The Importance of Autonomy and Performance Goals in Perceived Workload Among Behavioral Health Providers.

OBJECTIVE: The authors sought to assess workplace characteristics associated with perceived reasonable workload among behavioral health care providers in the Veterans Health Administration. METHODS: The authors evaluated perceived reasonable workload and workplace characteristics from the 2019 All Employee Survey (AES; N=14,824) and 2019 Mental Health Provider Survey (MHPS; N=10,490) and facility-level staffing ratios from Mental Health Onboard Clinical Dashboard data. Nine AES and 15 MHPS workplace predictors of perceived reasonable workload, 11 AES and six MHPS demographic predictors, and facility-level staffing ratios were included in mixed-effects logistic regression models. RESULTS: In total, 8,874 (59.9%) AES respondents and 5,915 (56.4%) MHPS respondents reported having a reasonable workload. The characteristics most strongly associated with perceived reasonable workload were having attainable performance goals (average marginal effect [AME]=0.10) in the AES and ability to schedule patients as frequently as indicated (AME=0.09) in the MHPS. Other AES characteristics significantly associated with reasonable workload included having appropriate resources, support for personal life, skill building, performance recognition, concerns being addressed, and no supervisor favoritism. MHPS characteristics included not having collateral duties that reduce care time, staffing levels not affecting care, support staff taking over some responsibilities, having spirit of teamwork, primary care-mental health integration, participation in performance discussions, well-coordinated mental health care, effective veteran programs, working at the top of licensure, and feeling involved in improving access. Facility-level staffing ratios were not significantly associated with perceived reasonable workload. CONCLUSIONS: Leadership may consider focusing resources on initiatives that support behavioral health providers' autonomy to schedule patients as clinically indicated and develop attainable performance goals.

Role of Institutional Support for Evidence-Based Psychotherapy in Satisfaction and Burnout Among Veterans Affairs Therapists.

OBJECTIVE: Burnout is widespread among psychotherapists and leads to negative mental and other health outcomes, absenteeism, and turnover. Job resources, including institutional support for evidence-based practices, can buffer against burnout and may improve satisfaction among therapists. The Veterans Health Administration (VHA) is the nation's largest integrated health system and employs 23,000 therapists, including psychologists, social workers, and counselors. The authors assessed associations between perceived institutional support for evidence-based treatment and satisfaction and burnout among VHA therapists. METHODS: This analysis used data from the VHA's national 2018 Mental Health Provider Survey. Responding therapists (N=5,341) answered questions about the quality of mental health care and job satisfaction. Multilevel logistic regression models were used to predict burnout and satisfaction. The authors tested availability of evidence-based treatment and measurement-based care (MBC) as predictors; analyses were adjusted for therapist workload, demographic characteristics, and potential clustering by facility. RESULTS: VHA therapists had less burnout and more job satisfaction when they perceived receiving institutional support for evidence-based psychotherapy (EBP) and MBC, irrespective of whether the analyses were adjusted for workload. Less difficulty in scheduling EBP was significantly associated with decreased likelihood of burnout (OR=0.83, p<0.001) and increased satisfaction (OR=1.09, p=0.008). Less difficulty ending psychotherapy was significantly associated with decreased likelihood of burnout (OR=0.89, p=0.002) and increased satisfaction (OR=1.12, p=0.004). CONCLUSIONS: Support for evidence-based practices, including EBP and MBC, was closely linked to VHA therapists' satisfaction and burnout. Expanding support for therapists to provide evidence-based treatment may benefit therapists, patients, and the health care system.

Veterans Health Administration Outpatient Psychiatry Staffing Model: Longitudinal Analysis on Mental Health Performance.

