A Randomized Controlled Trial of a Pay-for-Performance Initiative to Reduce Costs of Care for High-Need Psychiatric Patients.

OBJECTIVE: Pay-for-performance (P4P) initiatives hold promise for improving health care delivery but are rarely applied to behavioral health or tested in randomized controlled trials (RCTs). This RCT examined the effectiveness of a P4P initiative to reduce total cost of 24-hour care among patients with high needs for psychiatric care in a large county in California. METHODS: From August 2016 to March 2022, a total of 652 adult residents of Santa Clara County, California, were enrolled in a P4P initiative (mean±SD age=46.7±13.3 years, 61% male, 51% White, and 60% diagnosed as having a bipolar or psychotic disorder). Participants were randomly assigned to usual full-service partnerships from the county (N=327) or a comparable level of care from a contractor who agreed to a schedule of financial penalties and rewards based on whether enrollees (N=325) used more or less care than a historical cohort of similar county patients. The primary outcome was total cost of 24-hour psychiatric services. Secondary outcomes were costs of each of the 24-hour care services. RESULTS: The proportion of the total sample that used 24-hour psychiatric services decreased over the 36-month study period. Intent-to-treat analyses revealed no differences between the two study conditions in total care costs during the follow-up period. No significant care utilization differences were observed between the two conditions in most of the individual 24-hour services. CONCLUSIONS: A P4P initiative for high-need patients was no more effective than usual care for reducing costs of 24-hour psychiatric care.

Peer specialist-led interventions in primary care at the Veterans Health Administration: An integrative review.

The Veterans Health Administration (VHA) currently employs over 1,300 peer specialists-veterans with lived experience of mental illness who are in recovery and have been trained to provide support to other veterans experiencing these issues. VHA peer specialists have largely been employed in behavioral health settings. In 2014, VHA began to employ peer specialists in primary care settings via the peers in Patient Aligned Care Team (PACT) program, and congressional legislation was passed to expand this program in 2022. In light of this expansion, it is important to evaluate the effectiveness of interventions provided in the Peers in PACT program. This integrative review of studies of peer specialist-led interventions in VHA primary care includes 13 articles with 11 unique studies represented in these articles. These studies targeted mental health symptoms, substance use, health/well-being, and health/treatment engagement. Seven described single-arm studies, three described two-arm studies with a treatment as usual control group, and three described two-arm studies with an active control group. The majority of these studies demonstrated statistically significant improvements on at least one main outcome. Seven studies also included qualitative interviews with veterans; several common themes emerged, including the importance of working with a veteran peer with shared lived experiences, and finding peers helpful in providing accountability, motivation, encouragement, emotional support, resources, and assistance navigating VA health care. Recommendations for future research on the peers in PACT program are discussed, including a need for more RCTs with active controls. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Medical-surgical patients with untreated hazardous drinking: Randomized controlled trial of the DO-MoST intervention to improve health outcomes over 12-month follow-up.

INTRODUCTION: High prevalence and harmful consequences of hazardous drinking among medical-surgical patients underscore the importance of intervening with drinking to improve patients' health. This study evaluated a novel intervention, "Drinking Options - Motivate, Shared Decisions, Telemonitor" (DO-MoST). METHODS: In a randomized design, 155 medical-surgical patients with untreated hazardous drinking were assigned to enhanced usual care or DO-MoST, and followed 3, 6, and 12 months later. We conducted intent-to-treat and per-protocol analyses. RESULTS: For the primary outcome, percent days of alcohol abstinence in the past 30 days, intent-to-treat analyses did not find superior effectiveness of DO-MoST. However, per-protocol analyses found abstinence increased between 3 and 12 months among participants assigned to DO-MoST who engaged with the intervention (n=46). Among DO-MoST-assigned participants who did not engage (n=27), abstinence stayed stable during follow-up. Group comparisons showed an advantage on abstinence for Engaged compared to Non-Engaged participants on change over time. Intent-to-treat analyses found that DO-MoST was superior to usual care on the secondary outcome of physical health at 12 months; per-protocol analyses found that Engaged DO-MoST-assignees had better physical health at 12 months than Non-Engaged DO-MoST-assignees. DO-MoST-assignees had lower odds of receiving substance use care during follow-up than usual care-assignees. DISCUSSION: Patients engaged in DO-MoST showed a greater degree of abstinence and better physical health relative to the non-engaged or usual care group. DO-MoST may be a source of alcohol help in itself rather than only a linkage intervention. Work is needed to increase DO-MoST engagement among medical-surgical patients with untreated hazardous drinking.

