Coping in crisis: The role of psychologists in response to a pandemic.

The coronavirus disease 2019 (COVID-19) pandemic has had a major impact on the world. In the United States, healthcare systems have been taxed, medical supplies depleted, and healthcare providers overburdened by the increased need. Although psychologists cannot provide medical services, we possess a unique skillset that can alleviate some of the stress placed on healthcare providers, answer important questions about how this disease impacts patients, and support the growing mental health needs of providers and patients alike. The following commentary outlines the ways in which psychologists and mental health workers at one facility, the Southeast Louisiana Veterans Health Care System, supported the medical system and cared for patient and staff mental health in response to the COVID-19 pandemic. Lessons learned from this experience as well as important future steps are discussed. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Correlates of death among SARS-CoV-2 positive veterans: The contribution of lifetime tobacco use.

Despite a growing body of research examining correlates and consequences of COVID-19, few findings have been published among military veterans. This limitation is particularly concerning as preliminary data indicate that veterans may experience a higher rate of mortality compared to their civilian counterparts. One factor that may contribute to increased rates of death among veterans with COVID-19 is tobacco use. Indeed, findings from a recent meta-analysis highlight the association between lifetime smoking status and COVID-19 progression to more severe or critical conditions including death. Notably, prevalence rates of tobacco use are higher among veterans than civilians. Thus, the purpose of the current study was to examine demographic and medical variables that may contribute to likelihood of death among veterans testing positive for SARS-CoV-2. Additionally, we examined the unique influence of lifetime tobacco use on veteran mortality when added to the complete model. Retrospective chart reviews were conducted on 440 veterans (80.5% African American/Black) who tested positive for SARS-CoV-2 (7.3% deceased) at a large, southeastern Veterans Affairs (VA) hospital between March 11, 2020 and April 23, 2020, with data analysis occurring from May 26, 2020 to June 5, 2020. Older age, male gender, immunodeficiency, endocrine, and pulmonary diseases were positively related to the relative risk of death among SARS-CoV-2 positive veterans, with lifetime tobacco use predicting veteran mortality above and beyond these variables. Findings highlight the importance of assessing for lifetime tobacco use among SARS-CoV-2 positive patients and the relative importance of lifetime tobacco use as a risk factor for increased mortality.

Veterans Health Administration's Physician Assistant Primary Care Residency: An Evaluation of the First 3 Years.

PURPOSE: Results from an evaluation of a 12-month postgraduate Veterans Health Administration (VHA) residency in primary care for physician assistants (PAs). METHODS: Descriptive and open-ended data were collected to describe the experience of faculty and trainees participating in the first 3 years of this pilot residency. Quantitative data were summarized using descriptive statistics. Text data were transcribed and reviewed for common themes across residency sites and respondents. Data were collected at 2 time points-the end of the first year and the beginning of year 4. RESULTS: In the first 3 years of the program, 18 residents were enrolled at 6 sites, with 89% completing the residency. At the second time point, 8 more residents were enrolled. Residents were primarily female (69%). Of the residents completing the program, 56% obtained VHA employment, and 75% of the current residents planned to work for the VHA upon completing the program. Program infrastructure, such as written curriculum, a dedicated administrative staff, and written evaluations for trainees, was more common at the second time point. Recurring themes included the importance of establishing relationships with potential applicants, preceptors, medical center leadership, and trainees to support the program and the importance of securing resources such as space and protected time for faculty. CONCLUSIONS: Although postgraduate residency programs are less common for PAs than for some other health professions, our data suggest that a one-year residency can provide training for new graduates to help solidify their clinical experience and facilitate their transition to practice.

Physiological responses to acute psychological stress are reduced by the PPARγ agonist rosiglitazone.

Physiological reactions to psychological stress are positively associated with several important chronic conditions including cardiovascular and neurodegenerative diseases and are linked to increased mortality. As such, the identification of cellular and molecular pathways that act to reduce stress responding may represent important targets for therapeutic intervention. Here we report that acute treatment with the peroxisome-proliferator activated receptor-γ (PPARγ) agonist rosiglitazone (RSG) blunts systemic responses to acute psychological stress in rats. Rats that had previously received oral RSG for 5 d exhibited a 40% reduction in the initial heart rate response to an acute restraint stress, compared with vehicle-treated controls, suggesting that increased PPARγ signaling blunts the acute autonomic response to stress. Rats previously treated with RSG likewise had a blunted hormonal response to this stressor, exhibiting a 30% reduction in peak corticosterone levels compared with controls. Moreover, stress-induced expression of c-Fos, a marker of early neuronal activation, was similarly reduced in the paraventricular hypothalamus, a key site for brain stress integration, facilitating both autonomic and hypothalamic-pituitary-adrenocortical responses to stress. Taken as a whole, these data suggest that PPARγ stimulation potently inhibits physiological responses to psychological stress, prescribing a novel role for PPARγ signaling in the regulation of brain stress integration.