BACKGROUND: An adequate supply of mental health (MH) professionals is necessary to provide timely access to MH services. Veterans Health Administration (VHA) continues to prioritize the expansion of the MH workforce to meet increasing demand for services. OBJECTIVE: Validated staffing models are essential to ensure timely access to care, to plan for future demand, to ensure delivery of high-quality care, and to balance the demands of fiscal responsibility and strategic priorities. DESIGN: Longitudinal retrospective cohort of VHA outpatient psychiatry, fiscal years 2016-2021. PARTICIPANTS: Outpatient VHA psychiatrists. MAIN MEASURES: Quarterly outpatient staff-to-patient ratios (SPRs), defined as the number of full-time equivalent clinically assigned providers per 1000 veterans receiving outpatient MH care, were calculated. Longitudinal recursive partitioning models were created to identify optimal cut-offs for the outpatient psychiatry SPR associated with success on VHA's measures of quality, access, and satisfaction. KEY RESULTS: Among outpatient psychiatry staff, the root node identified an outpatient SPR of 1.09 for overall performance (p < 0.001). For metrics associated with Population Coverage, a root node identified an SPR of 1.36 (p < 0.001). Metrics associated with continuity of care and satisfaction were associated with a root node of 1.10 and 1.07 (p < 0.001), respectively. In all analyses, the lowest SPRs were associated with the lowest group performance on VHA MH metrics of interest. CONCLUSIONS: Establishing validated staffing models associated with high-quality MH care is critical given the national psychiatry shortage and increasing demand for services. Analyses support VHA's current recommended minimum outpatient psychiatry-specific SPR of 1.22 as a reasonable target to provide high-quality care, access, and satisfaction.

Outpatient provider staffing ratios: Binary recursive models associated with quality, access, and satisfaction.

Veterans Health Administration (VHA) continues to expand the mental health (MH) workforce to meet increasing demand for services. In the present study, longitudinal unbiased recursive partitioning models (conditional inference trees) were created to identify optimal cutoffs for outpatient staffing ratios associated with success on VHA's measures of quality, access, and satisfaction. Quarterly Staff-to-Patient Ratios (SPRs), defined as the number of full-time equivalent providers per 1,000 veterans receiving outpatient mental health care, were calculated for 12 quarters from fiscal years 2016-2018. Associations between VHA metrics associated with quality, access, and satisfaction were evaluated in relation to the overall outpatient SPR. The root node identified an overall outpatient SPR of 7.39 as the split for optimal MH performance. Root nodes associated with metrics addressing population coverage, continuity of care, and experience of care identified SPRs of 7.87, 6.81, and 7.42, respectively. In all analyses, the lowest SPRs were associated with the lowest performance on VHA MH metrics, while the highest SPRs were associated with the highest performance. Analyses support VHA's current recommended minimum outpatient SPR of 7.72 as a reasonable target to provide high-quality care, access, and satisfaction. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Correction: Predictors and Consequences of Veterans Affairs Mental Health Provider Burnout: Protocol for a Mixed Methods Study.

[This corrects the article DOI: 10.2196/18345.].

Predictors and Consequences of Veterans Affairs Mental Health Provider Burnout: Protocol for a Mixed Methods Study.

BACKGROUND: In the Veterans Health Administration (VHA), mental health providers (MHPs) report the second highest level of burnout after primary care physicians. Burnout is defined as increased emotional exhaustion and depersonalization and decreased sense of personal accomplishment at work. OBJECTIVE: This study aims to characterize variation in MHP burnout by VHA facility over time, identifying workplace characteristics and practices of high-performing facilities. METHODS: Using both qualitative and quantitative methods, we will evaluate factors that influence MHP burnout and their effects on patient outcomes. We will compile annual survey data on workplace conditions and annual staffing as well as productivity data to assess same and subsequent year provider and patient outcomes reflecting provider and patient experiences. We will conduct interviews with mental health leadership at the facility level and with frontline MHPs sampled based on our quantitative findings. We will present our findings to an expert panel of operational partners, Veterans Affairs clinicians, administrators, policy leaders, and experts in burnout. We will reengage with facilities that participated in the earlier qualitative interviews and will hold focus groups that share results based on our quantitative and qualitative work combined with input from our expert panel. We will broadly disseminate these findings to support the development of actionable policies and approaches to addressing MHP burnout. RESULTS: This study will assist in developing and testing interventions to improve MHP burnout and employee engagement. Our work will contribute to improvements within VHA and will generate insights for health care delivery, informing efforts to address burnout. CONCLUSIONS: This is the first comprehensive, longitudinal, national, mixed methods study that incorporates different types of MHPs. It will engage MHP leadership and frontline providers in understanding facilitators and barriers to effectively address burnout. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/18345.

Psilocybin-assisted group therapy for demoralized older long-term AIDS survivor men: An open-label safety and feasibility pilot study.

