. Both groups received SMS text messages as part of the intervention for 6 weeks. Both interventions are fully automated and self-guided. Primary outcome data were collected at 3 months after the randomization. Self-reported smoking abstinence was biochemically verified using saliva cotinine. Multivariable logistic regression, negative binomial regression, and linear regression models were used to evaluate the association between the treatment arm and outcomes of interest. RESULTS: Acceptability, as measured by overall treatment satisfaction, was high and similar across treatment arms: 100% (17/17) for Vet Flexiquit and 95% (18/19) for SmokefreeVET. Acceptability, as measured by utilization, was more modest (log-ins: M=3.7 for Vet Flexiquit and M=3.2 for SmokefreeVET). There were no statistically significant differences between treatment arms for any acceptability measures. Similarly, there were no statistically significant differences between treatment arms in the secondary outcomes of smoking cessation or change in Acceptance and Commitment Therapy's theory-based processes. In open-ended survey responses, some veterans in both treatment arms expressed interest in having support from a professional or peer to enhance their experience, as well as an expanded SMS text messaging program. CONCLUSIONS: Both programs had high ratings of acceptability, limited utilization, and a similar impact on cessation and cessation processes. Taken together with the qualitative data suggesting that additional support may enhance participants' experience of both programs, these preliminary findings suggest that the programs may have similar outcomes among veterans who are looking for a digital cessation treatment option and that integrating provider or peer support and enhancing the SMS text messaging program holds promise as a means of boosting engagement and outcomes for both programs. TRIAL REGISTRATION: ClinicalTrials.gov NCT04502524; https://clinicaltrials.gov/ct2/show/NCT04502524.

An Online Acceptance and Mindfulness Intervention for Chronic Pain in Veterans: Development and Protocol for a Pilot Feasibility Randomized Controlled Trial.

BACKGROUND: In the veteran community, chronic pain is particularly prevalent and often debilitating. Until recently, veterans with chronic pain were offered primarily pharmacological intervention options, which rarely suffice and can also have negative health consequences. To better address chronic pain in veterans, the Veterans Health Administration has invested in novel, nonpharmacological behavior interventions that target both pain management and chronic pain-related functional issues. One approach, acceptance and commitment therapy (ACT) for chronic pain, is supported by decades of efficacy evidence for improving pain outcomes; however, ACT can be difficult to obtain owing to issues such as a lack of trained therapists or veterans having difficulty committing to the time and resources needed for the full clinician-led ACT protocol. Given the strong ACT evidence base combined with access limitations, we set out to develop and evaluate Veteran ACT for Chronic Pain (VACT-CP), an online program guided by an embodied conversational agent to improve pain management and functioning. OBJECTIVE: The aims of this study are to develop, iteratively refine, and then conduct a pilot feasibility randomized controlled trial (RCT) of a VACT-CP group (n=20) versus a waitlist and treatment-as-usual control group (n=20). METHODS: This research project includes 3 phases. In phase 1, our research team consulted with pain and virtual care experts, developed the preliminary VACT-CP online program, and conducted interviews with providers to obtain their feedback on the intervention. In phase 2, we incorporated feedback from phase 1 into the VACT-CP program and completed initial usability testing with veterans with chronic pain. In phase 3, we are conducting a small pilot feasibility RCT, with the primary outcome being assessment of usability of the VACT-CP system. RESULTS: This study is currently in phase 3; recruitment for the RCT began in April 2022 and is expected to continue through April 2023. Data collection is expected to be completed by October 2023, with full data analysis completed by late 2023. CONCLUSIONS: The findings from this research project will provide information on the usability of the VACT-CP intervention, as well as secondary outcomes related to treatment satisfaction, pain outcomes (pain-related daily functioning and pain severity), ACT processes (pain acceptance, behavioral avoidance, and valued living), and mental and physical functioning. TRIAL REGISTRATION: ClinicalTrials.gov NCT03655132; https://clinicaltrials.gov/ct2/show/NCT03655132. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/45887.

Intersectionality in Intervention Development: Insights From Formative Work on a Tailored Tobacco Cessation Program for LGBTQIA+ Young Adults.