Best practices in the Veterans Health Administration's MOVE! Weight management program.

BACKGROUND: Obesity is a substantial problem in the Veterans Health Administration (VHA). VHA developed and disseminated the MOVE! Weight Management Program for Veterans to its medical facilities but implementation of the program has been variable. PURPOSE: The objective was to explore variation in MOVE! program implementation to identify facility structure, policies, and processes associated with larger patient weight-loss outcomes. METHODS: Qualitative comparative analysis (QCA) was used to identify facility conditions or combinations of conditions associated with larger 6-month patient weight-loss outcomes. QCA is a method that allows for systematic cross-case comparison to better understand causal complexity. Eleven sites with larger outcomes and 11 sites with smaller outcomes were identified and data were collected with site interviews, facility-completed program summary forms, and medical record abstraction in 2009 and 2010. Conditions were selected based on theory and experience implementing MOVE! and were calibrated using QCA methods. Configuration patterns were examined to identify necessary conditions (i.e., always present when outcome present, but alone do not guarantee outcome) and sufficient conditions (i.e., presence guarantees outcome) at sites with larger and smaller outcomes. A thematic analysis of site interview data supplemented QCA findings. RESULTS: No two sites shared the same condition pattern. Necessary conditions included the use of a standard curriculum and group care-delivery format, and they were present at all sites with larger outcomes but at only six sites with smaller outcomes. At the 17 sites with both necessary conditions, four combinations of conditions were identified that accounted for all sites with larger outcomes. These included high program complexity combined with high staff involvement; group care-delivery format combined with low accountability to facility leadership; an active physician champion combined with low accountability to facility leadership; and the use of quality-improvement strategies combined with not using a waiting list. CONCLUSIONS: The use of a standard curriculum delivered with a group care-delivery format is an essential feature of successful VHA facility MOVE! Weight Management Programs, but alone does not guarantee success. Program development and policy will be used to ensure dissemination of the best practices identified in this evaluation.

Forebrain origins of glutamatergic innervation to the rat paraventricular nucleus of the hypothalamus: differential inputs to the anterior versus posterior subregions.

The hypothalamic paraventricular nucleus (PVN) regulates numerous homeostatic systems and functions largely under the influence of forebrain inputs. Glutamate is a major neurotransmitter in forebrain, and glutamate neurosignaling in the PVN is known to mediate many of its functions. Previous work showed that vesicular glutamate transporters (VGluTs; specific markers for glutamatergic neurons) are expressed in forebrain sites that project to the PVN; however, the extent of this presumed glutamatergic innervation to the PVN is not clear. In the present study retrograde FluoroGold (FG) labeling of PVN-projecting neurons was combined with in situ hybridization for VGluT1 and VGluT2 mRNAs to identify forebrain regions that provide glutamatergic innervation to the PVN and its immediate surround in rats, with special consideration for the sources to the anterior versus posterior PVN. VGluT1 mRNA colocalization with retrogradely labeled FG neurons was sparse. VGluT2 mRNA colocalization with FG neurons was most abundant in the ventromedial hypothalamus after anterior PVN FG injections, and in the lateral, posterior, dorsomedial, and ventromedial hypothalamic nuclei after posterior PVN injections. Anterograde tract tracing combined with VGluT2 immunolabeling showed that 1) ventromedial nucleus-derived glutamatergic inputs occur in both the anterior and posterior PVN; 2) posterior nucleus-derived glutamatergic inputs occur predominantly in the posterior PVN; and 3) medial preoptic nucleus-derived inputs to the PVN are not glutamatergic, thereby corroborating the innervation pattern seen with retrograde tracing. The results suggest that PVN subregions are influenced by varying amounts and sources of forebrain glutamatergic regulation, consistent with functional differentiation of glutamate projections.