Virtual reality mindfulness training for veterans in residential substance use treatment: Pilot study of feasibility and acceptability.

BACKGROUND: Mindfulness training is effective in recovery from substance use disorders; however, adoption can be difficult due to environmental and personal distractions. Virtual reality (VR) may help overcome these challenges by providing an immersive environment for practicing mindfulness, but there is currently limited knowledge regarding patient and provider perceptions of VR-based tools. OBJECTIVE: The present study investigated the feasibility and acceptability of VR mindfulness training for veterans in residential substance use treatment as well as potential benefits of VR mindfulness interventions in this population. We conducted a pilot feasibility/acceptability study as a first step toward conducting a larger randomized controlled trial (RCT). METHODS: The study recruited participants (N = 32) from a 30-day residential substance use program and collected both qualitative and quantitative feedback on the VR mindfulness intervention using a mixed-methods approach. Patients (n = 20) and providers (n = 12) rated the acceptability, usability, and satisfaction of the intervention. Using a within-subjects design, patients provided pre-post emotion ratings and reported on state mindfulness and VR presence after completing a single-session self-guided VR mindfulness intervention. Patients provided qualitative interview data on their overall impressions, while providers gave the same information via survey. RESULTS: Both patients and providers reported high satisfaction and confidence in the intervention. Moreover, within subjects t-tests showed that patients experienced significant reductions in negative affect and significant increases in positive affect from pre-post, along with high levels of state mindfulness and presence. Results of thematic analysis revealed that the intervention facilitated focused attention on the present moment, induced a state of calm and relaxation, and reduced negative thoughts and emotions. Participants requested improvements such as better integration of audiovisual elements, a more personalized and longer intervention, and more comfortable fitting headset. Finally, the intervention presented with several advantages compared to other mindfulness experiences including reduced distractions and a sense of safety and privacy. CONCLUSIONS: Self-guided VR mindfulness intervention is feasible and acceptable to patients and providers. VR mindfulness training provides an immersive experience that uplifts mood and reduces distractions. VR may provide a scaffolding tool to set the stage for deepening mindfulness skills. Results of the present study could inform further development and tailoring for future interventions.

For whom are treatments for criminal recidivism effective? Moderator effects from a randomized controlled trial of justice-involved veterans.

OBJECTIVE: In a recent trial, moral reconation therapy (MRT)-a cognitive-behavioral intervention for criminal recidivism-was not more effective than usual care (UC) for veterans in behavioral health treatment. To determine for whom treatments of recidivism are most effective, we tested if recency of criminal history or psychopathic traits moderated MRT's effects on outcomes. METHOD: In a multisite trial, 341 veterans (95.3% male; 57.8% White/Non-Hispanic) with a criminal history who were admitted to behavioral health treatment programs were randomly assigned to UC or UC + MRT and followed at 6- and 12-months. Incarceration (yes/no) or criminal conviction (yes/no) in the year prior to enrollment and psychopathic traits at baseline (median split) were prespecified as moderators of treatment effects on primary (criminal thinking, criminal associations) and secondary outcomes (legal, employment, and family/social problems; substance use problems and days of use). RESULTS: Among veterans incarcerated in the year prior to enrollment, MRT (vs. UC) was associated with greater reductions in criminal associations (6 months) and days drinking or using drugs (12 months). Among those convicted in the year prior to enrollment, MRT (vs. UC) was associated with greater reductions in employment problems (12 months) and days drinking or using drugs at each follow-up. For those high in psychopathic traits, MRT (vs. UC) was associated with greater reductions in days drinking or using drugs at each follow-up. CONCLUSIONS: For veterans in behavioral health treatment with recent criminal histories and high in psychopathic traits, MRT may be effective for reducing risk for criminal recidivism. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Hazardous Drinking Interventions Delivered During Medical-Surgical Care: Patient and Provider Views.

