When Culture Matters: Using Compliments and Complaints to Define and Influence Chinese Patients' Satisfaction.

Despite patients' cultural background influencing their satisfaction with medical care the majority of studies draw on assumptions and models from the Western world. We move attention to the East Asian world by investigating the attributes of Chinese patients' satisfaction with their hospital in-patient care. Our research design is an exploratory qualitative study of 577 incidents of Chinese hospital in-patients' complaints and compliments. The data were drawn from a sample of reports of patients' satisfaction with their care in a district general hospital over a five-year period. Analysis focused on satisfactory and dissatisfactory events to derive attributes involved. We find patients in Chinese culture evaluate satisfaction with their care using eight attributes: professionalism, efficiency, chin-chièh, respect, patience, responsibility, value and ethics. We explore how Chinese patients' values and beliefs toward medicine and care-giving construct distinct meanings around these attributes. By synthesizing our findings with those in the literature we propose generic attributes which can form the basis of measures of Chinese patient satisfaction and inform training in cultural competence.

Mental Health Service Preferences and Utilization Among Women Veterans in Crisis: Perspectives of Veterans Crisis Line Responders.

Women military veterans are at increased risk of suicide compared to non-veterans, but little is known about the mental health service preferences and needs of women veterans in crisis. This study used qualitative, secondary source key informant interviews to ascertain the experiences of women veterans in crisis from 54 responders working at the Veterans Crisis Line. Responders indicated that women veterans reported different experiences with Veterans Administration (VA) and non-VA care, though drivers of satisfaction or dissatisfaction were similar. Availability of specialty care, sensitivity to veterans' issues or Military Sexual Trauma, strong provider relationships, and continuity of care contributed to satisfaction; lengthy appointment wait times, limited service options, and insensitivity to veterans' issues contributed to dissatisfaction. Responders suggested that barriers limiting VA access for women veterans are perceived as similar to non-VA care. Findings suggest that caller experiences with providers drive satisfaction with VA and non-VA mental health services.

Expanding Suicide Crisis Services to Text and Chat.

BACKGROUND: Crisis support services have historically been offered by phone-based suicide prevention hotlines, but are increasingly becoming available through alternative modalities, including Internet chat and text messaging. AIMS: To better understand differences in the use of phone and chat/text services. METHOD: We conducted semistructured interviews with call responders at the Veterans Crisis Line who utilize multimodal methods to respond to veterans in crisis. RESULTS: Responders indicated that veterans may access the chat/text service primarily for reasons that included a desire for anonymity and possible inability to use the phone. Responders were divided on whether callers and chatters presented with different issues or risk of suicide; however, they suggested that veterans frequently use chat/text to make their first contact with mental health services. LIMITATIONS: We spoke with call responders, not the veterans themselves. Additionally, as this is qualitative research, applicability to other settings may be limited. CONCLUSION: While new platforms offer promise, participants also indicated that chat services can supplement phone lines, but not replace them.

Connecting Veterans at Risk for Suicide to Care Through the HOME Program.

The Home-Based Mental Health Evaluation (HOME) program, which engages veterans in care following psychiatric hospitalization, was evaluated. Thirty-four veterans who participated in the HOME program were compared to 34 veterans from a matched archival control group on treatment engagement and implementation outcomes. Veterans who participated in the HOME program were significantly more likely to engage in care, engaged in care more quickly, and attended significantly more individual mental health appointments. Veterans reported high levels of satisfaction. Results suggest that the HOME program is effective at engaging veterans in care during the high-risk period of time following psychiatric hospitalization.

Barriers, facilitators, and benefits of implementation of dialectical behavior therapy in routine care: results from a national program evaluation survey in the Veterans Health Administration.

National implementation of evidence-based psychotherapies (EBPs) in the Veterans Health Administration (VHA) provides important lessons on the barriers and facilitators to implementation in a large healthcare system. Little is known about barriers and facilitators to the implementation of a complex EBP for emotional and behavioral dysregulation-dialectical behavioral therapy (DBT). The purpose of this study was to understand VHA clinicians' experiences with barriers, facilitators, and benefits from implementing DBT into routine care. This national program evaluation survey measured site characteristics of VHA sites (N = 59) that had implemented DBT. DBT was most often implemented in general mental health outpatient clinics. While 42% of sites offered all four modes of DBT, skills group was the most frequently implemented mode. Fifty-nine percent of sites offered phone coaching in any form, yet only 11% of those offered it all the time. Providers were often provided little to no time to support implementation of DBT. Barriers that were difficult to overcome were related to phone coaching outside of business hours. Facilitators to implementation included staff interest and expertise. Perceived benefits included increased hope and functioning for clients, greater self-efficacy and compassion for providers, and ability to treat unique symptoms for clinics. There was considerable variability in the capacity to address implementation barriers among sites implementing DBT in VHA routine care. Mental health policy makers should note the barriers and facilitators reported here, with specific attention to phone coaching barriers.