Hyperphagia and increased fat accumulation in two models of chronic CNS glucagon-like peptide-1 loss of function.

Central administration of glucagon-like peptide-1 (GLP-1) causes a dose-dependent reduction in food intake, but the role of endogenous CNS GLP-1 in the regulation of energy balance remains unclear. Here, we tested the hypothesis that CNS GLP-1 activity is required for normal energy balance by using two independent methods to achieve chronic CNS GLP-1 loss of function in rats. Specifically, lentiviral-mediated expression of RNA interference was used to knock down nucleus of the solitary tract (NTS) preproglucagon (PPG), and chronic intracerebroventricular (ICV) infusion of the GLP-1 receptor (GLP-1r) antagonist exendin (9-39) (Ex9) was used to block CNS GLP-1r. NTS PPG knockdown caused hyperphagia and exacerbated high-fat diet (HFD)-induced fat accumulation and glucose intolerance. Moreover, in control virus-treated rats fed the HFD, NTS PPG expression levels correlated positively with fat mass. Chronic ICV Ex9 also caused hyperphagia; however, increased fat accumulation and glucose intolerance occurred regardless of diet. Collectively, these data provide the strongest evidence to date that CNS GLP-1 plays a physiologic role in the long-term regulation of energy balance. Moreover, they suggest that this role is distinct from that of circulating GLP-1 as a short-term satiation signal. Therefore, it may be possible to tailor GLP-1-based therapies for the prevention and/or treatment of obesity.

Stimulation of the prelimbic cortex differentially modulates neuroendocrine responses to psychogenic and systemic stressors.

The medial prefrontal cortex is important for normal regulation of stress responses, and is implicated in stress-related affective disease states (e.g. depression). In the current study, we investigated the role of the prelimbic division of the prefrontal cortex in control of responses to psychogenic and systemic stressors (restraint and hypoxia, respectively). Acute stimulation of the prelimbic cortical region with bicuculline methiodide (BMI) caused significant reduction of ACTH and corticosterone responses to restraint and reduced Fos activation of paraventricular nucleus neurons, consistent with a role in central inhibition of acute psychogenic stress responses. In contrast, BMI enhanced corticosterone (but not ACTH) responses to hypoxia via a mechanism suggestive of central PVN drive and enhanced adrenal sensitivity. Acute BMI increased restraint stress-induced Fos activation in known downstream targets of the prelimbic cortex (e.g., the basolateral amygdala and central amygdaloid nuclei), suggesting a connection between modulation of amygdalar signaling and stress inhibition. In contrast, hypoxia caused robust Fos activation in the basolateral and central amygdala, which was not affected by prelimbic BMI injection. The data suggest that the prelimbic cortex stimulation is sufficient to trigger inhibition of the HPA axis to psychogenic stress, but may play a very different role in enhancing HPA responsiveness to physical threats.

RE-AIM evaluation of the Veterans Health Administration's MOVE! Weight Management Program.

UNLABELLED: Over one-third of patients treated in the Veterans Health Administration (VHA) are obese. VHA introduced the MOVE! Weight Management Program for Veterans in 2006 to provide comprehensive weight management services. An evolving, periodic evaluation using the RE-AIM framework (reach, effectiveness, adoption, implementation, and maintenance) has been conducted to gauge success and opportunities for improvement. Key metrics were identified in each RE-AIM dimension. Data were compiled over fiscal years (FY) 2006 through 2010 from a variety of sources including VHA administrative and clinical databases, electronic medical record reviews, and an annual, structured VHA facility self-report. REACH: Screening for obesity and offering weight management treatment to eligible patients increased from 66% to 95% over the past 3 years. MOVE! is currently provided at every VHA hospital facility and at over one-half of VHA community-based outpatient clinics. The percent of eligible patients who participate in at least one weight management visit has doubled since implementation began but has stabilized at 10 to 12%. EFFECTIVENESS: About 18.6% of the 31,854 patients with available weight data who participated in at least two treatment visits between Jul 1, 2008 and Sep 30, 2009 had at least a 5% body weight loss by 6 months as did almost one-third of those who participated in more intense and sustained treatment. By contrast, only 12.5% of a comparison group of patients matched on age, gender, body mass index (BMI) class, and comorbidity status who were not treated with MOVE! had at least a 5% body weight loss. ADOPTION: The median full-time staff equivalent providing weight management services at each facility has increased over time and was 1.76 in FY 2010. IMPLEMENTATION: Staff from multiple disciplines typically provide MOVE!-related care although not all disciplines are involved with providing care at every facility. Group-based treatment has become increasingly utilized, and in FY 2010 it represented 72% of all MOVE!-related visits. Intensity of treatment has increased from an average of 3.6 visits per patient per year in FY 2007 to 4.6 in FY 2010, but more than half of patients have two visits or less. Almost all facilities now report the consistent use of key evidence-based behavioral strategies with patients. MAINTENANCE: While participation in MOVE! by patients continues to grow each year, facility self-reported program staffing and space/equipment challenges are potential barriers to long-term program maintenance. Evidence-based weight management treatment can be delivered at VHA medical centers and community-based outpatient clinics, but the REACH remains limited after several years of implementation. Intense and sustained treatment with MOVE! results in a modest positive impact on short-term weight loss outcomes, but a relatively small proportion of patients engage in this level of care. Increasing reach, improving effectiveness of care, and keeping patients engaged in treatment are areas for future policy, practice, and research.

