Randomized Controlled Trial of a Brief Mindfulness-Based Intervention for Suicidal Ideation Among Veterans.

INTRODUCTION: This study was a preliminary evaluation of a manualized, brief mindfulness-based intervention (MB-SI) for veterans with suicidal ideation (SI), admitted into an inpatient psychiatric unit (IPU). MATERIALS AND METHODS: A randomized, controlled pilot study of 20 veterans aged 18-70 years with SI, admitted into a psychiatric unit, assigned to treatment as usual (TAU) or MB-SI groups. Outcome data were collected at three time points: preintervention (beginning of first session), postintervention (end of last session), and 1-month postintervention. Primary outcomes were safety and feasibility. Secondary outcome measures were SI and behavior, mindfulness state and trait, cognitive reappraisal, and emotion regulation. Additionally, psychiatric and emergency department admissions were examined. Data analysis included Generalized Linear Models, Wilcoxon Signed-Rank, Mann-Whitney U, and Fisher's exact tests for secondary outcomes. RESULTS: Mindfulness-based intervention for suicidal ideation was feasible to implement on an IPU, and there were no associated adverse effects. Mindfulness-based intervention for suicidal ideation participants experienced statistically significant increase in Toronto Mindfulness Scale curiosity scores 1-month postintervention compared to preintervention and greater Toronto Mindfulness Scale decentering scores 1-month postintervention compared to TAU. Emotion Regulation Questionnaire Reappraisal scores significantly increased for the MB-SI group and significantly decreased for TAU over time. IPU and emergency department admissions were not statistically different between groups or over time. Both TAU and MB-SI participants experienced a significant reduction in Columbia-Suicide Severity Rating Scale-SI scores after the intervention. MB-SI participants experienced a higher increase in Five-Facet Mindfulness Questionnaire scores postintervention compared to TAU. CONCLUSIONS: Mindfulness-based intervention for suicidal ideation is feasible and safe to implement among veterans during an inpatient psychiatric admission with SI, as it is not associated with increased SI or adverse effects. Preliminary evidence suggests that MB-SI increases veterans' propensity to view experiences with curiosity while disengaging from experience without emotional overreaction. Further, more rigorous research is warranted to determine efficacy of MB-SI. TRIAL REGISTRATION: The clinicaltrials.gov registration number is NCT04099173 and dates are July 16, 2019 (initial release) and February 24, 2022 (most recent update).

Utilization and outcomes of a Whole Health model of care by Veterans with psychiatric illness.

OBJECTIVES: The Veterans Health Administration (VHA) is implementing a model of healthcare known as Whole Health (WH). The goal of WH is to shift from a disease-oriented system to one that emphasizes health promotion and disease prevention as well as promotes the use of Complementary and Integrative Health. The aim of this project was to investigate utilization and outcomes of WH programming among Veterans with psychiatric disorders. DESIGN: This was a retrospective study. Subjects were 7138 Veterans who had a mental health diagnosis. Descriptive data, as well as within- and between-subjects analyses were conducted to investigate utilization and outcomes. SETTING: The study was conducted at a large VHA medical center. INTERVENTIONS: Whole health interventions considered in this study were mindfulness training, health education, wellbeing, and nutrition classes as well as health coaching. Other whole health interventions, such as acupuncture and message were not evaluated. MAIN OUTCOME MEASURES: Utilization of mental health treatment services, medication prescriptions, pain scores and suicide-related behaviors were the primary outcome measures. RESULTS: There were 305 Veterans with at least one WH appointment. The existence of several specific psychiatric disorders was associated with WH utilization. The mean number of appointments completed per individual was 6.9 for all WH programming. Finally, WH participation was associated with decreased risk of suicide as well as reduced use of mental health services. There were no significant changes to other outcome variables. CONCLUSIONS: WH programming shows promise to reduce suicide risk and the need for mental health services among this population. Additionally, WH services were underutilized and there was a lack of treatment engagement.

