Evaluation of the Implementation of the FLOW Program for Increasing Access to Mental Health Care.

The FLOW program was designed to facilitate appropriate and safe transitions of patients from specialty mental health (SMH) to primary care (PC) as a method of improving access and reducing appointment burden on veterans who have improved or remitted. In this study, the team evaluated the implementation of FLOW across nine Veterans Affairs (VA) sites using a mixed-methods evaluation in a cluster-randomized stepped wedge trial design. Outcome assessments used data from VA databases, dashboards, and semi-structured interviews and were guided by the Reach, Adoption, Effectiveness, Implementation, and Maintenance (RE-AIM) framework. Across the sites, mean level reach was 1.36% of all specialty mental health patients transitioned to primary care (standard deviation [SD] = 1.05). Mean provider adoption was 10.2% (SD = 8.3%). Approximately 75% of veterans were fully satisfied with their transition and reported shared decision-making in the decision to transition. Rates of transitions did not decrease over the 6-month maintenance period following implementation. These data suggest that FLOW can be successfully implemented and maintained, although there was wide variation in implementation across sites. Future research should examine how to support sites that struggle with implementation.

The role of depression and anxiety symptom severity in remotely delivered mental health care.

This study examined differences in mental health characteristics of Veterans who received VA Video Connect (VVC) or audio-only care during initial phases of the COVID-19 pandemic. A cohort of Veterans with primary diagnoses of depressive or anxiety disorders (diagnosed between March 2019 and February 2020) was identified, and data were obtained for Veterans who engaged in virtual care from April to December 2020. Two groups were created: Veterans receiving audio-only care (n = 161,071) and Veterans receiving two or more VVC visits (n = 84,505). Multiple logistic regression models examined symptom severity in the year before COVID as a predictor of treatment modality during COVID. Chi-square tests examined associations between modality and the number of assessments. Symptom severity as evaluated by the nine-item Patient Health Questionnaire and Generalized Anxiety Disorder-7 significantly predicted modality of encounters during the pandemic such that those who had moderate or severe symptoms prior to COVID-19 were more likely than those with low or no symptoms to have two or more VVC encounters during the pandemic. Of those who received VVC, 55.62% had no Patient Health Questionnaire-9 assessments compared to 68.96% of those who received audio-only. In the VVC group, 70.36% had no Generalized Anxiety Disorder-7 assessments compared to 81.02% in the audio-only group. Taken together, these findings suggest that VVC, when compared to audio-only, was used during the pandemic to reach Veterans with more severe mental health symptomatology and to engage in administration of measurement-based care. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Black veteran use of video telehealth for mental health care.

Black veterans experience disparities in mental health (MH) care access and are disproportionately affected by COVID-19. Video telehealth to home (VTH) may reduce disparities by addressing barriers, particularly with pandemic-related shifts to remotely delivered care. Considering potential needs for tailored implementation across racial/ethnic groups, we examined differences in VTH use by non-Hispanic Black veterans versus all other races/ethnicities and among Black (Hispanic and non-Hispanic) veterans by age, rurality, and gender during the pandemic. We extracted a cohort of Veterans Health Administration-enrolled veterans receiving at least one MH encounter between October 2019 and September 2020 (n = 1,627,791) from electronic health records. Multilevel linear growth curve models examined the percentage of VTH use for non-Hispanic Black versus other races/ethnicities before and after pandemic onset. Black veteran-only subgroup analyses examined differences by ethnicity in percentage of VTH MH encounters since pandemic onset by age, rurality, and gender, using regression and analysis of covariance models. Despite significant increases in VTH during the pandemic, on average, VTH use was consistently lower for non-Hispanic Black veterans across both periods. During the pandemic, differences in VTH use between non-Hispanic Black and non-Black veterans accelerated over time. VTH use was greater during the pandemic for Black veterans who were Hispanic, younger, urban, and female. Adoption of VTH for MH was low for non-Hispanic Black veterans before COVID-19 and during COVID-19 compared to non-Black groups. Future VTH research and implementation efforts should question why adoption remains low, work to meet cultural needs, and promote equitable adoption for Black veterans. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Impact of routine urine cultures on antibiotic usage in those undergoing a routine annual spinal cord injury evaluation.