Tailored tobacco cessation interventions focusing on minoritized communities are proliferating, but the extent to which these interventions address the needs of individuals with multiple minoritized social identities is unclear. We developed Empowered, Queer, Quitting, and Living (EQQUAL), an avatar-led digital smoking cessation intervention tailored for lesbian, gay, bisexual, transgender, queer or questioning, intersex, asexual, and more (LGBTQIA+) young adults based on acceptance and commitment therapy (ACT), via a multistage user-centered design process. The purpose was to evaluate feedback from EQQUAL development activities using an intersectional lens. Intersectionality is a paradigm created by Kimberlé Crenshaw illustrating the multiple social identities each person possesses along with the marginalization of these different social identities. We conducted a rapid deductive content analysis focused on intersectional design gaps using interviewer notes from user testing (n = 7), a diary study (n = 8), and treatment satisfaction responses from a single-arm trial of the EQQUAL intervention (n = 22). Feedback related to intersectional design fell under three broad themes: (a) inadequate representativeness of the avatar, (2) inadequate representativeness within the program broadly, and (3) non-inclusive ACT intervention content. Feedback on inclusiveness included reference to socioeconomic status, race/ethnicity, religious/cultural affiliation, and ability/disability. Although we previously found that EQQUAL was highly acceptable and showed promise in terms of efficacy in a single-arm pilot trial, we identified several gaps in intersectional design as the iterative intervention development proceeded. Because intersectional design is a critical part of developing interventions with a health equity focus, applying standardized procedures for intersectional design and analysis could improve intervention design and better address tobacco cessation treatment needs of individuals who may experience multiple forms of marginalization.

Veteran Acceptance of Sleep Health Information Technology: a Mixed-Method Study.

Sleep disturbances, including chronic insomnia and sleep apnea, are major concerns for US veterans, with rising rates and detrimental effects on physical, mental, and social well-being. Sleep disturbances in veterans are also underdiagnosed and undertreated for reasons that include limited sleep clinician availability, long wait times, and the time commitment for treatment. Greater use of sleep health information technologies could improve access to assessment and treatment of sleep disturbances. However, the assessment of acceptance of these technologies among veterans is still ongoing. This mixed-method study combines data from two separate but similar randomized controlled trials to assess acceptance of sleep health information technologies for veterans with chronic insomnia. Sleep health information technologies included in these trials were the following: (1) a WatchPAT sleep monitor for home-based sleep assessment, including detection of sleep apnea, and (2) the VA mobile app Cognitive Behavioral Therapy for Insomnia (CBT-i Coach), which supports self-management of insomnia. The combined sample of 37 veterans receiving care within one New England VA medical center completed a six-week trial using both health information technology tools. Participants completed a survey and interview at the end of the 6 weeks. Overall, participants found the tools acceptable, easy to use, and useful and reported they would use them in the future. Thus, these sleep health information technologies appear to provide an acceptable remote option for assessing and managing sleep issues for veterans. ClinicalTrials.gov NCT02392000; http://clinicaltrials.gov/ct2/show/NCT02392000 and ClinicalTrials.gov NCT03305354; https://clinicaltrials.gov/ct2/show/NCT03305354.

The effects of loneliness and psychological flexibility on veterans' substance use and physical and mental health functioning during the COVID-19 pandemic.

During the COVID-19 pandemic, social isolation was a common experience as people were trying to keep themselves and others safe from infection. Veterans with problematic substance use are at particular risk of the consequences of social isolation. This study evaluated the nature of social interactions during the COVID-19 pandemic and the effects of loneliness and psychological flexibility on self-reported substance use and physical and mental health functioning among U.S. veterans who reported problematic substance use. Data from 409 veterans with self-reported substance use concerns were obtained via a cross-sectional online survey. Results showed that many veterans who engaged in problematic substance use during the COVID-19 pandemic reported a number of social supports during this period and frequent communication with others, but still felt lonelier during the pandemic. In regression analyses, higher levels of loneliness were associated with more negative impacts of the pandemic, greater substance use, and poorer physical and mental health functioning. Psychological flexibility demonstrated significant unique variance in explaining mental health functioning during the pandemic after accounting for loneliness, but not for substance use or physical functioning. For veterans with high levels of loneliness, high levels of psychological flexibility were associated with a lower negative impact on quality of life due to the pandemic, but for veterans with low levels of loneliness, differing levels of psychological flexibility were not significantly associated with the negative impact of COVID-19. Overall, loneliness and psychological flexibility appear to be highly associated with the negative impact of COVID-19 on veterans with problematic substance use.