Addressing hazardous drinking during medical-surgical care improves patients' health. This formative evaluation examined patients' consideration of options to change drinking and engage in treatment. It explored whether interventions such as "DO-MoST" overcome treatment barriers. We interviewed 20 medical-surgical patients with hazardous drinking in a trial of DO-MoST, and 16 providers. Analyses used a directed content approach. Patients were receptive to and comfortable discussing drinking during medical-surgical care. Interventions like DO-MoST (patient-centered, motivational approach to shared decision making) addressed some treatment barriers. Patients and providers viewed such interventions as helpful by building a relationship with a psychologist who facilitated self-awareness of drinking behaviors, and discussing connections between alcohol- and physical health-related problems and potential strategies to address drinking. However, both groups expressed concerns about individual and system-level barriers to long-term change. Interventions like DO-MoST bridge the gap between the patient's medical treatment episode and transition to other health care settings. TRIAL REGISTRATION: The study is registered on ClinicalTrials.gov (ID: NCT03258632).

Patterns and predictors of mental health service use among older veterans with alcohol use disorder who received a video-enabled tablet.

Objectives: Video-based telehealth may expand access to mental health services among older veterans with alcohol use disorder (AUD). We examined the modalities through which mental health services were rendered, and predictors of video visits before and after video-enabled tablet receipt from the Veterans Health Administration. Method: 11,210 veterans aged 60 or older with a diagnosis of AUD who received a tablet between 1 April 2020 and 25 October 2021 were identified. The electronic health record was used to characterized encounters by modality of mental health care delivery in the six months pre/post tablet receipt. Logistic regression examined predictors of a video visit for mental health. Results: Phone was the most common modality; however, the proportion of video encounters increased from 8.7% to 26.2% after tablet receipt. Individuals who were older, male, and had more physical health conditions, were less likely to have a video visit. Individuals who were married, resided in urban areas, had a history of housing instability, and had more mental health conditions, were more likely to have a video visit. Conclusion: Video-enabled tablets may help older adults with AUD overcome access barriers to mental health services, although targeted support for certain groups may be necessary.

A Research Agenda for Criminal Justice Involvement Among U.S. Veterans.

INTRODUCTION: A substantial proportion of adults in the U.S. criminal justice system are military veterans. Justice-involved veterans are of particular public concern given their service to the country and the high rates of health and social problems in the general veteran population. This article describes the development of a national research agenda for justice-involved veterans. MATERIALS AND METHODS: In the summer of 2022, the VA National Center on Homelessness among Veterans in partnership with the VA Veterans Justice Programs Office convened a national group of subject matter experts and stakeholders across three listening sessions that included 40-63 attendees per session. These sessions were recorded, and transcriptions of all sessions and chats were synthesized to generate a preliminary list of 41 agenda items. The Delphi method involving two rounds of ratings from subject matter experts was used to develop consensus. RESULTS: The final research agenda consists of 22 items covering five domains: Epidemiology and knowledge of the population, treatment and services, systems and systems interface, methodology and research resources, and policies. CONCLUSIONS: The intent of sharing this research agenda is to spur stakeholders to conduct, collaborate, and support further study in these areas.

Criminogenic Needs and Legal Problem Severity Among Legal System Involved Veterans.

BACKGROUND: Many veterans seeking behavioral health services have history of criminal-legal involvement. Research on criminogenic needs of legal system involved veterans is burgeoning. However, most research has relied on cross-sectional examinations and the vast majority of prior work has focused assessment on just one criminogenic need per study. METHODS: The present study evaluated seven key criminogenic needs of legal system involved veterans (N = 341) enrolled in one of three U.S. Veterans Health Administration residential behavioral health treatment programs. Criminogenic needs and legal problem severity were assessed at baseline, and at 6 months and 12 months post-baseline. Directionality of associations between participants' criminogenic needs and legal problem severity was examined using latent change score models. RESULTS: Results revealed having more antisocial associates at a previous timepoint was associated with greater subsequent improvements in legal problem severity ($\beta $=-0.01, P < 0.02) and greater improvements in legal problem severity predicted greater subsequent improvements in alcohol problem severity ($\beta $=0.13, P < 0.01). CONCLUSIONS: In one of the most comprehensive single-study assessments of criminogenic needs among a sample of legal system involved veterans, results highlight links between antisocial associates and alcohol problem severity with legal problem severity.