OBJECTIVE: The Veterans Health Administration (VHA), the largest single provider of spinal cord injury and disorder (SCI/D) care in the United States, currently mandates that every patient receives a screening urine culture during the annual evaluation, a yearly comprehensive history and physical examination. This testing has shown in a small subset of patients to overidentify asymptomatic bacteriuria that is then inappropriately treated with antibiotics. The objective of the current analysis was to assess the association of the annual evaluation on urine testing and antibiotic treatment in a national sample of Veterans with SCI/D. DESIGN/METHOD: A retrospective cohort study using national VHA electronic health record data of Veterans with SCI/D seen between October 1, 2017-September 30, 2019 for their annual evaluation. RESULTS: There were 9447 Veterans with SCI/D who received an annual evaluation; 5088 (54%) had a urine culture obtained. 2910 cultures (57%) were positive; E. coli was the most common organism obtained (12.9% of total urine cultures). Of the patients with positive urine cultures, 386 were prescribed antibiotics within the 7 days after that encounter (13%); of the patients with negative cultures (n = 2178), 121 (6%) were prescribed antibiotics; thus, a positive urine culture was a significant driver of antibiotic use (p < 0.001). CONCLUSION: The urine cultures ordered at the annual exam are often followed by antibiotics; this practice may be an important target for antibiotic stewardship programs in SCI.

Rural Veterans with HIV and Alcohol Use Disorder receive less video telehealth than urban Veterans.

PURPOSE: Alcohol use disorder (AUD) is highly prevalent among Veterans with HIV. Rural Veterans with HIV are at especially high risk for not receiving appropriate treatment. This retrospective cohort cross-sectional study aimed to investigate patterns of mental health treatment utilization across delivery modality among Veterans diagnosed with HIV and AUD. It was hypothesized that rural Veterans with HIV and AUD would receive a lower rate of mental health treatment delivered via video telehealth than urban Veterans with HIV and AUD. METHODS: A national Veterans Health Association administrative database was used to identify a cohort of Veterans diagnosed with HIV and AUD (N = 2,075). Geocoding was used to categorize rural Veterans (n = 246) and urban Veterans (n = 1,829). Negative binomial regression models tested associations between rurality and mental health treatment delivered via face-to-face, audio-only, and video telehealth modalities. FINDINGS: Results demonstrated that rural Veterans with HIV and AUD received fewer mental health treatment sessions delivered via telehealth than urban Veterans with HIV and AUD (incidence rate ratio = 0.62; 95% confidence intervals [0.44, 0.87]; P < .01). No differences were found in terms of treatment delivered face-to-face or by audio-only. CONCLUSIONS: Rural Veterans with HIV and AUD represent a vulnerable subpopulation of Veterans who may most benefit from video telehealth. Efforts to increase access and improve the uptake of evidence-based mental health treatment delivered via video telehealth are needed.

Quantifying the Implementation and Cost of a Multisite Antibiotic Stewardship Intervention for Asymptomatic Bacteriuria.

Objective: The intensity of an antibiotic stewardship intervention to achieve clinical impact is not known. We conducted a multisite dissemination project of an intervention to reduce treatment of asymptomatic bacteriuria (ASB) and studied: (1) the association between implementation metrics and clinical outcomes and (2) the cost of implementation. Design/Setting/Participants: A central site facilitated a multimodality intervention to decrease unnecessary urine cultures and antibiotic treatment in patients with ASB at 4 Veterans Affairs medical centers. Methods: The intervention consisted of a decision support aid algorithm and interactive teaching cases that provided in the moment audit and feedback on how to manage ASB. Implementation outcomes included minutes spent in intervention delivery, number of healthcare professionals reached, and number of sessions delivered. Clinical outcomes included days of antibiotic therapy (DOT), length of antibiotic therapy (LOT), and number of urine cultures ordered per 1000 bed days. Personnel reported weekly time logs. Results: Minutes spent in intervention delivery were inversely correlated with two clinical outcomes, DOT (R -0.3, P = .04) and LOT (R -0.3, P = .02). Number of healthcare professionals reached and number of sessions delivered were not correlated with clinical outcomes of DOT (R -0.003, P = .98, R = -0.059, P = .69) or LOT (R +0.073, P = .62, R -0.102, P = .49). Physician champions spent an average of 3.8% of effort on the intervention. The implementation cost was USD 22,299/year per site on average. Conclusions: The amount of time local teams spent in delivery of an antibiotic stewardship intervention was correlated with the desired decrease in antibiotic use. Implementing this successful antibiotic stewardship intervention required minimal time.