BACKGROUND: Psilocybin therapy has shown promise as a rapid-acting treatment for depression, anxiety, and demoralization in patients with serious medical illness (e.g., cancer) when paired with individual psychotherapy. This study assessed the safety and feasibility of psilocybin-assisted group therapy for demoralization in older long-term AIDS survivor (OLTAS) men, a population with a high degree of demoralization and traumatic loss. METHODS: Self-identified gay men OLTAS with moderate-to-severe demoralization (Demoralization Scale-II ≥8) were recruited from the community of a major US city for a single-site open-label study of psilocybin-assisted group therapy comprising 8-10 group therapy visits and one psilocybin administration visit (0·3-0·36 mg/kg po). Primary outcomes were rate and severity of adverse events, and participant recruitment and retention. The primary clinical outcome was change in mean demoralization from baseline to end-of-treatment and to 3-month follow-up assessed with a two-way repeated measures ANOVA. Trial registration: Clinicaltrials.gov (NCT02950467). FINDINGS: From 17 July 2017 to 16 January 2019, 18 participants (mean age 59·2 years (SD 4·4)) were enrolled, administered group therapy and psilocybin, and included in intent-to-treat analyses. We detected zero serious adverse reactions and two unexpected adverse reactions to psilocybin; seven participants experienced self-limited, severe expected adverse reactions. We detected a clinically meaningful change in demoralization from baseline to 3-month follow-up (mean difference -5·78 [SD 6·01], ηp 2 = 0·47, 90% CI 0·21-0·60). INTERPRETATION: We demonstrated the feasibility, relative safety, and potential efficacy of psilocybin-assisted group therapy for demoralization in OLTAS. Groups may be an effective and efficient means of delivering psychotherapy pre- and post-psilocybin to patients with complex medical and psychiatric needs. FUNDING: Carey Turnbull, Heffter Research Institute, NIMH R25 MH060482, NIH UL1 TR001872, River Styx Foundation, Saisei Foundation, Sarlo Foundation, Stupski Foundation, Usona Institute, US Department of Veterans Affairs (Advanced Neurosciences Fellowship and IK2CX001495).

Using patient-reported outcome measures for program evaluation: Design and findings on intention-to-treat outcomes from the Veterans Outcome Assessment survey.

The Veterans Outcomes Assessment (VOA) program surveys Veteran Health Administration (VHA) patients when they begin mental health treatment and at follow-up at three months to obtain patient-reported outcomes measures (PROM). It complements VA's evolving program in measurement-based care by providing additional data that can be useful for program evaluation including assessments of patients who have not been seen for ongoing mental health care. In principle, it provides data on intention-to-treat outcomes for program evaluation to complement the outcomes for patients who are receiving ongoing treatment that can be derived from measurement-based care. VOA findings confirm differences in outcomes between patients who have continued to be seen for treatment and those who have not. Patients in general mental health clinics with no encounters between the baseline and follow-up assessments who reported discontinuing care because they did not want or need treatment improved more, and those who discontinued due to problems improved less than those who remained in treatment. Experience with VOA has identified a number of issues that must be addressed before it is possible to use intention-to-treat outcomes for program evaluation.

DLG2 variants in patients with pubertal disorders.

PURPOSE: Impaired function of gonadotropin-releasing hormone (GnRH) neurons can cause a phenotypic spectrum ranging from delayed puberty to isolated hypogonadotropic hypogonadism (IHH). We sought to identify a new genetic etiology for these conditions. METHODS: Exome sequencing was performed in an extended family with autosomal dominant, markedly delayed puberty. The effects of the variant were studied in a GnRH neuronal cell line. Variants in the same gene were sought in a large cohort of individuals with IHH. RESULTS: We identified a rare missense variant (F900V) in DLG2 (which encodes PSD-93) that cosegregated with the delayed puberty. The variant decreased GnRH expression in vitro. PSD-93 is an anchoring protein of NMDA receptors, a type of glutamate receptor that has been implicated in the control of puberty in laboratory animals. The F900V variant impaired the interaction between PSD-93 and a known binding partner, Fyn, which phosphorylates NMDA receptors. Variants in DLG2 that also decreased GnRH expression were identified in three unrelated families with IHH. CONCLUSION: The findings indicate that variants in DLG2/PSD-93 cause autosomal dominant delayed puberty and may also contribute to IHH. The findings also suggest that the pathogenesis involves impaired NMDA receptor signaling and consequently decreased GnRH secretion.