Veterans' experiences with mindfulness-based eating: A mixed methods study on MB-SAVOR.

BACKGROUND: Disordered eating is prevalent among US Military Veterans who have a high incidence of obesity, diabetes, and mental illness. Mindfulness is an evidenced-based intervention for some mental health disorders, is well received by Veterans, and may be useful in treating disordered eating behavior in this population. The aim of this study was to assess and describe Veterans' experience with MB-SAVOR, a novel mindfulness-based eating program, and determine if it improved their relationship with food and the body. METHODS: In-depth qualitative interviews were conducted among 16 Veterans completing the program. Interviews were audio recorded, transcribed, and analyzed using constant comparative method, an iterative and inductive process. Rapid assessment process was used to understand their views on program structure. Inferential statistics were conducted to assess outcomes of pre-topost-intervention weight, BMI, and HbA1C, and influences of demographics. RESULTS: Five themes were identified related to experience: Awareness of Eating Cues, Noticing Eating Behaviors and Patterns, Greater Enjoyment of Food, Dietary Improvements, and Mind Body Connection. Four themes were identified related to program structure: Reasons for Enrollment, Prior Experiences and Comparison with MB-SAVOR, Program Information, Impression, and Barriers, and Improvement Suggestions. Clinical outcomes were decreased weight (p = 0.007, d = 0.82), BMI (p = 0.004, d = 0.9), and HbA1C (p = 0.3) post-intervention. CONCLUSIONS: These findings contribute to our understanding of the feasibility, safety, and efficacy of MB-SAVOR on improving Veterans' relationship with food and the body. These data help us understand Veterans' perspectives and motivations regarding treatment engagement for several diet related problems contributing to obesity and diabetes.

Mindfulness-based Therapeutic Sailing for Veterans With Psychiatric and Substance Use Disorders.

INTRODUCTION: Complementary interventions have the potential to enhance treatment engagement and/or response among veterans with psychiatric disorders and/or substance use disorders (SUDs). Mindfulness-based therapeutic sailing (MBTS) is a novel three-session, complementary intervention, which combines nature exposure via recreational sailing and mindfulness training. It was developed specifically to augment both treatment response and engagement among veterans with psychiatric disorders or SUDs. The study reports a follow-up investigation of a version of MBTS modified based upon a previous initial pilot study. MATERIALS AND METHODS: This is an institutional review board-approved study of 25 veterans, 23 males and 2 females, who participated in MBTS along with a diagnosis-, gender-, and age-matched control group. All participants had at least one psychiatric disorder or SUD and most (92%) had two or more conditions, with the most common being any SUD (76%) and PTSD (72%). Instruments used to evaluate within-subjects pre- to post-intervention psychological changes were the Acceptance and Action Questionnaire II (AAQII), the Toronto Mindfulness Scale (TMS), and the Five Facet Mindfulness Questionnaire (FFMQ). The Physical Activity Enjoyment Scale (PACES) was administered to evaluate how much the participants enjoyed the intervention. Outcome measures were collected for 1-year pre-intervention and 1-year post-intervention for between-subject analyses. These were numbers of medical and psychiatric hospitalizations, emergency department visits, mental health (MH) and substance abuse treatment visits, and MH and substance abuse treatment failed appointments. Data analysis consisted of using paired, two-tailed t-tests on psychological instrument results, Poisson regression on discrete outcome measures, and chi-square test of independence on demographic factors. RESULTS: Within-subjects comparisons revealed significant mean pre- to post-intervention increases in AAQII (P = .04) and TMS scores (P = .009). The FFMQ scores increased but the change was nonsignificant (P = .12). The PACES scores were high for all sessions, indicating enjoyment of the intervention by participants. Although the coefficient was nonsignificant, Poisson regression uncovered reduction in substance abuse treatment visits post-intervention. There were no significant differences for the other variables. For demographic factors, the differences between intervention and control groups were not statistically significant. CONCLUSIONS: The MBTS is associated with increases in psychological flexibility (AAQII) and state mindfulness (TMS). The intervention was perceived as pleasurable by participants (PACES) and is potentially associated with decreased utilization of substance use treatment services. These results must be considered as preliminary; however, these finding corroborate results from a previous pilot study and indicate that MBTS holds promise as a complementary intervention that could result in enhanced treatment engagement and/or outcomes for the population studied. A randomized controlled trial of MBTS is warranted. Further, the model of a three-session intervention combining mindfulness training with nature exposure could be adapted for other types of nature exposure, such as hiking or snowshoeing or other complementary interventions including equine-assisted activities and therapies.