Systemic Adverse Events Among Patients With Diabetes Treated With Intravitreal Anti-Vascular Endothelial Growth Factor Injections.

Importance: Anti-vascular endothelial growth factor (VEGF) agents are currently the mainstay of treatment for diabetic retinopathy (DR). Although effective, data on their systemic safety remains inconclusive, particularly in high-risk patient groups. Objective: To explore the systemic safety of intravitreal anti-VEGF agents among patients with diabetes. Design, Setting, and Participants: This was a retrospective, longitudinal population-based analysis of the Corporate Data Warehouse, a large-scale database of patients within the US Veteran Health Affairs. All patients 18 years and older with type 2 diabetes who were seen at any Veterans Affairs health care facility in the US between January 1, 2011, and December 31, 2012, were identified. Data were then extracted on incident systemic adverse events among this patient cohort from January 1, 2013, to December 31, 2017. All individuals with diabetes who did and did not receive anti-VEGF injections were included. Patients with a history of prior systemic adverse events and those who received an intravitreal injection between January 1, 2011, and December 31, 2012, were excluded. Data were analyzed from October 2019 to March 2023. Exposure: Anti-VEGF injection. Main Outcomes and Measures: Proportion of patients with any incident systemic adverse event, acute myocardial infarction, cardiovascular disease, or kidney disease at 1-, 3-, and 5-year follow-up. Results: A total of 1 731 782 patients (mean [SD] age, 63.8 [12.3] years; 1 656 589 [95.7%] male) with type 2 diabetes were included. DR was present in 476 013 (27.5%), and 14 022 (0.8%) received anti-VEGF injections. Of the total number of patients with type 2 diabetes, 321 940 (18.6%) developed systemic adverse events between 2013 and 2017. The 5-year cumulative incidence of any systemic adverse event was 37.0% (5187/14 022) in the injection group vs 18.4% (316 753/1 717 760) in the noninjection group (P < .001). Anti-VEGF injections were independently associated with a higher likelihood of developing any systemic adverse event (odds ratio, 1.8; 95% CI, 1.7-1.9) when controlling for age, race, sex, ethnicity, tobacco use, severity of DR, Deyo-Charlson Comorbidity Index score, mean hemoglobin A1c, total number of injections, and statin use. Conclusion and Relevance: In this study, intravitreal anti-VEGF injections were independently associated with a higher likelihood of systemic adverse events among patients with diabetes.

Prevalence of sexual desire and arousal difficulties among women veterans: A retrospective cohort design.

Low sexual desire and arousal are associated with several negative health outcomes, including reduced quality of life, depression, anxiety, and relationship discord. Although women veterans have high rates of risk factors for sexual dysfunctions (e.g., elevated rates of trauma, depression, anxiety), research on their sexual functioning is lacking. Using a retrospective cohort design, we examined the prevalence of documented sexual desire and arousal disorder diagnoses or symptoms, using International Classification of Diseases, 10th Revision codes, among 790,726 women veterans receiving care in the Veterans Health Administration (VHA). In fiscal year 2020, these symptoms and disorders were documented for only 0.19% (n = 1,494) of women veterans receiving care and symptoms of low sexual desire were documented more frequently than formal desire and arousal diagnoses. Most women veterans with desire and arousal problems were married (53.88%), and most (52.28%) were prescribed antidepressants. Mental health (MH) treatment for desire and arousal difficulties was commonly delivered in person (as compared to telephone or telehealth). Psychologists primarily treated desire and arousal concerns, providing an average of 2.81 MH encounters (SD = 7.53) compared to an average of 1.62 (SD = 5.25) MH encounters by social workers and 1.22 (SD = 2.53) by psychiatrists. Problems with low sexual desire and arousal are likely underassessed and undertreated within the VHA. Better assessment of women veterans' low desire and arousal is warranted to improve their well-being and quality of life. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

History of Suicide Attempt and Clozapine Treatment in Veterans With Schizophrenia or Schizoaffective Disorder.