Sociodemographic Differences in the Impacts of Video-Enabled Tablets on Psychotherapy Usage Among Veterans.

OBJECTIVE: To examine potential health disparities due to a broad reliance on telehealth during the COVID-19 pandemic, the authors studied the impact of video-enabled tablets provided by the U.S. Department of Veterans Affairs (VA) on psychotherapy usage among rural versus urban, Black versus White, and female versus male veterans. METHODS: Psychotherapy usage trends before and after onset of the COVID-19 pandemic were examined among veterans with at least one mental health visit in 2019 (63,764 tablet recipients and 1,414,636 nonrecipients). Adjusted difference-in-differences and event study analyses were conducted to compare psychotherapy usage among tablet recipients and nonrecipients (March 15, 2020-December 31, 2021) 10 months before and after tablet issuance. Analyses were stratified by rurality, sex, and race. RESULTS: Adjusted analyses demonstrated that tablet receipt was associated with increases in psychotherapy visit frequency in every patient group studied (rural, 27.4%; urban, 24.6%; women, 30.5%; men, 24.4%; Black, 20.8%; White, 28.1%), compared with visits before tablet receipt. Compared with men, women had statistically significant tablet-associated psychotherapy visit increases (video visits, 1.2 per year; all modalities, 1.0 per year). CONCLUSIONS: VA-issued tablets led to increased psychotherapy usage for all groups examined, with similar increases found for rural versus urban and Black versus White veterans and higher increases for women versus men. Eliminating barriers to Internet access or device ownership may improve mental health care access among underserved or historically disadvantaged populations. VA's tablet program offers insights to inform policy makers' and health systems' efforts to bridge the digital divide.

Disentangling the relationship between posttraumatic stress disorder, criminogenic risk, and criminal history among veterans.

OBJECTIVE: Posttraumatic stress disorder (PTSD) is positively associated with involvement in the criminal justice system among veterans. Research that examines whether this association is confounded by risk factors ("criminogenic needs") from the risk-need-responsivity model of correctional rehabilitation can inform risk management with this population. HYPOTHESES: We hypothesized that (a) veterans with probable PTSD would score higher on all criminogenic needs than veterans without PTSD and (b) probable PTSD would be associated with criminal history but not after accounting for criminogenic needs. METHOD: We conducted secondary analyses of data from 341 veterans (95.3% male; 57.8% White/non-Hispanic/Latinx; Mage = 46.2 years) with a history of criminal justice system involvement who were admitted to mental health residential treatment. At treatment entry, participants completed interviews to assess criminal history, risk-need-responsivity-based criminogenic needs, and PTSD symptom severity. Cross-sectional analyses tested for differences between participants with and without probable PTSD on criminogenic needs and criminal history, and a multiple regression model examined the unique contributions of probable PTSD and criminogenic needs on criminal history. RESULTS: The majority of the sample (74%, n = 251) met probable criteria for PTSD. Compared with veterans without PTSD, those with probable PTSD scored significantly higher on criminogenic needs of antisocial personality patterns, antisocial cognitions, antisocial associates, substance use, and family/marital dysfunction but did not differ on multiple indices of criminal history (Cohen's ds = 0.60-0.86). In the regression model, higher age (ß = 0.52, p < .001) and higher scores on measures of antisocial personality patterns (ß = 0.19, p = .04) and antisocial cognitions (ß = 0.22, p = .02) were significantly associated with higher scores on a criminal history index. CONCLUSIONS: The findings suggest that veterans with probable PTSD may score higher on a number of criminogenic needs that are known to be drivers of recidivism. An approach that integrates trauma-informed and risk-need-responsivity principles to address veterans' dynamic criminogenic and clinical needs may be critical to risk management in this population. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Cannabis Use Among U.S. Military Veterans Following Residential Substance Use Disorder Treatment.