Pleasurable behaviors reduce stress via brain reward pathways.

Individuals often eat calorically dense, highly palatable "comfort" foods during stress for stress relief. This article demonstrates that palatable food intake (limited intake of sucrose drink) reduces neuroendocrine, cardiovascular, and behavioral responses to stress in rats. Artificially sweetened (saccharin) drink reproduces the stress dampening, whereas oral intragastric gavage of sucrose is without effect. Together, these results suggest that the palatable/rewarding properties of sucrose are necessary and sufficient for stress dampening. In support of this finding, another type of natural reward (sexual activity) similarly reduces stress responses. Ibotenate lesions of the basolateral amygdala (BLA) prevent stress dampening by sucrose, suggesting that neural activity in the BLA is necessary for the effect. Moreover, sucrose intake increases mRNA and protein expression in the BLA for numerous genes linked with functional and/or structural plasticity. Lastly, stress dampening by sucrose is persistent, which is consistent with long-term changes in neural activity after synaptic remodeling. Thus, natural rewards, such as palatable foods, provide a general means of stress reduction, likely via structural and/or functional plasticity in the BLA. These findings provide a clearer understanding of the motivation for consuming palatable foods during times of stress and influence therapeutic strategies for the prevention and/or treatment of obesity and other stress-related disorders.

Design and dissemination of the MOVE! Weight-Management Program for Veterans.

BACKGROUND: Practitioners in the Veterans Health Administration (VHA) identified comprehensive weight management as a high priority in early 2001. PROGRAM DESIGN: The MOVE! Weight-Management Program for Veterans was developed on the basis of published guidelines from the National Institutes of Health and other organizations. Testing of program feasibility occurred at 17 VHA sites, and the program was refined during early implementation throughout 2005. DISSEMINATION: MOVE! was disseminated nationally in January 2006. Local program coordinators and physician champions were named, and toolkits, online training, marketing materials, and ongoing field support were provided. EVALUATION: MOVE! has been implemented at nearly all VHA medical centers. By June 2008, more than 100,000 patients had participated in MOVE! during more than 500,000 visits. An evaluation based on an established framework is under way. CONCLUSION: MOVE! is an example of the large-scale translation of research into practice. It has the potential to reduce the burden of disease from obesity and related conditions.

Risk behaviors and resiliency within physically abused adolescents.

OBJECTIVE: This study examines the relationship between physical abuse and several risk behaviors, and thriving behaviors, and the relationship between potential protective factors and engagement in risk and thriving behaviors among victims of physical abuse. Three categories of potential protective factors were examined: (1) individual characteristics, (2) family processes, and (3) extra-familial factors. We expected that high levels of protective factors would reduce engagement in risk behaviors (i.e., alcohol use, tobacco use, drug use, sexual activity, antisocial behavior, attempted suicide, and purging) among abused adolescents. RESULTS: Across all the risk behaviors, abused adolescents reported a higher frequency of engagement than non-abused adolescents. Several protective factors were identified for the seven risk behaviors. Peer group characteristics was a significant predictor in all seven of the logistic regressions, followed by positive school climate (six models), religiosity (five models), other adult support (five models), family support (four models), view of the future (two models), and involvement in extra-curricular activities (two models). The variance accounted for by the models ranged from 2% (risk behavior of purging) to 26% (risk behavior of alcohol use and antisocial behavior). CONCLUSIONS: The findings indicate that, with the exception of sexual activity, the majority of abused adolescents were not engaging in risk behaviors; however, significantly more abused adolescents were engaging in risk behaviors than their non-abused counterparts. In addition, that protective factors were found to exist at various levels of the adolescents' ecology has strong implications for practice.