A Randomized Pilot Study of Acceptance and Commitment Therapy to Improve Social Support for Veterans with PTSD.

Veterans with PTSD often have substantial interpersonal difficulties and low levels of social support, which puts them at increased risk of mortality, but few treatments address global social impairment for veterans with PTSD. This study is a pilot randomized trial of Acceptance and Commitment Therapy to Improve Social Support for Veterans with PTSD (ACT-SS), a psychotherapy that targets social avoidance and eroded social relationships, compared to Person-Centered Therapy (PCT), a non-directive psychotherapy. Participants were randomized to twelve sessions of either ACT-SS (n = 21) or PCT (n = 19). The results showed that veterans with PTSD had high ratings of satisfaction for both treatments. Contrary to the PCT group, participants in the ACT-SS group showed a significant improvement in the quality of social relationships, engagement in social and leisure activities, and PTSD symptoms from the baseline assessment to the end of treatment and a three-month follow-up. Veterans in the ACT-SS group, but not the PCT group, also showed significant improvements in mindfulness and valued living and a reduction in experiential avoidance from baseline to the end of treatment, with sustained improvements in valued living at the three-month follow-up. Overall, the present study demonstrated the feasibility, acceptability, and positive preliminary outcomes of ACT-SS for veterans with PTSD.

The Impact of COVID-19 on Self-Reported Substance Use, Well-Being, and Functioning Among United States Veterans: A Cross-Sectional Study.

As the COVID-19 pandemic sweeps the globe, many veterans with substance use issues have faced the closure of treatment facilities, mandates to shelter in place, and social distancing measures. To better understand their pandemic experiences, substance use changes, and functioning, a survey was nationally administered to a sample of United States veterans reporting substance use issues during the pandemic. The purpose of this cross-sectional online survey for veterans (N = 409) was to report on COVID-19 experiences, safety behaviors, and infection experiences while also investigating the relationship among addictive behaviors, mental and physical health, and COVID-19 impact. Measures also assessed specific substance use concerns, pandemic-related loneliness, and functioning. Though few veterans reported personally receiving a confirmed COVID-19 medical diagnosis (10.5%), the impact of pandemic stressors was evident, with a majority reporting anxiety related to contracting COVID-19 (61.4%) or fear of a family member or close friend contracting COVID-19 (58.7%). Participants reported increased use of alcohol (45.3%), sedatives (36.6%), inhalants (35.7%), tobacco (35.0%), and cannabis (34.9%), attributed specifically to the pandemic. Regression analyses revealed that even when controlling for the contribution of problematic substance use issues, negative pandemic impacts and self-reported COVID-19 related loneliness were related to more impaired physical and mental health functioning during the pandemic. Findings from this sample of veterans with addiction issues add to the growing literature suggesting unique and adverse effects of COVID-19 stressors on functioning while also revealing specific pandemic impacts for this group.

Understanding Adoption and Preliminary Effectiveness of a Mobile App for Chronic Pain Management Among US Military Veterans: Pre-Post Mixed Methods Evaluation.