INTRODUCTION: Use rates of cannabis, a substance associated with a host of comorbid physical and mental health concerns, continue to rise for military veterans. Despite this prevalence, descriptive patterns of use among veterans and research on treatment factors that predict cannabis outcomes are lacking. This study aimed to conduct a descriptive profile of veterans who endorse cannabis use, compare veterans endorsing cannabis use to those who do not endorse use, and investigate what factors (other substance use, psychiatric symptoms, and treatment outcomes) predicted return to cannabis use following residential treatment. MATERIALS AND METHODS: The study was a secondary data analysis of a longitudinal sample of U.S. military veterans (N = 200, 193 males, Mage = 50.14, SD = 9) participating in residential substance use disorder treatment through a Veterans Affairs medical center. Interview, survey, and electronic health data were collected over 12 months. Analyses included descriptive and frequency statistics to identify patterns in cannabis use behaviors and motives, independent t-tests to examine differences between the cannabis-using group and non-using group, and a series of univariate logistic regressions to examine potential predictors for cannabis use after treatment discharge. RESULTS: Lifetime cannabis use was common among veterans (77.5%), and 29.5% reported use during the study. On average, veterans had made one quit attempt before treatment entry. Veterans who endorsed cannabis use consumed more alcohol in the past 30 days at baseline and reported less impulse control and less confidence in maintaining abstinence at discharge. Length of stay in the residential program and no diagnosis of Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV cannabis use disorder criteria predicted post-treatment cannabis use such that veterans who remained in the program longer were more likely to abstain from cannabis use following treatment, and those who did not meet DSM-IV cannabis use disorder criteria were more likely to use following treatment. CONCLUSIONS: Identification of relevant risk factors and treatment processes, such as impulse control, confidence in treatment, and length of stay in treatment, provides practical recommendations for future intervention efforts. This study calls for further examination of cannabis use outcomes among veterans, particularly those participating in substance use treatment.

Impact of VA's video telehealth tablets on substance use disorder care during the COVID-19 pandemic.

BACKGROUND: Telehealth has the potential to improve health care access for patients but it has been underused and understudied for examining patients with substance use disorders (SUD). VA began distributing video-enabled tablets to veterans with access barriers in 2016 to facilitate participation in home-based telehealth and expanded this program in 2020 due to the coronavirus COVID-19 pandemic. OBJECTIVE: Examine the impact of VA's video-enabled telehealth tablets on mental health services for patients diagnosed with SUD. METHODS: This study included VA patients who had ≥1 mental health visit in the calendar year 2019 and a documented diagnosis of SUD. Using difference-in-differences and event study designs, we compared outcomes for SUD-diagnosed patients who received a video-enabled tablet from VA between March 15th, 2020 and December 31st, 2021 and SUD-diagnosed patients who never received VA tablets, 10 months before and after tablet-issuance. Outcomes included monthly frequency of SUD psychotherapy visits, SUD specialty group therapy visits and SUD specialty individual outpatient visits. We examined changes in video visits and changes in visits across all modalities of care (video, phone, and in-person). Regression models adjusted for several covariates such as age, sex, rurality, race, ethnicity, physical and mental health chronic conditions, and broadband coverage in patients' residential zip-code. RESULTS: The cohort included 21,684 SUD-diagnosed tablet-recipients and 267,873 SUD-diagnosed non-recipients. VA's video-enabled tablets were associated with increases in video visits for SUD psychotherapy (+3.5 visits/year), SUD group therapy (+2.1 visits/year) and SUD individual outpatient visits (+1 visit/year), translating to increases in visits across all modalities (in-person, phone and video): increase of 18 % for SUD psychotherapy (+1.9 visits/year), 10 % for SUD specialty group therapy (+0.5 visit/year), and 4 % for SUD specialty individual outpatient treatment (+0.5 visit/year). CONCLUSIONS: VA's distribution of video-enabled tablets during the COVID-19 pandemic were associated with higher engagement with video-based services for SUD care among patients diagnosed with SUD, translating to modest increases in total visits across in-person, phone and video modalities. Distribution of video-enabled devices can offer patients critical continuity of SUD therapy, particularly in scenarios where they have heightened barriers to in-person care.

Stand Down-Think Before You Drink: protocol for an effectiveness-implementation trial of a mobile application for unhealthy alcohol use with and without peer support.