Mindfulness-based interventions for military veterans: A systematic review and analysis of the literature.

BACKGROUND: In recent years, mindfulness-based interventions (MBIs) have experienced exponential growth in terms of development, application, and research. However, few studies have examined implementation and efficacy of these interventions in particular populations, such as military Veterans. Such studies are needed as one cannot assume that the literature on MBIs implemented with the general population or other specific populations apply equally well to Veterans. This population is unique regarding professional competencies, military ethos, high degrees of medical comorbidities and barriers to treatment. The aim of this work was to review and summarize the literature over the previous five years (2014-2020) assessing the use of MBIs among military Veterans to guide clinical care and future research. METHODS: Systematic literature review. RESULTS: A total of 88 articles were found. Screening titles and abstracts resulted in 49 articles being excluded. The remaining 39 articles were read in full, and of these, 12 were excluded due to not fully meeting the inclusion criteria. Thus, the present review included a total of 27 articles, 3 of which used qualitative methods and 24 of which used quantitative methods. CONCLUSIONS: MBIs hold promise as complementary adjunctive interventions for Veterans with PTSD and possibly other psychiatric disorders. Currently there are significant gaps in the literature that must be addressed to move the field forward. The main deficiency is, with a few exceptions, the lack of rigorous RCTs. Another major concern is the lack of generalizability to female and non-white Veterans given that the subject samples across all studies reviewed were 85% male and 76% white. At this time, MBSR, PCBMT and MBCT can be recommended as adjunctive complementary interventions for the reduction of PTSD symptoms. Research recommendations to move the field forward are provided.

The Veterans Health Administration Whole Health Model of Care: Early Implementation and Utilization at a Large Healthcare System.

INTRODUCTION: The U.S. Veterans Health Administration (VHA) is changing the way it provides healthcare to a model known as Whole Health (WH). The aim is to shift from a primarily medical/disease-oriented system to a model that focuses on health promotion and disease prevention; utilizes personalized, proactive, and patient-driven care; and emphasizes the use of complementary and integrative health. This investigation aimed to examine referral and utilization patterns in early implementation at tertiary care VHA medical care system. Specific aims were to evaluate (1) referral patterns, (2) initial treatment engagement, and (3) continuity of treatment engagement. MATERIALS AND METHODS: This is an institutional review board-approved, retrospective study of the first 561 veterans referred to WH programming in the first 20 months of implementation. Data analyses included a chi-square goodness of fit to compare demographics of veterans who were referred to WH Services with those of local patient population. At this facility, WH offers services in three tracks (General WH, Mindfulness Center [MC], and WH Nutrition), which offer unique services to veterans. A chi-square test for independence was conducted to analyze differences in initial engagement among the WH components, in referrals and retention among WH components by time period, and in demographics or diagnoses among self-referred or veterans referred by a consult. Finally, a regression model was used to assess for predictive factors that might influence continuity of treatment engagement across all the WH tracks. RESULTS: Key findings indicated potential implementation challenges including disproportionate numbers of referrals from clinical services; poor initial and ongoing treatment engagement; and older, male, and non-service-connected Veterans being less likely to be referred. CONCLUSION: Implementation of the WH model of care has the potential to transform the way VHA delivers healthcare and improve the health and lives of veterans. However, a shift of this magnitude is likely to face challenges during implementation. This article reports on initial barriers to implementation, which can guide implementation at other sites as well as future investigations. Further research is needed to replicate these results as well as to determine underlying causal factors. However, if replicated, these results indicate that successful implementation of WH, or similar models of care, will require extensive efforts focused on outreach to, and education of, facility providers and certain patient demographic groups. Finally, efforts will be required to enhance treatment engagement.