Plasma midkine concentrations in healthy children, children with increased and decreased adiposity, and children with short stature.

BACKGROUND: Midkine (MDK), one of the heparin-binding growth factors, is highly expressed in multiple organs during embryogenesis. Plasma concentrations have been reported to be elevated in patients with a variety of malignancies, in adults with obesity, and in children with short stature, diabetes, and obesity. However, the concentrations in healthy children and their relationships to age, nutrition, and linear growth have not been well studied. SUBJECTS AND METHODS: Plasma MDK was measured by immunoassay in 222 healthy, normal-weight children (age 0-18 yrs, 101 boys), 206 healthy adults (age 18-91 yrs, 60 males), 61 children with BMI ≥ 95th percentile (age 4-18 yrs, 20 boys), 20 girls and young women with anorexia nervosa (age 14-23 yrs), and 75 children with idiopathic short stature (age 3-18 yrs, 42 boys). Body fat was evaluated by dual-energy X-ray absorptiometry (DXA) in a subset of subjects. The associations of MDK with age, sex, adiposity, race/ethnicity and stature were evaluated. RESULTS: In healthy children, plasma MDK concentrations declined with age (r = -0.54, P < 0.001) with values highest in infants. The decline occurred primarily during the first year of life. Plasma MDK did not significantly differ between males and females or between race/ethnic groups. MDK concentrations were not correlated with BMI SDS, fat mass (kg) or percent total body fat, and no difference in MDK was found between children with anorexia nervosa, healthy weight and obesity. For children with idiopathic short stature, MDK concentrations did not differ significantly from normal height subjects, or according to height SDS or IGF-1 SDS. CONCLUSIONS: In healthy children, plasma MDK concentrations declined with age and were not significantly associated with sex, adiposity, or stature-for-age. These findings provide useful reference data for studies of plasma MDK in children with malignancies and other pathological conditions.

State emotional clarity and attention to emotion: a naturalistic examination of their associations with each other, affect, and context.

Despite emotional clarity and attention to emotion being dynamic in nature, research has largely focused on their trait forms. We examined the association between state and trait forms of these two constructs, and how they are related to affect intensity and two contextual variables: Social context and significant event occurrence. Seventy-nine adults recruited from the community reported eight times a day for a week on the extent to which they were clear about their emotions, attended to their emotions, levels of affect intensity, the number of people with whom they were interacting, and whether a significant event had occurred. State clarity and attention were positively associated, demonstrating a moderate relation similar to that of their trait forms. Trait and state attention, but not trait and state clarity, were significantly positively associated. Positive and negative affect were quadratically associated with clarity and attention, with the highest levels of affect intensity reported at high levels of clarity and attention. Clarity and attention were positively associated with increasing numbers of people with whom people were interacting. Attention and clarity were elevated when significant events occurred - especially during positive events. We discuss the findings in the context of functional adaptation theories of emotion.

Mental Health Treatment Quality, Access, and Satisfaction: Optimizing Staffing in an Era of Fiscal Accountability.

OBJECTIVE: Mental health treatment access and quality are influenced by the interplay of structural, organizational, and performance factors-including the number of mental health staff providing direct clinical care relative to patients treated (i.e., staffing ratio), mental health staff productivity, and wait times for scheduled mental health appointments. With no industry standards to follow, the Veterans Health Administration (VHA) developed an outpatient mental health staffing model and a recommended minimum total staffing ratio. METHODS: At the level of VHA health care facility (N=140), we conducted cross-sectional regression analyses to examine the relative importance of outpatient mental health staffing and productivity and mental health patient wait times in predicting measures of mental health treatment access and quality. RESULTS: Outpatient mental health staffing ratios (especially total and therapist staffing ratios) had substantial, positive relationships with overall mental health treatment access and quality, broadly and in specific domains. Staffing ratios generally had stronger relationships with treatment access and quality than did staff productivity and patient wait times. CONCLUSIONS: Mental health staffing ratios should be a primary consideration when trying to improve mental health treatment access and quality at the facility level. Having more mental health staff of all types is associated with better overall access to and quality of mental health services, and multiple staff types are needed to provide high-quality mental health care. Knowledge gained may guide efforts to address challenges in improving access to and quality of mental health services within and outside of VHA.