INTRODUCTION: Mobile apps can increase access to alcohol-related care but only if patients actively engage with them. Peers have shown promise for facilitating patients' engagement with mobile apps. However, the effectiveness of peer-based mobile health interventions for unhealthy alcohol use has yet to be evaluated in a randomised controlled trial. The goal of this hybrid I effectiveness-implementation study is to test a mobile app ('Stand Down-Think Before You Drink'), with and without peer support, to improve drinking outcomes among primary care patients. METHODS AND ANALYSIS: In two US Veterans Health Administration (VA) medical centres, 274 primary care patients who screen positive for unhealthy alcohol use and are not currently in alcohol treatment will be randomised to receive usual care (UC), UC plus access to Stand Down (App), or UC plus Peer-Supported Stand Down (PSSD-four peer-led phone sessions over the initial 8 weeks to enhance app engagement). Assessments will occur at baseline and 8-, 20- and 32-weeks postbaseline. The primary outcome is total standard drinks; secondary outcomes include drinks per drinking day, heavy drinking days and negative consequences from drinking. Hypotheses for study outcomes, as well as treatment mediators and moderators, will be tested using mixed effects models. Semi-structured interviews with patients and primary care staff will be analysed using thematic analysis to identify potential barriers and facilitators to implementation of PSSD in primary care. ETHICS AND DISSEMINATION: This protocol is a minimal risk study and has received approval from the VA Central Institutional Review Board. The results have the potential to transform the delivery of alcohol-related services for primary care patients who engage in unhealthy levels of drinking but rarely seek treatment. Study findings will be disseminated through collaborations with healthcare system policymakers as well as publications to scholarly journals and presentations at scientific conferences. TRIAL REGISTRATION NUMBER: NCT05473598.

Integrating data analytics, peer support, and whole health coaching to improve the health outcomes of homeless veterans: Study protocol for an effectiveness-implementation trial.

BACKGROUND: Homelessness is a strong determinant of acute care service utilization (inpatient hospitalization, emergency department visits) among US adults. Data analytics, peer support, and patient-centered approaches can collectively offer high-quality care for homeless patients who frequently utilize acute care ("super utilizers"). However, few outpatient programs have integrated these components and tested their effectiveness for this patient population. OBJECTIVE: To test the effectiveness and implementation potential of a novel intervention that integrates data analytics with peers trained in whole health coaching ("Peer Whole Health") to reduce use of acute care among homeless adults. METHODS: Using a randomized controlled trial design at two US Veterans Health Administration Medical Centers, we plan to enroll 220 veterans in primary care on VHA's Homeless Registry who are flagged on a super-utilizer clinical dashboard. Participants will complete a baseline interview, be randomized to Enhanced Usual Care (EUC; primary care and data analytics) or EUC plus 18 sessions of Peer Whole Health over 6 months, and be re-interviewed at 3, 6, and 9 months. Qualitative interviews with primary care staff and patients will identify facilitators and barriers to more widespread implementation of the intervention. DISCUSSION: The primary hypothesis is that those who receive the intervention will have fewer total days of all-cause hospitalization. If confirmed, the findings can provide healthcare systems that serve homeless super-utilizers with a high-value approach to care that can be integrated into primary care services and reduce overall costs for these patients. CLINICAL TRIAL REGISTRATION: The study is registered with ClinicalTrials.gov (NCT05176977).

Peer-supported mobile mental health for veterans in primary care: A pilot study.

One in four veteran primary care patients suffers from a mental health condition; however, most do not receive any treatment for these problems. Mobile health (mHealth) can overcome barriers to care access, but poor patient engagement limits the effectiveness and implementation of these tools. Peers may facilitate patient engagement with mHealth. We designed a protocol for peers to support implementation of mobile mental health tools in primary care and tested the feasibility, acceptability, and clinical utility of this approach. Thirty-nine patients across two Veterans Affairs sites who screened positive for depression during a primary care visit and were not currently in mental health treatment were enrolled. Participants were scheduled for four phone sessions with a peer over 8 weeks and introduced to five mobile apps for a range of transdiagnostic mental health issues (stress, low mood, sleep problems, anger, and trauma). Pre/post phone interviews using quantitative and qualitative approaches assessed participants' self-reported app use, satisfaction with the intervention, symptom change (stress, anxiety, depression, insomnia), and progress with personal health goals. On average, patients reported using 3.04 apps (SD = 1.46). Per the Client Satisfaction Questionnaire, global satisfaction with the intervention was high (M = 25.71 out of 32, SD = 3.95). Pre to post participants reported significant improvements in their level of stress, based on a quantitative measure (p = .008), and 87% reported progress on at least one personal health goal. Findings support the feasibility, acceptability, and clinical utility of peer-supported mobile mental health for veterans in primary care. A randomized controlled trial of an adaptive version of this intervention is recommended. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Peer support and whole health coaching to address the healthcare needs of homeless veterans: a pilot study.