Objective: To evaluate whether a history of suicide attempt increases the odds of receiving clozapine treatment in veterans with schizophrenia or schizoaffective disorder.Methods: Electronic health record data were obtained for veterans with schizophrenia or schizoaffective disorder treated at any US Veterans Affairs Medical Center between January 1, 2000, and January 31, 2021 (N = 134,692). Logistic regression (adjusted and unadjusted) was applied to estimate odds ratios (ORs) for clozapine treatment in suicide attempters relative to nonattempters.Results: 3,407 patients had a documented history of suicide attempt, while 6,867 patients had received clozapine treatment. Also, 9.4% (n = 321) of suicide attempters versus 5.0% (n = 6546) of nonattempters had received clozapine treatment. The odds of being treated with clozapine was approximately 2-fold in patients with a history of suicide attempt in unadjusted (OR = 1.98, 95% CI, 1.76-2.22) and adjusted (OR = 1.91, 95% CI, 1.67-2.15) analyses.Conclusions: Despite the higher odds of clozapine treatment in suicide attempters with schizophrenia or schizoaffective disorder, clozapine was underutilized in the current sample of veterans. Concerted efforts should be made to expand the use of clozapine in patients with schizophrenia or schizoaffective disorder, especially those with a history of suicide attempt.

Early insights of the COVID-19 pandemic in the Veterans' Affairs spinal cord injury and disorders population.

STUDY DESIGN: Retrospective cohort. OBJECTIVES: The primary outcome of the study was to identify patient characteristics associated with a positive COVID-19 test. The secondary outcome was to identify patient characteristics associated with mortality from COVID-19. SETTING: Veterans Health Administration (VHA) National Spinal Cord Injury and Disorders (SCI) Registry, created by the National Spinal Cord Injury and Disorders SCI Program Office in March 2020. METHODS: Data was analyzed in the form of descriptive statistics and then subsequent regression analysis was performed. RESULTS: A total of 4,562 persons with SCI were tested for COVID-19 between March and July 2020, and 290 were positive. The study found that African Americans had increased odds of testing positive for COVID-19 (OR 1.53 (1.18-2.00), p < 0.01). Increased age correlated with increased odds of mortality after testing positive for COVID-19 (1.046 (1.003-1.090)). Non-smokers had lower odds of mortality following positive COVID-19 test (0.15 (0.04-0.52)). No association was found between neurologic level of injury (NLI) and positive COVID-19 test or increased mortality. Increased Body Mass Index (BMI) did correlate with positive COVID-19 test but not increased mortality. The case fatality rate for persons with SCI and a positive test for COVID-19 was 12%. CONCLUSIONS: It is important to define the risk factors for patients with SCI to elucidate and mitigate individual and population risks. These risk factors also can play a role in determining the allocation of critical healthcare resources.

Analysis of an Antibiotic Stewardship Program for Asymptomatic Bacteriuria in the Veterans Affairs Health Care System.

Importance: Antibiotic stewardship for asymptomatic bacteriuria (ASB) is an important quality improvement target. Understanding how to implement successful antibiotic stewardship interventions is limited. Objective: To evaluate the effectiveness of a quality improvement stewardship intervention on reducing unnecessary urine cultures and antibiotic use in patients with ASB. Design, Setting, and Participants: This interrupted time series quality improvement study was performed at the acute inpatient medical and long-term care units of 4 intervention sites and 4 comparison sites in the Veterans Affairs (VA) health care system from October 1, 2017, through April 30, 2020. Participants included the clinicians who order or collect urine cultures and who order, dispense, or administer antibiotics. Clinical outcomes were measured in all patients in a study unit during the study period. Data were analyzed from July 6, 2020, to May 24, 2021. Intervention: Case-based teaching on how to apply an evidence-based algorithm to distinguish urinary tract infection and ASB. The intervention was implemented through external facilitation by a centralized coordinating center, with a site champion at each intervention site serving as an internal facilitator. Main Outcomes and Measures: Urine culture orders and days of antibiotic therapy (DOT) and length of antibiotic therapy in days (LOT) associated with urine cultures, standardized by 1000 bed-days, were obtained from the VA's Corporate Data Warehouse. Results: Of 11 299 patients included, 10 703 (94.7%) were men, with a mean (SD) age of 72.6 (11.8) years. The decrease in urine cultures before and after the intervention was not significant in intervention sites per segmented regression analysis (-0.04 [95% CI, -0.17 to 0.09]; P = .56). However, difference-in-differences analysis comparing intervention with comparison sites found a significant reduction in the number of urine cultures ordered by 3.24 urine cultures per 1000 bed-days (P = .003). In the segmented regression analyses, the relative percentage decrease of DOT in the postintervention period at the intervention sites was 21.7% (P = .007), from 46.1 (95% CI, 28.8-63.4) to 37.0 (95% CI, 22.6-51.4) per 1000 bed-days. The relative percentage decrease of LOT in the postintervention period at the intervention sites was 21.0% (P = .001), from 36.7 (95% CI, 23.2-50.2) to 29.6 (95% CI, 18.2-41.0) per 1000 bed-days. Conclusions and Relevance: The findings of this quality improvement study suggest that an individualized intervention for antibiotic stewardship for ASB was associated with a decrease in urine cultures and antibiotic use when implemented at multiple sites via external and internal facilitation. The electronic health record database-derived outcome measures and centralized facilitation approach are both suitable for dissemination.