BACKGROUND: The Veterans Health Administration Pain Coach mobile health app was developed to support veterans with chronic pain. OBJECTIVE: Our objective was to evaluate early user experiences with the Pain Coach app and preliminary impacts of app use on pain-related outcomes. METHODS: Following a sequential, explanatory, mixed methods design, we mailed surveys to veterans at 2 time points with an outreach program in between and conducted semistructured interviews with a subsample of survey respondents. We analyzed survey data using descriptive statistics among veterans who completed both surveys and examined differences in key outcomes using paired samples t tests. We analyzed semistructured interview data using thematic analysis. RESULTS: Of 1507 veterans invited and eligible to complete the baseline survey, we received responses from 393 (26.1%). These veterans received our outreach program; 236 (236/393, 60.1%) completed follow-up surveys. We conducted interviews with 10 app users and 10 nonusers. Among survey respondents, 10.2% (24/236) used Pain Coach, and 58% (14/24) reported it was easy to use, though interviews identified various app usability issues. Veterans who used Pain Coach reported greater pain self-efficacy (mean 23.1 vs mean 16.6; P=.01) and lower pain interference (mean 34.6 vs mean 31.8; P=.03) after (vs before) use. The most frequent reason veterans reported for not using the app was that their health care team had not discussed it with them (96/212, 45.3%). CONCLUSIONS: Our findings suggest that future efforts to increase adoption of Pain Coach and other mobile apps among veterans should include health care team endorsement. Our findings regarding the impact of Pain Coach use on outcomes warrant further study.

Social Functioning in Individuals With Post-Traumatic Stress Disorder: A Systematic Review.

Post-traumatic stress disorder (PTSD) can lead to multiple deleterious outcomes and has negative, sometimes debilitating, impacts on general functioning of those affected. This systematic review of 26 articles evaluates the existing literature on social functioning outcomes used in PTSD research, the association between PTSD and social functioning, and the impact of interventions for PTSD on social functioning. A review of 26 articles using the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines for systematic reviews showed that PTSD was associated with significant impairment in global social functioning. This review also reveals the need for both standardized definitions and better assessment methods to operationalize social functioning and improve our ability to compare findings across studies. The literature also suggests that some evidence-based treatments for PTSD improve social functioning despite not explicitly targeting social functioning in the treatment. The findings of this review suggest that there are ample opportunities for improving both research and interventions to improve global social functioning in PTSD.

A quantitative and qualitative examination of the impacts of the COVID-19 pandemic on U.S. veterans with self-reported anxiety and alcohol use disorder.

Introduction: The COVID-19 pandemic generated concerns about rising stress and alcohol use, especially in U.S. veterans who experience high rates of anxiety disorders (ADs), alcohol use disorder (AUD), and dual AD+AUD diagnoses. This study investigated differences among these diagnostic groups in a veteran population related to their concern about COVID-19, impacts of COVID-19 on quality of life, and self-reported changes to urge to drink and drinking frequency. Methods: A nationally administered online survey was given to a sample of U.S. veterans reporting substance use issues during the pandemic. Differences in the level of concern about COVID-19, impacts of COVID-19 on quality of life, and drinking behaviors were examined in those self-reporting AD (n = 98), AUD (n = 46), or AD+AUD (n = 67). Consensual qualitative research was used to analyze an open-ended question about COVID-19's impact on substance use, health, and quality of life. Results: Veterans with AD+AUD experienced significant increases in urge to drink and alcohol consumption compared to veterans with AD only. Greater urge and frequency of drinking were associated with greater negative impacts of COVID-19 on quality of life. There were no differences among groups in global negative impact on quality of life or level of COVID-19 concern. However, respondents described specific COVID-19 worries, with qualitative findings revealing that those with AD+AUD reported a disproportionate psychosocial burden due to the pandemic. Discussion: Special attention in screening and treatment should be given to those with a dual AD+AUD diagnosis who may be experiencing both an increase in alcohol use and psychosocial burden as stress increases due to the pandemic.

An Avatar-Led Digital Smoking Cessation Program for Sexual and Gender Minority Young Adults: Intervention Development and Results of a Single-Arm Pilot Trial.