Veterans' interests, perceptions, and use of mindfulness.

OBJECTIVE: Mindfulness-based interventions are an evidence-based approach utilized in health care. There is developing evidence for effective use with military Veterans. However, little is known about Veterans' view of mindfulness. This study aims to understand their interests, perceptions, and use of mindfulness to enhance educational outreach and treatment engagement. METHODS: A cross-sectional study was conducted across the Veterans Health Administration in Salt Lake City, UT by administering a questionnaire to military Veterans. The questionnaire included the following themes: (1) demographics and respondents' mindfulness practice; (2) respondents' perceptions and beliefs about mindfulness; and (3) respondents' knowledge and interest in learning about mindfulness. RESULTS: In all, 185 military Veterans were surveyed; 30% practiced mindfulness in the past year, mainly for stress, posttraumatic stress disorder, sleep, and depression. Over 75% who practiced reported perceived benefit. Veterans rarely reported negative beliefs about mindfulness; 56% perceived an understanding of mindfulness and 46% were aware of Veterans Health Administration mindfulness offerings. In all, 55% were interested in learning about mindfulness, 58% were interested in learning how it could help, and 43% were interested in combining mindfulness with a pleasurable activity. CONCLUSION: Educational engagement approaches should be directed toward the benefits of mindfulness practice with minimal need to address negative beliefs. Outreach including education, with an experiential component, about mindfulness classes, availability of evening and weekend classes, individual sessions, and virtual offerings into Veteran's homes, may enhance engagement in mindfulness-based interventions. Mindfulness-based interventions that combine mindfulness training with an experiential pleasurable activity may be one mechanism to enhance treatment engagement.

Mindfulness Training plus Nature Exposure for Veterans with Psychiatric and Substance Use Disorders: A Model Intervention.

There is a need to develop novel complementary interventions aimed at enhancing treatment engagement and/or response for veterans with psychiatric and substance use disorders. There is evidence that both mindfulness training and nature exposure (MT/NE) may be beneficial for this population and that combining the two approaches into one intervention might result in synergistic benefit. However, to date, the MT/NE concept has not been tested. This article reports a pilot feasibility and acceptability study of MT/NE which was, in this case, provided via recreational sailing. The primary aim of this project was to develop a model intervention and evaluation process that could be used for future studies of MT/NE interventions using a variety of methods of nature exposure (e.g., hiking, skiing, mountain biking). Results indicate preliminary evidence that it is feasible to utilize MT/NE interventions for the population studied and that the MT/NE model described can serve as a template for future investigations. Further, there were significant pre- to post-intervention decreases in state anxiety, as well as increases in trait mindfulness. Three psychological instruments were identified that might be used in future studies to evaluate MT/NE outcomes. Results from this project provide a model MT/NE intervention template along with evaluation metrics for use in future studies.

Treatment Engagement and Outcomes of Mindfulness-Based Cognitive Therapy for Veterans with Psychiatric Disorders.