Substance Use Disorders Among Veterans in a Nationally Representative Sample: Prevalence and Associated Functioning and Treatment Utilization.

OBJECTIVE: Several epidemiological studies have reported that veterans and nonveterans have comparable substance use disorder (SUD) prevalence and SUD treatment rates for SUD and treatments of several types. No studies have compared functioning among veterans with SUD to veterans without SUD or to nonveterans. METHOD: We investigated the prevalence of past-year and lifetime SUD (based on criteria from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition), overall and by substance, and estimated the association with physical and mental health functioning and treatment utilization and need among veterans and nonveterans in a nationally representative sample. RESULTS: Predicted prevalence of any past-year SUD, with and without tobacco use disorder (TUD), among veterans was 32.9% and 17.1%, and prevalence of any lifetime SUD, with and without TUD, was 52.5 and 38.7%, respectively. Veterans had higher prevalence of past-year and lifetime SUD for some substances (e.g., tobacco, alcohol) but not others (e.g., cannabis, opioid). Lower physical and mental health functioning was found among veterans, relative to nonveterans, and participants with SUD, relative to those without SUD, and veterans with SUD reported the lowest functioning across all domains. More veterans than nonveterans received any SUD treatment and SUD treatment in specific domains (e.g., self-help). About 70% of veterans with past-year SUD did not receive treatment, but only 5.4% reported needing and not receiving treatment. CONCLUSIONS: Relative to nonveterans, veterans have higher prevalence of past-year TUD and lifetime alcohol use disorder or TUD and lower physical or mental health functioning. A minority of veterans receive SUD treatment, and few report unmet need for treatment.

Unique Variant of NOD2 Pediatric Granulomatous Arthritis With Severe 1,25-Dihydroxyvitamin D-Mediated Hypercalcemia and Generalized Osteosclerosis.

Pediatric granulomatous arthritis (PGA) refers to two formerly separate entities: autosomal dominant Blau syndrome (BS) and its sporadic phenocopy early-onset sarcoidosis (EOS). In 2001 BS and in 2005 EOS became explained by heterozygous mutations within the gene that encodes nucleotide-binding oligomerization domain-containing protein 2 (NOD2), also called caspase recruitment domain-containing protein 15 (CARD15). NOD2 is a microbe sensor in leukocyte cytosol that activates and regulates inflammation. PGA is characterized by a triad of autoinflammatory problems (dermatitis, uveitis, and arthritis) in early childhood, which suggests the causal NOD2/CARD15 mutations are activating defects. Additional complications of PGA were recognized especially when NOD2 mutation analysis became generally available. However, in PGA, hypercalcemia is only briefly mentioned, and generalized osteosclerosis is not reported, although NOD2 regulates NF-κB signaling essential for osteoclastogenesis and osteoclast function. Herein, we report a 4-year-old girl with PGA uniquely complicated by severe 1,25(OH)2 D-mediated hypercalcemia, nephrocalcinosis, and compromised renal function together with radiological and histopathological features of osteopetrosis (OPT). The classic triad of PGA complications was absent, although joint pain and an antalgic gait accompanied wrist, knee, and ankle swelling and soft non-tender masses over her hands, knees, and feet. MRI revealed tenosynovitis in her hands and suprapatellar effusions. Synovial biopsy demonstrated reactive synovitis without granulomas. Spontaneous resolution of metaphyseal osteosclerosis occurred while biochemical markers indicated active bone turnover. Anti-inflammatory medications suppressed circulating 1,25(OH)2 D, corrected the hypercalcemia, and improved her renal function, joint pain and swelling, and gait. Mutation analysis excluded idiopathic infantile hypercalcemia, type 1, and known forms of OPT, and identified a heterozygous germline missense mutation in NOD2 common in PGA (c.1001G>A, p.Arg334Gln). Thus, radiological and histological findings of OPT and severe hypercalcemia from apparent extrarenal production of 1,25(OH)2 D can complicate NOD2-associated PGA. Although the skeletal findings seem inconsequential, treatment of the hypercalcemia is crucial to protect the kidneys. © 2018 American Society for Bone and Mineral Research.