BACKGROUND: Sexual and gender minority young adults have a high prevalence of smoking and unique barriers to accessing tobacco treatment. OBJECTIVE: To address these challenges as well as their preferences for sexual and gender minority-targeted interventions and digital programs, we developed and evaluated the acceptability, preliminary efficacy, and impact on theory-based change processes of an acceptance and commitment therapy-based digital program called Empowered, Queer, Quitting, and Living (EQQUAL). METHODS: Participants (n=22) of a single-arm trial conducted to evaluate the program were young adults, age 18 to 30 years, who self-identified as sexual and gender minority individuals and smoked at least one cigarette per day. All participants received access to the EQQUAL program. Participants completed web-based surveys at baseline and at a follow-up 2 months after enrollment. We verified self-reported smoking abstinence with biochemical testing; missing data were counted as smoking or using tobacco. RESULTS: For young adults who logged in at least once (n=18), the mean number of log-ins was 5.5 (SD 3.6), mean number of sessions completed was 3.1 (SD 2.6), and 39% (7/18) completed all 6 sessions. Overall, 93% of participants (14/15) were satisfied with the EQQUAL program, 100% (15/15) found it easy to use, and 100% (15/15) said it helped them be clearer about how to quit. Abstinence from smoking or using tobacco was confirmed with biochemical testing for 23% of participants (5/22). Both quantitative and qualitative results suggested a positive overall response to the avatar guide, with areas for future improvement largely centered on the avatar's appearance and movements. CONCLUSIONS: Treatment acceptability of EQQUAL was very promising. The rate of abstinence, which was biochemically confirmed, was 3 times higher than that of the only other digital program to date that has targeted sexual and gender minority young adults and 6 to 13 times higher than those of nontargeted digital smoking interventions among sexual and gender minority young adults. Planned improvements for the next iteration of the program include making the avatar's movements more natural; offering multiple avatar guides with different on characteristics such as race, ethnicity, and gender identity from which to choose; and providing a support forum for users to connect anonymously with peers.

Beyond the Lab: Empirically Supported Treatments in the Real World.

Laboratory studies of empirically supported treatments (ESTs) for mental health problems achieve much higher rates of clinical improvement than has been observed following treatment in the community. This discrepancy is likely to due to limited reliance on ESTs by therapists outside of academia. Concerns about the generalizability of ESTs to patients in the community, who may have comorbid problems, likely limit rates of adoption. The present study examined the impact of ESTs delivered in the real-world for 1,256 adults who received services through an employee assistance program specializing in the delivery of ESTs. Rates of anxiety and depression decreased significantly, following treatment with an EST, and 898 (71.5%) patients demonstrated reliable improvement. Even among patients comorbid for depression and anxiety at baseline, over half reported reliable improvement in both disorders. Findings suggest ESTs can be effectively delivered outside of academic RCTs. However, additional research is needed to understand and overcome barriers to disseminating ESTs to the broader community.

Mobile App Use for Insomnia Self-Management: Pilot Findings on Sleep Outcomes in Veterans.

BACKGROUND: Sleep disturbance is a major health concern among US veterans who have served since 2001 in a combat theater in Iraq or Afghanistan. We report subjective and objective sleep results from a pilot trial assessing self-management-guided use of a mobile app (CBT-i Coach, which is based on cognitive behavioral therapy for insomnia) as an intervention for insomnia in military veterans. OBJECTIVE: The primary aim of this study was to evaluate changes in subjective and objective sleep outcomes from pre to postintervention. METHODS: Subjective outcomes included the Insomnia Severity Index, the Pittsburgh Sleep Quality Inventory, and sleep-related functional status. A wearable sleep monitor (WatchPAT) measured objective sleep outcomes, including sleep efficiency, percent rapid eye movement (REM) during sleep, sleep time, and sleep apnea. A total of 38 participants were enrolled in the study, with 18 participants being withdrawn per the protocol because of moderate or severe sleep apnea and 9 others who dropped out or withdrew. Thus, 11 participants completed the full 6-week CBT-i Coach self-management intervention (ie, completers). RESULTS: Completer results indicated significant changes in subjective sleep measures, including reduced reports of insomnia (Z=-2.68, P=.007) from pre (mean 16.63, SD 5.55) to postintervention (mean 12.82, SD 3.74), improved sleep quality (Z=-2.37, P=.02) from pre (mean 12.82, SD 4.60) to postintervention (mean 10.73, SD 3.32), and sleep-related functioning (Z=2.675, P=.007) from pre (mean 13.86, SD 3.69) to postintervention (mean 15.379, SD 2.94). Among the objective measures, unexpectedly, objective sleep time significantly decreased from pre to postintervention (χ22=7.8, P=.02). There were no significant changes in percent REM sleep or sleep efficiency. CONCLUSIONS: These findings suggest that the CBT-i Coach app can improve subjective sleep and that incorporating objective sleep measures into future, larger clinical trials or clinical practice may yield important information, particularly by detecting previously undetected sleep apnea. TRIAL REGISTRATION: ClinicalTrials.gov NCT02392000; http://clinicaltrials.gov/ct2/show/NCT02392000.