Objectives: The aim of this study was to evaluate utilization and outcomes of mindfulness-based cognitive therapy (MBCT) provided to veterans with psychiatric disorders. Design: Retrospective chart review. Settings: Veterans Administration Medical Center (VAMC). Subjects: Ninety-eight veterans with psychiatric illness who were enrolled in an MBCT class between May of 2012 and January of 2016. Subjects were predominately white (95%), male (81%), and >50 years old (74%). The most common psychiatric conditions were any mood disorder (82%) and post-traumatic stress disorder (54%). Intervention: Eight-week MBCT class. Outcome measures: Session attendance and pre- to postintervention changes in numbers of emergency department (ED) visits and psychiatric hospitalizations. Results: The average number of sessions attended was 4.87 of 8 and only 16% were present for all sessions. Veteran demographic variables did not predict the number of MBCT sessions attended. However, both greater numbers of pre-MBCT ED visits (p = 0.004) and psychiatric admissions (p = 0.031) were associated with attending fewer sessions. Among patients who experienced at least one pre- or post-treatment psychiatric admission in the 2 years pre- or postintervention (N = 26, 27%), there was a significant reduction in psychiatric admissions from pre to post (p = 0.002). There was no significant change in ED visits (p = 0.535). Conclusions: MBCT may be challenging to implement for veterans with psychiatric illness in, at least some, outpatient VAMC settings due to a high attrition rate. Possible mediation approaches include development of methods to screen for high dropout risk and/or development of shorter mindfulness-based interventions (MBIs) and/or coupling MBIs with pleasurable activities. The finding of a significant decrease in psychiatric hospitalizations from pre- to post-MBCT suggests that prospective studies are warranted utilizing MBCT for veterans at high risk for psychiatric hospitalization.

The Image Gently pediatric digital radiography safety checklist: tools for improving pediatric radiography.

Transition from film-screen to digital radiography requires changes in radiographic technique and workflow processes to ensure that the minimum radiation exposure is used while maintaining diagnostic image quality. Checklists have been demonstrated to be useful tools for decreasing errors and improving safety in several areas, including commercial aviation and surgical procedures. The Image Gently campaign, through a competitive grant from the FDA, developed a checklist for technologists to use during the performance of digital radiography in pediatric patients. The checklist outlines the critical steps in digital radiography workflow, with an emphasis on steps that affect radiation exposure and image quality. The checklist and its accompanying implementation manual and practice quality improvement project are open source and downloadable at www.imagegently.org. The authors describe the process of developing and testing the checklist and offer suggestions for using the checklist to minimize radiation exposure to children during radiography.

Image gently campaign back to basics initiative: ten steps to help manage radiation dose in pediatric digital radiography.

OBJECTIVE: The purpose of this review is to summarize 10 steps a practice can take to manage radiation exposure in pediatric digital radiography. CONCLUSION: The Image Gently campaign raises awareness of opportunities for lowering radiation dose while maintaining diagnostic quality of images of children. The newest initiative in the campaign, Back to Basics, addresses methods for standardizing the approach to pediatric digital radiography, highlighting challenges related to the technology in imaging of patients of widely varying body sizes.

Pediatric digital radiography education for radiologic technologists: current state.

BACKGROUND: Digital radiography (DR) is one of several new products that have changed our work processes from hard copy to digital formats. The transition from analog screen-film radiography to DR requires thorough user education because of differences in image production, processing, storage and evaluation between the forms of radiography. Without adequate education, radiologic technologists could unknowingly expose children to higher radiation doses than necessary for adequate radiograph quality. OBJECTIVE: To evaluate knowledge about image quality and dose management in pediatric DR among radiologic technologists in the U.S. MATERIALS AND METHODS: This communication describes a survey of 493 radiologic technologists who are members of the American Society of Radiologic Technologists (ASRT) and who evaluated the current state of radiological technologist education in image quality and dose management in pediatric DR. The survey included 23 survey questions regarding image acquisition issues, quality assurance, radiation exposure and education in DR of infants and children. RESULTS: Radiologic technologists express many needs in areas of training and education in pediatric DR. Suggested improvements include better tools for immediate feedback about image quality and exposure, more information about appropriate technique settings for pediatric patients, more user-friendly vendor manuals and educational materials, more reliable measures of radiation exposure to patients, and more regular and frequent follow-up by equipment vendors. CONCLUSION: There is a clear and widespread need for comprehensive and practical education in digital image technology for radiologic technologists, especially those engaged in pediatric radiography. The creation of better educational materials and training programs, and the continuation of educational opportunities will require a broad commitment from equipment manufacturers and vendors, educational institutions, pediatric radiology specialty organizations, and individual imaging specialists.