Differential Impact of COVID-19 on the Use of Tele-mental Health Among Veterans Living in Urban or Rural Areas.

OBJECTIVE: The authors examined the use of Veterans Affairs Video Connect (VVC) for mental health care by rural and urban veterans and the impact of the COVID-19 pandemic on patterns of VVC use. METHODS: Data from 557,668 rural and 1,384,093 urban veterans (collected July 2019-October 2020) from the Veterans Health Administration Corporate Data Warehouse were examined with interrupted time-series models to determine rural versus urban VVC use before and during the initial 7 months of the pandemic. RESULTS: Before COVID-19, rates of VVC use as percentages of all mental health care were higher among rural veterans. After implementation of pandemic restrictions, rural veteran VVC use continued to increase, but this increase was surpassed by that of urban veterans. CONCLUSIONS: These findings highlight the need to monitor emerging disparities in telehealth use and to encourage and support use of VVC and access to mental health care for all veterans, particularly those experiencing barriers to care.

Veteran stroke survivors' lived experiences after being discharged home: a phenomenological study.

BACKGROUND: Stroke is a leading cause of disability in adults and third cause of death in the United States. Survivors face challenges postdischarge, including risks in self-management (SM) following prescribed regimens. Although SM education can help develop skills to control risk factors for stroke recurrence, little is known about lived experiences of patients adopting SM. AIMS: To examine Veterans' lived poststroke experiences after discharge and their experiences in SM goal setting/attainment. METHODS: Patients within one year of discharge from a Veterans Administration Medical Center in the United States with two risk factors for stroke recurrence were enrolled and received an SM workbook. Eight patients were interviewed (six males, two females; mean age 62: range 45-80). Part I concerned lived experience. Part II described experiences with goal setting and attainment. Data were analyzed inductively, identifying common experiences. Deductive analysis described goal setting and attainment. Transcript reviews identified SM themes and strategies. RESULTS: Lived experiences included 1) uncertainty about life, 2) anger and frustration, and 3) healthcare system challenges. Coping skills and setting goals to manage risks were critical for physical and emotional functioning. CONCLUSIONS: SM coping and goal setting aided recovery and improved life quality among Veterans after stroke. SM interventions assisted in regaining physical and emotional function. Findings may help in design of interventions for survivors, using SM and goal setting and attainment.IMPLICATIONS FOR REHABILITATIONSeveral implications for clinical practice were identified:Providers should acknowledge Veterans' challenges and struggles after their stroke and help Veterans to re-establish social identity, enhance self-esteem and improve mood.More emphasis should be given to the Veterans' caregivers' availability and willingness to help with their loved one's recovery, work reinstatement status and financial struggles.Recognition of the importance of the social context of recovery after a stroke is important, as nonmedical social interaction is often overlooked.Improvements are needed in the area of providers working with social workers and physical, occupational and mental health therapists to arrange more inpatient and outpatient treatments, including more frequent home visits.Veterans should be strongly encouraged to attend self-management diabetes education classes and smoking cessation and weight-loss programs offered for free within the Veterans Health Administration system.Self-management strategies using goal-setting and attainment concepts may assist individuals with stroke to regain physical and emotional functions, subsequently preventing another stroke.