An Intervention With Meaning.

BACKGROUND: The Veterans Health Administration (VHA) health-care system utilizes a multilevel suicide prevention intervention that features the use of standardized safety plans with veterans considered to be at high risk for suicide. AIMS: Little is known about clinician perceptions on the value of safety planning with veterans at high risk for suicide. METHOD: Audio-recorded interviews with 29 VHA behavioral health treatment providers in a southeastern city were transcribed and analyzed using qualitative methodology. RESULTS: Clinical providers consider safety planning feasible, acceptable, and valuable to veterans at high risk for suicide owing to the collaborative and interactive nature of the intervention. Providers identified the types of veterans who easily engaged in safety planning and those who may experience more difficulty with the process. CONCLUSION: Additional research with VHA providers in other locations and with veteran consumers is needed.

Suicide Risk among Women Veterans in Distress: Perspectives of Responders on the Veterans Crisis Line.

BACKGROUND: Women veterans are at increasingly high risk of suicide, but little is known about the concerns and needs of this population. This is, in part, owing to the low base rate of suicide and the inability to conduct retrospective interviews with individuals who died. In this study, we used a qualitative approach to gain insight about the concerns and nature of comments regarding suicidal ideation and intent among women veterans calling the Veterans Crisis Line (VCL). METHODS: Fifty-four VCL call responders were interviewed in the spring of 2015. They were asked about the concerns and level of suicide risk of women veteran callers with whom they have spoken and about the ways in which women callers are similar to or different from men callers. Interviews were transcribed and thematic analyses were conducted to examine patterns or themes emerging from the data. FINDINGS: Military sexual trauma and non-suicidal self-harm were two commonly reported concerns of women veteran callers according to responders. VCL responders also noted differences between men and women veteran callers, including differences in clinical presentation, suicidal means, and protective factors. CONCLUSIONS: Our findings shed light on potential avenues to prevent suicide among women veterans, although we spoke to VCL responders about their impressions, rather than to women veterans themselves. Efforts to 1) prevent and treat the consequences of military sexual trauma, 2) recognize, prevent, and treat non-suicidal self-harm, and 3) restrict access to lethal means most commonly reported among women veteran callers may be helpful to mitigate suicide risk in this vulnerable group of veterans.

Dialectical Behavior Therapy Training and Desired Resources for Implementation: Results From a National Program Evaluation in the Veterans Health Administration.

CONTEXT: Little is known about nonresearch training experiences of providers who implement evidence-based psychotherapies for suicidal behaviors among veterans. EVIDENCE ACQUISITION: This national program evaluation identified the history of training, training needs, and desired resources of clinicians who work with at-risk veterans in a national health care system. This sequential mixed methods national program evaluation used a post-only survey design to obtain needs assessment data from clinical sites (N = 59) within Veterans Health Administration (VHA) facilities that implemented dialectical behavior therapy (DBT). Data were also collected on resources preferred to support ongoing use of DBT. RESULTS: While only 33% of clinical sites within VHA facilities reported that staff attended a formal DBT intensive training workshop, nearly 97% of participating sites reported having staff who completed self-study using DBT manuals. Mobile apps for therapists and clients and templates for documentation in the electronic health records to support measurement-based care were desired clinical resources. CONCLUSION: Results indicate that less-intensive training models can aid staff in implementing DBT in real-world health care settings. While more training is requested, a number of VHA facilities have successfully implemented DBT into the continuum of care for veterans at risk for suicide.

VA Suicide Prevention Applications Network: A National Health Care System-Based Suicide Event Tracking System.

OBJECTIVES: The US Department of Veterans Affairs' Suicide Prevention Applications Network (SPAN) is a national system for suicide event tracking and case management. The objective of this study was to assess data on suicide attempts among people using Veterans Health Administration (VHA) services. METHODS: We assessed the degree of data overlap on suicide attempters reported in SPAN and the VHA's medical records from October 1, 2010, to September 30, 2014-overall, by year, and by region. Data on suicide attempters in the VHA's medical records consisted of diagnoses documented with E95 codes from the International Classification of Diseases, Ninth Revision. RESULTS: Of 50 518 VHA patients who attempted suicide during the 4-year study period, data on fewer than half (41%) were reported in both SPAN and the medical records; nearly 65% of patients whose suicide attempt was recorded in SPAN had no data on attempted suicide in the VHA's medical records. CONCLUSION: Evaluation of administrative data suggests that use of SPAN substantially increases the collection of data on suicide attempters as compared with the use of medical records alone, but neither SPAN nor the VHA's medical records identify all suicide attempters. Further research is needed to better understand the strengths and limitations of both systems and how to best combine information across systems.