Use of Social Robots in Mental Health and Well-Being Research: Systematic Review.

BACKGROUND: Technology-assisted clinical interventions are increasingly common in the health care field, often with the proposed aim to improve access to and cost-effectiveness of care. Current technology platforms delivering interventions are largely mobile apps and online websites, although efforts have been made to create more personalized and embodied technology experiences. To extend and improve on these platforms, the field of robotics has been increasingly included in conversations of how to deliver technology-assisted, interactive, and responsive mental health and psychological well-being interventions. Socially assistive robots (SARs) are robotic technology platforms with audio, visual, and movement capabilities that are being developed to interact with individuals socially while also assisting them with management of their physical and psychological well-being. However, little is known about the empirical evidence or utility of using SARs in mental health interventions. OBJECTIVE: The review synthesizes and describes the nascent empirical literature of SARs in mental health research and identifies strengths, weaknesses, and opportunities for improvement in future research and practice. METHODS: Searches in Medline, PsycINFO, PsycARTICLES, PubMed, and IEEE Xplore yielded 12 studies included in the final review after applying inclusion and exclusion criteria. Abstract and full-text reviews were conducted by two authors independently. RESULTS: This systematic review of the literature found 5 distinct SARs used in research to investigate the potential for this technology to address mental health and psychological well-being outcomes. Research on mental health applications of SARs focuses largely on elderly dementia patients and relies on usability pilot data with methodological limitations. CONCLUSIONS: The current SARs research in mental health use is limited in generalizability, scope, and measurement of psychological outcomes. Opportunities for expansion of research in this area include diversifying populations studied, SARs used, clinical applications, measures used, and settings for those applications.

A supported education service pilot for returning veterans with posttraumatic stress disorder.

A randomized controlled pilot of supported education services was conducted with 33 Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn (OEF, OIF, OND, respectively) veterans with posttraumatic stress disorder (PTSD) who had higher education goals. Veteran peers delivered supported education services to an intervention group; for the control group, peers provided "matched attention" of generalized support without supporting educational goals. The intervention was based on a manualized veteran-centric program of supported education using principles of supported employment for individuals living with mental illness and components of civilian models of supported education. The attrition rate was high, with 30% lost to services between the baseline screening and the first peer session, although this drop-out rate is comparable to other rehabilitation studies. Despite a small sample and a matched attention control that could have diluted possible effects, significant positive differences were found, with the intervention group spending greater amounts of time on educational activities than did the control group. Effect sizes for the impact of the intervention were large between Time 1 and Time 2, and moderately large between Time 2 and Time 3. PTSD-symptom severity and recovery attitudes did not predict the impact of the supported education intervention. Implementation of the veteran supported education program using veteran peers appears feasible, although assertive outreach may be necessary to recruit and engage veterans with PTSD. Findings suggest that supported education services can have a measurable effect on time spent attaining an educational goal. Future studies will need to be longitudinal, as well as attend to the attrition issue and capture the impact on other education outcomes, such as successful program completion. (PsycINFO Database Record

Patterns of diagnoses in hospital admissions in a multistate cohort of HIV-positive adults in 2001.