BACKGROUND: Homelessness is a robust social determinant of acute care service utilization among veterans. Although intensive outpatient programs have been developed for homeless veterans who are high utilizers of acute care ("super utilizers"), few scalable programs have been implemented to address their needs. OBJECTIVE: Describe the development and pilot testing of a novel intervention that integrates the roles of a peer and whole health coach ("Peer-WHC") in coordination with primary care teams to reduce homeless veterans' frequent use of acute care. DESIGN: Single-arm trial in three outpatient primary care clinics at a Veterans Health Administration (VHA) medical center; pre/post design using mixed-methods. PARTICIPANTS: Twenty veterans from VHA's homeless registry who were super-utilizers of acute care and enrolled in primary care. INTERVENTION: Weekly health coaching sessions with a peer over 12 weeks, including discussions of patients' health care utilization patterns and coordination with primary care. MAIN MEASURES: Rates of session attendance and intervention fidelity, patient-reported satisfaction and changes in patient engagement and perceptions of health, pre/post utilization of acute and supportive care services, and qualitative interviews with multiple stakeholders to identify barriers and facilitators to implementation. KEY RESULTS: On average, patients attended 6.35 sessions (SD = 3.5, Median = 7). Satisfaction scores (M = 28.75 out of 32; SD = 2.79) exceeded a priori benchmarks. Patients' perceptions of health improved from pre to post [t(df)=-2.26(14), p = 0.04]. In the 3-months pre/post, 45% (n = 9) and 15% (n = 3) of patients, respectively, were hospitalized. Qualitative feedback from patients, providers, and peers and fidelity metrics suggested value in increasing the length of the intervention to facilitate goal-setting with patients and coordination with primary care. CONCLUSION: Findings support the feasibility, acceptability, and utility of Peer-WHC to address the healthcare needs of homeless veterans. A future trial is warranted to test the impact of Peer-WHC on reducing these patients' frequent use of acute care.

Substance use and criminogenic thinking: Longitudinal latent class analysis of veterans with criminal histories.

INTRODUCTION: The objective of this study was to inform clinical practice by identifying distinct subgroups of US veterans with criminal histories in residential mental health treatment. The study characterized veteran patients on their alcohol and drug use and criminogenic thinking. We also examined predictors and outcomes of subgroup membership. METHODS: Participants were 341 veterans with a criminal history in residential mental health care. A parallel latent growth trajectory model characterized participants' alcohol and drug use and criminogenic thinking at treatment entry and at 6- and 12-month follow-ups. RESULTS: The study identified four distinct classes: 53 % Normative Improvement, 27 % High Criminogenic Thinking, 11 % High Recurrence (of substance use), and 9 % High Drug Use. Compared to the Normative Improvement class, prior to treatment entry, patients in the High Recurrence class were less likely to be on parole or probation, and patients in the High Criminogenic Thinking class were more likely to be chronically homeless. Compared to the Normative Improvement class, at follow-ups, patients in the High Drug Use and High Criminogenic Thinking classes were more likely to recidivate, and patients in the High Drug Use class were more likely to report unstable housing. Depression scores were higher (nearly double) in the High Drug Use, High Recurrence, and High Criminogenic Thinking classes at follow-ups compared to the Normative Improvement class. CONCLUSIONS: That the Normative Improvement class entered mental health residential treatment with relatively low alcohol and drug use and criminogenic thinking, and sustained these low levels, suggests that treatment does not need to be broadened or intensified to improve these domains for these patients with criminal histories. In contrast, findings for the High Drug Use, High Recurrence, and High Criminogenic Thinking classes, which composed 47 % of the sample, suggest that more integrated and sustained treatment may be needed to reduce recidivism, depression, and homelessness among these patients.