Predictive Modeling and Concentration of the Risk of Suicide: Implications for Preventive Interventions in the US Department of Veterans Affairs.

OBJECTIVES: The Veterans Health Administration (VHA) evaluated the use of predictive modeling to identify patients at risk for suicide and to supplement ongoing care with risk-stratified interventions. METHODS: Suicide data came from the National Death Index. Predictors were measures from VHA clinical records incorporating patient-months from October 1, 2008, to September 30, 2011, for all suicide decedents and 1% of living patients, divided randomly into development and validation samples. We used data on all patients alive on September 30, 2010, to evaluate predictions of suicide risk over 1 year. RESULTS: Modeling demonstrated that suicide rates were 82 and 60 times greater than the rate in the overall sample in the highest 0.01% stratum for calculated risk for the development and validation samples, respectively; 39 and 30 times greater in the highest 0.10%; 14 and 12 times greater in the highest 1.00%; and 6.3 and 5.7 times greater in the highest 5.00%. CONCLUSIONS: Predictive modeling can identify high-risk patients who were not identified on clinical grounds. VHA is developing modeling to enhance clinical care and to guide the delivery of preventive interventions.

Changes in Suicide Mortality for Veterans and Nonveterans by Gender and History of VHA Service Use, 2000-2010.

OBJECTIVE: Veterans are believed to be at high risk of suicide. However, research comparing suicide rates between veterans and nonveterans is limited, and even less is known regarding differences by history of Veterans Health Administration (VHA) service use. This study directly compared veteran and nonveteran suicide risk while for the first time differentiating veterans by VHA service use. METHODS: The cross-sectional study analyzed data from 173,969 adult suicide decedents from 23 states (2000-2010) included in the U.S. Department of Veterans Affairs suicide data archive. Annual standardized mortality ratios (SMRs) were computed for veterans compared with nonveterans and for veterans who used VHA services compared with veterans who did not, overall and separately for males and females. RESULTS: After the analysis controlled for age and gender differences, the number of observed veteran suicides was approximately 20% higher than expected in 2000 (SMR=1.19, 95% confidence interval [CI]=1.10-1.28), and this increased to 60% higher by 2010 (SMR=1.63, CI=1.58-1.68). The elevated risk for female veterans (2010 SMR=5.89) was higher than that observed for male veterans (2010 SMR=1.54). Trends for non-VHA-utilizing veterans mirrored those of the veteran population as a whole, and the SMR for VHA-utilizing veterans declined. Since 2003, the number of suicides among VHA-utilizing veterans was less than expected when compared directly with the suicide rate among non-VHA-utilizing veterans. CONCLUSIONS: Veterans are members of the community and, as such, are an important part of observed increases in U.S. suicide rates. Not all veterans are at equal or increasing risk of suicide, however. VHA-utilizing veterans appear to have declining absolute and relative suicide rates.

Associations between the Department of Veterans Affairs' suicide prevention campaign and calls to related crisis lines.

OBJECTIVE: The Transit Authority Suicide Prevention (TASP) campaign was launched by the Department of Veterans Affairs (VA) in a limited number of U.S. cities to promote the use of crisis lines among veterans of military service. METHODS: We obtained the daily number of calls to the VCL and National Suicide Prevention Lifeline (NSPL) for six implementation cities (where the campaign was active) and four control cities (where there was no TASP campaign messaging) for a 14-month period. To identify changes in call volume associated with campaign implementation, VCL and NSPL daily call counts for three time periods of equal length (pre-campaign, during campaign, and post-campaign) were modeled using a Poisson log-linear regression with inference based on the generalized estimating equations. RESULTS: Statistically significant increases in calls to both the VCL and the NSPL were reported during the TASP campaign in implementation cities, but were not reported in control cities during or following the campaign. Secondary outcome measures were also reported for the VCL and included the percentage of callers who are veterans, and calls resulting in a rescue during the study period. CONCLUSIONS: Results from this study reveal some promise for suicide prevention messaging to promote the use of telephone crisis services and contribute to an emerging area of research examining the effects of campaigns on help seeking.

Age-related concerns of male veteran callers to a suicide crisis line.