Biofeedback treatment of constipation: a critical review.

PURPOSE: This review was designed to 1) critically examine the research design used in investigations of biofeedback for pelvic floor dyssynergia, 2) compare the various biofeedback treatment protocols for pelvic floor dyssynergia-type constipation used in this research, 3) identify factors that influence treatment outcome, and 4) identify goals for future biofeedback research for pelvic floor dyssynergia. METHODS: A comprehensive review of both the pediatric and adult research from 1970 to 2002 on "biofeedback for constipation" was conducted using a Medline search in all languages. Only prospective studies including five or more subjects that described the treatment protocol were included. In addition, a meta-analysis of these studies was performed to compare the outcome of different biofeedback protocols for treating constipation. RESULTS: Thirty-eight studies were reviewed, and sample size, treatment protocol, outcome rates, number of sessions, and etiology are shown in a table. Ten studies using a parallel treatment design were reviewed in detail, including seven that randomized subjects to treatment groups. A meta-analysis (weighted by subjects) was performed to compare the results of two treatment protocols prevalent in the literature. The mean success rate of studies using pressure biofeedback (78 percent) was superior (P = 0.018) to the mean success rate for studies using electromyography biofeedback (70 percent). However, the mean success rates comparing studies using intra-anal electromyography sensors to studies using perianal electromyography sensors were 69 and 72 percent, respectively, indicating no advantages for one type of electromyography protocol over the other (P = 0.428). In addition to the varied protocols and instrumentation used, there also are inconsistencies in the literature regarding the severity and etiology of symptoms, patient selection criteria, and the definition of a successful outcome. Finally, no anatomic, physiologic, or demographic variables were identified that would assist in predicting successful outcome. Having significant psychological symptoms was identified as a factor that may influence treatment outcome, but this requires further study. CONCLUSION: Although most studies report positive results using biofeedback to treat constipation, quality research is lacking. Specific recommendations are made for future investigations to 1) improve experimental design, 2) clearly define outcome measures, 3) identify the etiology and severity of symptoms, 4) determine which treatment protocol and which component of treatment is most effective for different types of subjects, 5) systematically explore the role of psychopathology in this population, 6) use an adequate sample size that allows for meaningful analysis, and 7) include long-term follow-up data.

Systematic review of the comorbidity of irritable bowel syndrome with other disorders: what are the causes and implications?

BACKGROUND & AIMS: Comorbid or extraintestinal symptoms occur frequently with irritable bowel syndrome and account for up to three fourths of excess health care visits. This challenges the assumption that irritable bowel is a distinct disorder. The aims of this study were to (1) assess comorbidity in 3 areas: gastrointestinal disorders, psychiatric disorders, and nongastrointestinal somatic disorders; and (2) evaluate explanatory hypotheses. METHODS: The scientific literature since 1966 in all languages cited in Medline was systematically reviewed. RESULTS: Comorbidity with other functional gastrointestinal disorders is high and may be caused by shared pathophysiological mechanisms such as visceral hypersensitivity. Psychiatric disorders, especially major depression, anxiety, and somatoform disorders, occur in up to 94%. The nongastrointestinal nonpsychiatric disorders with the best-documented association are fibromyalgia (median of 49% have IBS), chronic fatigue syndrome (51%), temporomandibular joint disorder (64%), and chronic pelvic pain (50%). CONCLUSIONS: Multivariate statistical analyses suggest that these are distinct disorders and not manifestations of a common somatization disorder, but their strong comorbidity suggests a common feature important to their expression, which is most likely psychological. Some models explain the comorbidity of irritable bowel with other disorders by suggesting that each disorder is the manifestation of varying combinations of interacting physiological and psychological factors. An alternative hypothesis is that the irritable bowel diagnosis is applied to a heterogeneous group of patients, some of whom have a predominantly psychological etiology, whereas others have a predominantly biological etiology, and that the presence of multiple comorbid disorders is a marker for psychological influences on etiology.