BACKGROUND: Admissions for AIDS-related illnesses decreased soon after the introduction of highly active antiretroviral therapy (HAART), but it is unclear if the trends have continued in the current HAART era. An understanding of healthcare utilization patterns is important for optimization of care and resource allocation. We examined the diagnoses for hospitalizations of patients with HIV in 2001. METHODS: Demographic and healthcare data were collected for 8376 patients from 6 U.S. HIV care sites in 2001. We categorized diagnoses into 18 disease groups and used Poisson regression to analyze the number of admissions for each of the 4 most common groups. We also compared patients with admissions for AIDS-defining illnesses (ADI) with patients admitted for other diagnoses. RESULTS: Twenty-one percent of patients had at least 1 hospitalization. Among patients hospitalized at least once, 28% were hospitalized for an ADI. Comparing diagnosis categories, the most common hospitalizations were AIDS-defining illnesses (21.6%), gastrointestinal (GI) diseases (9.5%), mental illnesses (9.0%), and circulatory diseases (7.4%). In multivariate analysis, women had higher hospitalization rates than men for ADI (incidence rate ratio [IRR], 1.50; 95% confidence interval [CI], 1.25-1.79) and GI diseases (IRR, 1.52; 95% CI, 1.15-2.00). Compared with whites, blacks had higher admission rates for mental illnesses (IRR, 1.70; 95% CI, 1.22-2.36), but not for ADI. As expected, CD4 count and viral load were associated with ADI admission rates; CD4 counts were also related to hospitalizations for GI and circulatory conditions. CONCLUSIONS: Five years after the introduction of HAART, AIDS-defining illnesses continue to have the highest hospitalization rate among the diagnosis categories examined. This result emphasizes the importance of vaccination for pneumonia and influenza, as well as prophylaxis for Pneumocystis jiroveci pneumonia. The relatively large number of mental illness admissions highlights the need for comanagement of psychiatric disease, substance abuse, and HIV. Overall, the majority of patients were hospitalized for reasons other than ADI, illustrating the importance of managing comorbid conditions in this population. Data from this cohort of patients with HIV may help guide the allocation of healthcare resources by enhancing our understanding of factors associated with variation in inpatient utilization rates.

High rates of primary Mycobacterium avium complex and Pneumocystis jiroveci prophylaxis in the United States.

BACKGROUND: National data from the mid-1990s demonstrated that many eligible patients with HIV infection do not receive prophylaxis for opportunistic infections (OIs) and that racial and gender disparities existed in OI prophylaxis receipt. OBJECTIVE: We examined whether demographic disparities in use of OI prophylaxis persist in 2001 and if outpatient care is associated with OI prophylaxis utilization. RESEARCH DESIGN: Demographic, clinical, and pharmacy utilization data were collected from 10 U.S. HIV primary care sites in the HIV Research Network. SUBJECTS: This study consisted of adult patients (>or=18 years old) in longitudinal HIV primary care. MEASURES: Indications for Pneumocystis jiroveci pneumonia (PCP) or Mycobacterium avium complex (MAC) prophylaxis were 2 or more CD4 counts less than 200 or 50 cells/mm(3) during calendar year (CY) 2001, respectively. Using multivariate logistic regression, we examined demographic and clinical characteristics associated with receipt of PCP or MAC prophylaxis and the association of outpatient utilization with appropriate OI prophylaxis. RESULTS: Among eligible patients, 88.1% received PCP prophylaxis and 87.6% received MAC prophylaxis. Approximately 80% had 4 or more outpatient visits during CY 2001. Adjusting for care site, male gender (odds ratio [OR], 1.47), Medicare coverage (OR, 1.60), and having 4 or more outpatient visits in a year (OR, 2.34) were significantly associated with increased likelihood of PCP prophylaxis. Adjusting for care site, having 4 or more outpatient visits in a year (OR, 1.85) was associated with increased likelihood of receipt of MAC prophylaxis. There were no demographic or insurance characteristics associated with receipt of MAC prophylaxis. CONCLUSIONS: The overall prevalence of OI prophylaxis has increased since the mid-1990s, and previous racial and HIV risk factor disparities in receipt of OI prophylaxis have waned. Integration into the healthcare system is an important correlate of receiving OI prophylaxis.

Hospital and outpatient health services utilization among HIV-infected adults in care 2000-2002.