A randomized controlled trial of moral reconation therapy to reduce risk for criminal recidivism among justice-involved adults in mental health residential treatment.

OBJECTIVE: Moral reconation therapy (MRT) is a cognitive-behavioral intervention to reduce risk for criminal recidivism. Despite being implemented widely in correctional settings, there are no randomized controlled trials of MRT, and its effectiveness for reducing recidivism among justice-involved adults in noncorrectional settings is unknown. METHOD: In a pragmatic trial, 341 justice-involved patients (95.3% male; 57.8% White/non-Hispanic) admitted to one of three mental health residential treatment programs were randomly assigned to usual care (UC) or UC plus two MRT groups per week for 12 weeks. Follow-ups were conducted at 6- and 12-month postbaseline (71.3% and 74.8% retention, respectively). Primary outcomes were criminal thinking and criminal associates. Secondary outcomes were legal problem severity, days incarcerated in the past 30, rearrested/charged (per official records), substance use, and employment and family/social problems. The study design, analysis, and outcomes were preregistered (ClinicalTrials.gov; ID: NCT02524171). RESULTS: Patients in both conditions improved over time on most outcomes. In intent-to-treat analyses, the rate of change in outcomes over time did not differ by condition, nor did the prevalence of being rearrested and charged within 1 year of baseline (UC = 20.2%, MRT = 24.9%; OR = 1.14; 95% CI [0.67, 1.94], p = .63). MRT engagement was low; 37% of those randomized to MRT received a minimum dose-that is, completed at least Step 3. In per-protocol analyses, this subgroup, relative to UC, improved more on criminal associates, days incarcerated, legal problem severity, and alcohol use severity. CONCLUSIONS: In this study, MRT was not more effective than UC at reducing recidivism risk for patients in mental health residential treatment. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Web-Based Problem-solving Training With and Without Peer Support in Veterans With Unmet Mental Health Needs: Pilot Study of Feasibility, User Acceptability, and Participant Engagement.

BACKGROUND: eHealth tools have the potential to meet the mental health needs of individuals who experience barriers to accessing in-person treatment. However, most users have less than optimal engagement with eHealth tools. Coaching from peer specialists may increase their engagement with eHealth. OBJECTIVE: This pilot study aims to test the feasibility and acceptability of a novel, completely automated web-based system to recruit, screen, enroll, assess, randomize, and then deliver an intervention to a national sample of military veterans with unmet mental health needs; investigate whether phone-based peer support increases the use of web-based problem-solving training compared with self-directed use; and generate hypotheses about potential mechanisms of action for problem-solving and peer support for future full-scale research. METHODS: Veterans (N=81) with unmet mental health needs were recruited via social media advertising and enrolled and randomized to the self-directed use of a web-based problem-solving training called Moving Forward (28/81, 35%), peer-supported Moving Forward (27/81, 33%), or waitlist control (26/81, 32%). The objective use of Moving Forward was measured with the number of log-ins. Participants completed pre- and poststudy measures of mental health symptoms and problem-solving confidence. Satisfaction was also assessed post treatment. RESULTS: Automated recruitment, enrollment, and initial assessment methods were feasible and resulted in a diverse sample of veterans with unmet mental health needs from 38 states. Automated follow-up methods resulted in 46% (37/81) of participants completing follow-up assessments. Peer support was delivered with high fidelity and was associated with favorable participant satisfaction. Participants randomized to receive peer support had significantly more Moving Forward log-ins than those of self-directed Moving Forward participants, and those who received peer support had a greater decrease in depression. Problem-solving confidence was associated with greater Moving Forward use and improvements in mental health symptoms among participants both with and without peer support. CONCLUSIONS: Enrolling and assessing individuals in eHealth studies without human contact is feasible; however, different methods or designs are necessary to achieve acceptable participant engagement and follow-up rates. Peer support shows potential for increasing engagement in web-based interventions and reducing symptoms. Future research should investigate when and for whom peer support for eHealth is helpful. Problem-solving confidence should be further investigated as a mechanism of action for web-based problem-solving training. TRIAL REGISTRATION: ClinicalTrials.gov NCT03555435; http://clinicaltrials.gov/ct2/show/NCT03555435.