Veteran adherence to oral versus injectable AUD medication treatment.

INTRODUCTION: AUD medication treatment has been shown to improve outcomes compared with placebo when confined to per-protocol analysis. The same outcomes, however, have not always been maintained in intent-to-treat analysis, thus suggesting adherence may have a significant impact on efficacy outcomes. There is conflicting evidence present in the literature comparing adherence to oral versus injectable AUD pharmacotherapy and a paucity of information in the veteran population on risk factors for low adherence. METHODS: The primary end point of this retrospective chart review was to determine whether adherence rates differ between oral and injectable AUD treatments in veterans during the first year of treatment (at 3, 6, 9, and 12 months) using the portion of days covered model. Secondary end points were to determine differing characteristics between patients with high versus low adherence and compare alcohol-related readmission rates and discontinuation rates between groups. RESULTS: Adherence to injectable extended-release (XR) naltrexone was significantly higher than oral naltrexone at all time points and was significantly higher than disulfiram at 3, 6, and 9 months, but it was not significantly different from acamprosate at any time point. At months 9 and 12, acamprosate had significantly higher adherence compared with oral naltrexone. Patients with higher adherence were seen more frequently in the mental health clinic and had previously tried more AUD medications. The discontinuation rates and alcohol-related admission rates were not significantly different between groups at 1 year. DISCUSSION: XR naltrexone may improve adherence rates compared with oral naltrexone or disulfiram, but not acamprosate based on these outcomes. Patients may have increased adherence if they are seen more often in clinic and have trialed more AUD medications.

Resource Use by Hospital Type for Frequent Inpatient Pediatric Conditions.

BACKGROUND: Children's hospitals (CHs) deliver care to underserved, critically ill, and medically complex patients. However, non-CHs care for the majority of children with frequently occurring conditions. In this study, we aimed to examine resource use across hospitals where children receive care for frequent inpatient conditions. METHODS: This was a cross-sectional, observational analysis of pediatric hospitalizations for 8 frequent inpatient conditions (pneumonia, asthma, bronchiolitis, mood disorders, appendicitis, epilepsy, skin and soft tissue infections, and fluid and electrolyte disorders) in the 2016 Kids' Inpatient Database. Primary outcomes were median length of stay (LOS) and median total cost. The primary independent variable was hospital type: nonchildren's, nonteaching; nonchildren's, teaching (NCT); and freestanding CHs. Multivariable linear regression was used to assess differences in mean LOS and costs. RESULTS: There were 354 456 pediatric discharges for frequent inpatient conditions. NCT hospitals cared for more than one-half of all frequent inpatient conditions. CHs and NCT hospitals cared for the majority of patients with higher illness severity and medical complexity. After controlling for patient and hospital factors, discharges for frequent inpatient conditions at CHs had 0.48% longer mean LOS and 61% greater costs compared with NCT hospitals (P < .01). CONCLUSIONS: CHs revealed higher estimated costs in caring for frequent inpatient conditions despite controlling for patient- and hospital-level factors but also cared for higher illness severity and medical complexity. Further research is warranted to explore whether we lack sufficient measures to control for patient-level factors and whether higher costs are justified by the specialized care at CHs.

FLOW: Early results from a clinical demonstration project to improve the transition of patients with mental health disorders back to primary care.

Access to mental health (MH) care is of paramount concern to U.S. health care delivery systems, including the Veterans Health Administration. To improve access, there is a need to better focus existing MH resources toward care for those most in need of specialty-level MH treatment. This article provides early results of Project FLOW's (not an acronym) approach to developing and evaluating electronic medical record (EMR)-based criteria to identify clinically stable patients and promote their effective transition from specialty MH back to primary care (PC). Implementation utilized a blended facilitation approach consistent with Integrated Promoting Action on Research Implementation in Health Services (iPARIHS). The Reach Effectiveness Adoption Implementation Maintenance (RE-AIM) framework guided measurement of implementation outcomes. During FLOW, 424 unique MH patients transitioned from MH to PC; of those, only 9 (2.1%) returned to MH after that transition. Most of those patients (n = 335; 79.0%) were first identified on the MH FLOW report, but 89 (21.0%) were other MH patients. The total number of patients discharged due to recovery or stabilization was 411. The 335 patients represent 21.3% of all unique patients (n = 1,566) who met the EMR criteria during the project. The 411 recovered/stabilized patients are 16.4% of all unique MH patients (n = 2,504) treated at the site. These early results suggest that this EMR-based system, combined with sound clinical practices, can be used to identify MH patients who are candidates for transition and foster their effective transition to care management in PC. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