BACKGROUND: Rapid changes in HIV epidemiology and antiretroviral therapy may have resulted in recent changes in patterns of healthcare utilization. OBJECTIVE: The objective of this study was to examine sociodemographic and clinical correlates of inpatient and outpatient HIV-related health service utilization in a multistate sample of patients with HIV. DESIGN: Demographic, clinical, and resource utilization data were collected from medical records for 2000, 2001, and 2002. SETTING: This study was conducted at 11 U.S. HIV primary and specialty care sites in different geographic regions. PATIENTS: In each year, HIV-positive patients with at least one CD4 count and any use of inpatient, outpatient, or emergency room services. Sample sizes were 13,392 in 2000, 15,211 in 2001, and 14,403 in 2002. MAIN OUTCOME MEASURES: Main outcome measures were number of hospital admissions, total days in hospital, and number of outpatient clinic/office visits per year. Inpatient and outpatient costs were estimated by applying unit costs to numbers of inpatient days and outpatient visits. RESULTS: Mean numbers of admissions per person per year decreased from 2000 (0.40) to 2002 (0.35), but this difference was not significant in multivariate analyses. Hospitalization rates were significantly higher among patients with greater immunosuppression, women, blacks, patients who acquired HIV through drug use, those 50 years of age and over, and those with Medicaid or Medicare. Mean annual outpatient visits decreased significantly between 2000 and 2002, from 6.06 to 5.66 visits per person per year. Whites, Hispanics, those 30 years of age and over, those on highly active antiretroviral therapy (HAART), and those with Medicaid or Medicare had significantly higher outpatient utilization. Inpatient costs per patient per month (PPPM) were estimated to be 514 dollars in 2000, 472 dollars in 2001, and 424 dollars in 2002; outpatient costs PPPM were estimated at 108 dollars in 2000, 100 dollars in 2001, and 101 dollars in 2002. CONCLUSION: Changes in utilization over this 3-year period, although statistically significant in some cases, were not substantial. Hospitalization rates remain relatively high among minority or disadvantaged groups, suggesting persistent disparities in care. Combined inpatient and outpatient costs for patients on HAART were not significantly lower than for patients not on HAART.

Racial and gender disparities in receipt of highly active antiretroviral therapy persist in a multistate sample of HIV patients in 2001.

BACKGROUND: National data from the mid-1990s demonstrated that many eligible patients did not receive highly active antiretroviral therapy (HAART) and that racial and gender disparities existed in HAART receipt. We examined whether demographic disparities in the use of HAART persist in 2001 and if outpatient care is associated with HAART utilization. METHODS: Demographic, clinical, and pharmacy utilization data were collected from 10 US HIV primary care sites in the HIV Research Network (HIVRN). Using multivariate logistic regression, we examined demographic and clinical differences associated with receipt of HAART and the association of outpatient utilization with HAART. RESULTS: In our cohort in 2001, 84% of patients received HAART and 66% had 4 or more outpatient visits during calendar year (CY) 2001. Of those with 2 or more CD4 counts below 350 cells/mm in 2001, 91% received HAART; 82% of those with 1 CD4 test result below 350 cells/mm received HAART; and 77% of those with no CD4 counts below 350 cells/mm received HAART. Adjusting for care site in multivariate analyses, age >40 years (adjusted odds ratio [AOR] = 1.13), male gender (AOR = 1.23), Medicaid coverage (AOR = 1.16), Medicare coverage (AOR = 1.73), having 1 or more CD4 counts less than 350 cells/mm (AOR = 1.33), and having 4 or more outpatient visits in a year (OR = 1.34) were significantly associated with an increased likelihood of HAART. African Americans (odds ratio [OR] = 0.84) and those with an injection drug use risk factor (OR = 0.86) were less likely to receive HAART. CONCLUSIONS: Although the overall prevalence of HAART has increased since the mid-1990s, demographic disparities in HAART receipt persist. Our results support attempts to increase access to care and frequency of outpatient visits for underutilizing groups as well as increased efforts to reduce persistent disparities in women, African Americans, and injection drug users (IDUs).