Emotional clarity and attention to emotions in cognitive behavioral group therapy and mindfulness-based stress reduction for social anxiety disorder.

We examined (1) differences between controls and patients with social anxiety disorder (SAD) in emotional clarity and attention to emotions; (2) changes in emotional clarity and attention to emotions associated with cognitive-behavioral group therapy (CBGT), mindfulness-based stress reduction (MBSR), or a waitlist (WL) condition; and (3) whether emotional clarity and attention to emotions moderated changes in social anxiety across treatment. Participants were healthy controls (n = 37) and patients with SAD (n = 108) who were assigned to CBGT, MBSR, or WL in a randomized controlled trial. At pretreatment, posttreatment, and 12-month follow-up, patients with SAD completed measures of social anxiety, emotional clarity, and attention to emotions. Controls completed measures at baseline only. At pretreatment, patients with SAD had lower levels of emotional clarity than controls. Emotional clarity increased significantly among patients receiving CBGT, and changes were maintained at 12-month follow-up. Emotional clarity at posttreatment did not differ between CBGT and MBSR or between MBSR and WL. Changes in emotional clarity predicted changes in social anxiety, but emotional clarity did not moderate treatment outcome. Analyses of attention to emotions were not significant. Implications for the role of emotional clarity in the treatment of SAD are discussed.

Prevalence of mental disorders and related functioning and treatment engagement among people with diabetes.

AIMS: To examine prevalence, functioning and treatment associated with all DSM-5 12-month mood, anxiety, eating and substance use disorders among people with diabetes in data obtained from the National Epidemiologic Survey on Alcohol and Related Conditions-III. METHODS: Through multistage stratified randomized sampling a sample representative of the United States civilian population was obtained. Prevalence of diabetes (Type 1 and 2), DSM-5 disorders, physical and mental functioning, and treatment utilization were assessed via telephone interview. Analyses of weighted data (N=36,138) included calculation of descriptive statistics, and chi-square, logistic and linear regression analyses. RESULTS: Participants with (vs. without) diabetes (9.3% of weighted sample) had a significantly: (a) higher prevalence of any anxiety disorder and posttraumatic stress disorder (with and without adjustment for sociodemographic characteristics), and any mood disorder, major depressive disorder and specific phobia (with adjustment), (b) lower prevalence of any substance use disorder and alcohol and tobacco use disorders (with and without adjustment), and cannabis use disorder (without adjustment). Among participants with diabetes, mental disorder prevalence was consistently associated with sex and age, and to a lesser frequency, race/ethnicity. Lower levels of physical and mental functioning were found among participants with diabetes and a comorbid mental disorder. A minority of participants with diabetes and a comorbid mental disorder received treatment for mood and anxiety disorders, and few received treatment for eating and substance use disorders. CONCLUSIONS: Multiple types of mood, anxiety, eating and substance use disorders are prevalent, problematic, and often untreated among people with diabetes.

Exploring correlates of diabetes-related stress among adults with Type 1 diabetes in the T1D exchange clinic registry.

AIMS: To explore relations between diabetes-related stress and multiple sociodemographic, diabetes health, other health, and treatment-related variables among a large sample of adults with Type 1 Diabetes (T1D). METHODS: The sample consisted of 10,821 adults (over 18 years old) enrolled in the T1D Exchange Clinic Registry. The T1D Exchange clinic network consists of 67 diabetes clinical centers throughout the United States selected to broadly represent pediatric and adult patients with T1D. Variables were assessed through participant self-report and extraction of clinic chart data. Univariate and multiple linear regression (with simultaneous entry of all predictors) analyses were conducted. RESULTS: Robustly associated with increased diabetes-related stress across analyses were multiple sociodemographic (female [vs. male], native Hawaiian/other Pacific islander [vs. white/Caucasian], decreased age and diabetes duration), diabetes health (higher HbA1c), other health (lower general health, presence of major life stress and depression, less physical activity), and treatment related variables (use of injections/pen or combination injection/pen/pump [vs. pump], use of CGM, increased frequency of missing insulin doses and BG checking, decreased frequency of BG checking prior to bolus, receipt of mental health treatment). CONCLUSIONS: We replicated and extended research demonstrating that diabetes-related stress among people with T1D occurs at higher levels among those with particular sociodemographic characteristics and is associated with a range poorer diabetes health and other health variables, and multiple treatment-related variables. The strong incremental prediction of diabetes-related stress by multiple variables in our study suggests that a multi-variable, personalized approach may increase the effectiveness of treatments for diabetes-related stress.