History of Suicide Attempts and COVID-19 Infection in Veterans with Schizophrenia or Schizoaffective Disorder: Moderating Effects of Age and Body Mass Index.

INTRODUCTION: Relative to the general population, patients with schizophrenia or schizoaffective disorder have higher rates of suicide attempts and mortality from COVID-19 infection. Therefore, determining whether a history of suicide attempt is associated with COVID-19 in patients with schizophrenia or schizoaffective disorder has implications for COVID-19 vulnerability stratification in this patient population. METHODS: We carried out cross-sectional analyses of electronic health records of veterans with a diagnosis of schizophrenia or schizoaffective disorder that received treatment at any United States Veterans Affairs Medical Center between January 1, 2020, and January 31, 2021. We used logistic regression to estimate unadjusted and adjusted (including age, sex, race, marital status, body mass index (BMI), and a medical comorbidity score) odds ratios (ORs) for COVID-19 positivity in suicide attempters relative to nonattempters. RESULTS: A total of 101,032 veterans (mean age 56.67 ± 13.13 years; males 91,715 [90.8%]) were included in the analyses. There were 2,703 (2.7%) suicide attempters and 719 (0.7%) patients were positive for COVID-19. The association between history of suicide attempt and COVID-19 positivity was modified by age and BMI, such that the relationship was only significant in patients younger than 59 years, and in obese (BMI ≥30) patients (adjusted OR 3.42, 95% CI 2.02-5.79 and OR 2.85, 95% CI 1.65-4.94, respectively). CONCLUSIONS: Higher rates of COVID-19 in young or obese suicide attempters with a diagnosis of schizophrenia or schizoaffective disorder might be due to the elevated risk for the infection in this subgroup of patients.

Mental and Physical Health Correlates of Tobacco Use Among Transgender Veterans of the Iraq and Afghanistan Conflicts.

The aim of the study was to identify prevalence of tobacco use and associated correlates in a cohort of 332 transgender veterans who served in Iraq and Afghanistan. We identified tobacco use, nicotine replacement therapies (NRTs), and clinical comorbidities from veteran medical record databases. We compared differences in use and clinical comorbidities, using nonparametric bivariate analyses. Approximately 67% of veterans were using tobacco, with 25% receiving NRTs. Major depressive disorder, alcohol-use disorders, and drug-use disorders were significantly higher in transgender women tobacco users than in nonusers. Results emphasize future research and clinical intervention necessary to address these health conditions in this vulnerable subgroup.

Role of deployment-related mTBI and resilience in perceived participation limitations among Veterans.

Problems with social functioning are common following combat deployment, and these may be greater among individuals with a history of traumatic brain injury (TBI). The present investigation examined the impact of mild TBI (mTBI), deployment-related characteristics, and resilience on perceived participation limitations among combat Veterans. This was a cross-sectional study of 143 participants with a history of at least one deployment-related mTBI (TBI group) and 80 without a history of lifetime TBI (Comparison group). Self-report measures of participation, resilience, posttraumatic stress disorder (PTSD) symptoms, and combat exposure were administered. In addition, each participant completed a structured interview to assess lifetime TBI history. The groups did not differ in basic demographics, but significant differences were found for perceived limitations in participation, the presence of PTSD symptoms, and intensity of combat exposure. A stepwise model indicated a significant effect of resilience on reported limitations in participation (adjusted R2 = 0.61). Individuals with higher resiliency reported a higher degree of social participation, and this effect was stronger in the TBI group. Deployment-related characteristics, including intensity of combat exposure, did not have a significant effect (adjusted R2 = 0.28) on social participation. The role of resilience should be recognized within post-deployment transition and rehabilitation programs.