Measurement-based management of mental health quality and access in VHA: SAIL mental health domain.

We outline the development of a Mental Health Domain to track accessibility and quality of mental health care in the United States Veterans Health Administration (VHA) as part of a broad-based performance measurement system. This domain adds an important element to national performance improvement efforts by targeting regional and facility leadership and providing them a concise yet comprehensive measure to identify facilities facing challenges in their mental health programs. We present the conceptual framework and rationale behind measure selection and development. The Mental Health Domain covers three important aspects of mental health treatment: Population Coverage, Continuity of Care, and Experience of Care. Each component is a composite of existing and newly adapted measures with moderate to high internal consistency; components are statistically independent or moderately related. Development and dissemination of the Mental Health Domain involved a variety of approaches and benefited from close collaboration between local, regional, and national leadership and from coordination with existing quality-improvement initiatives. During the first year of use, facilities varied in the direction and extent of change. These patterns of change were generally consistent with qualitative information, providing support for the validity of the domain and its component measures. Measure maintenance remains an iterative process as the VHA mental health system and potential data resources continue to evolve. Lessons learned may be helpful to the broader mental health-provider community as mental health care consolidates and becomes increasingly integrated within healthcare systems. (PsycINFO Database Record

Emotional variability and clarity in depression and social anxiety.

Recent research has underscored the importance of elucidating specific patterns of emotion that characterise mental disorders. We examined two emotion traits, emotional variability and emotional clarity, in relation to both categorical (diagnostic interview) and dimensional (self-report) measures of major depressive disorder (MDD) and social anxiety disorder (SAD) in women diagnosed with MDD only (n = 35), SAD only (n = 31), MDD and SAD (n = 26) or no psychiatric disorder (n = 38). Results of the categorical analyses suggest that elevated emotional variability and diminished emotional clarity are transdiagnostic of MDD and SAD. More specifically, emotional variability was elevated for MDD and SAD diagnoses compared to no diagnosis, showing an additive effect for co-occurring MDD and SAD. Similarly diminished levels of emotional clarity characterised all three clinical groups compared to the healthy control group. Dimensional findings suggest that although emotional variability is associated more consistently with depression than with social anxiety, emotional clarity is associated more consistently with social anxiety than with depression. Results are interpreted using a threshold and dose-response framework.

Feasibility and challenges of inpatient psychotherapy for psychosis: lessons learned from a veterans health administration pilot randomized controlled trial.

BACKGROUND: In large health care systems, decision regarding broad implementation of psychotherapies for inpatients with psychosis require substantial evidence regarding effectiveness and feasibility for implementation. It is important to recognize challenges in conducting research to inform such decisions, including difficulties in obtaining consent from and engaging inpatients with psychosis in research. We set out to conduct a feasibility and effectiveness Hybrid Type I pilot randomized controlled trial of acceptance and commitment therapy (ACT) and a semi-formative evaluation of barriers and facilitators to implementation. FINDINGS: We developed a training protocol and refined an ACT treatment manual for inpatient treatment of psychosis for use at the Veterans Health Administration. While our findings on feasibility were mixed, we obtained supportive evidence of the acceptability and safety of ACT. Identified strengths of ACT included a focus on achievement of valued goals rather than symptoms. Weaknesses included that symptoms may limit patient's understanding of ACT. Facilitators included building trust and multi-stage informed consent processes. Barriers included restrictive eligibility criteria, rigid use of a manualized protocol, and individual therapy format. Conclusions are limited by our randomization of only 18 patient participants (with nine completing all aspects of the study) out of 80 planned. CONCLUSIONS: Future studies should include (1) multi-stage informed consent processes to build trust and alleviate patient fears, (2) relaxation of restrictions associated with obtaining efficacy/effectiveness data, and (3) use of Hybrid Type II and III designs.