In July 2007, the United States Department of Veterans Affairs (VA) partnered with the Department of Health and Human Services' Substance Abuse and Mental Health Service Administration (SAMHSA) to create the Veterans Crisis Line (VCL) in order to meet the unique needs of Veterans in distress. The current study utilized a mixed methods design to examine characteristics of male callers to the VCL. Results from qualitative analyses demonstrated that the majority of callers between April 1 and August 31, 2008 contacted the VCL with concerns related to mental health issues, suicide ideation, and substance abuse issues. Quantitative analyses demonstrated age differences associated with concerns presented by callers such that middle-aged and older callers were more likely to present with loneliness and younger callers were more likely to present with mental health concerns. The results of this study will help to inform future research designed to optimize the effectiveness of the VCL for suicide prevention in Veterans.

Suicide prevention and postvention resources: what psychiatry residencies can learn from the Veteran's Administration experience.

Suicide risk assessment and coping with the loss of a patient through suicide are two of the more challenging aspects of psychiatry residency. Over the last decade, the Department of Veterans Affairs has focused on a significant effort into the development of a comprehensive suicide prevention. This article aims to describe the initiatives and resources in place at the VHA to help address the issue of suicidal behavior in veterans and how residency programs can use this to enhance teaching of suicide prevention and postvention.

Using media to promote suicide prevention hotlines to Veteran households.

This article presents preliminary evidence that media campaigns are valuable in promoting suicide prevention hotlines to Veteran households by reporting data from 2526 telephone surveys. Findings from this study underscore the need for further investigation of the use of media campaigns to support suicide prevention initiatives aimed at Veteran populations.

Influences on call outcomes among veteran callers to the National Veterans Crisis Line.

The association of caller and call characteristics with proximal outcomes of Veterans Crisis Line calls were examined. From October 1-7, 2010, 665 veterans with recent suicidal ideation or a history of attempted suicide called the Veterans Crisis Line; 646 had complete data and were included in the analyses. A multivariable multinomial logistic regression was conducted to identify correlates of a favorable outcome (a resolution or a referral) when compared to an unfavorable outcome (no resolution or referral). A multivariable logistic regression was used to identify correlates of responder-rated caller risk in a subset of calls. Approximately 84% of calls ended with a favorable outcome, 25% with a resolution, and 59% with a referral to a local health care provider. Calls from high-risk callers had greater odds of ending with a referral than without a resolution or referral, as did weekday calls (6:00 am to 5:59 pm EST, Monday through Friday). Responders used caller intent to die and the absence of future plans to determine caller risk. Findings suggest that the Veterans Crisis Line is a useful mechanism for generating referrals for high-risk veteran callers. Responders appeared to use known risk and protective factors to determine caller risk.

Changes in suicide rates and in mental health staffing in the veterans health administration, 2005-2009.

OBJECTIVE: Between 2005 and 2009, the Veterans Health Administration (VHA) enhanced its mental health programs and increased outpatient mental health staffing by 52.8%. However, suicide rates among VHA patients remained the same. This study evaluated this finding by examining variability in staffing increases between VHA's 21 regional networks (Veterans Integrated Service Networks) (VISNs) and associations with suicide rates. METHODS: Suicide rates among VHA patients were derived from the National Death Index and VHA clinical and administrative records for 2005 and 2009. Comparisons across VISNs used measures of proportional change in mental health staffing (overall and in inpatient, residential, intensive case management, and outpatient programs) and comparable measures of mental health staffing per 1,000 mental health patients. RESULTS: Significant correlations were found between proportional changes from 2005 to 2009 in suicide rates and outpatient mental health staffing (r=-.453, p=.039) and outpatient mental health staffing per 1,000 patients (r=-.533, p=.013). The ten VISNs above the median in proportional changes in mental health staffing had average decreases in suicide rates of 12.6% while those below had increases of 11.6% (p=.005). For proportional changes in mental health staffing per 1,000 patients, those above the median had decreases of 11.2% and those below had increases of 13.8% (p=.014). For the average VISN, it would have required a 27.5%-36.8% increase in outpatient staff over 2005 levels to decrease suicide rates by 10%. CONCLUSIONS: Mental health enhancements in VHA were associated with decreases in suicide rates in VISNs where the increases in mental health outpatient staffing were greatest.

Helping elderly patients to avoid suicide: a review of case reports from a National Veterans Affairs database.

This study examines the health system factors associated with completed suicide among veterans older than 65 years. All root cause analysis reports of suicides that occurred between 2008 and 2010 in the Veterans Health Administration were reviewed; of those, 46 reports were for those 65 years or older. The average age in the sample was 76.96 years; all were men. Method of suicide, stressors, previous attempts, root causes, and action plans designed to address the root causes are reported. Based on these results, recommendations are made for the assessment and treatment of suicide in elderly men.

Evaluation of a suicide prevention training curriculum for substance abuse treatment providers based on Treatment Improvement Protocol Number 50.

Substance use disorders (SUDs) confer risk for suicide yet there are no empirically supported suicide prevention training curricula tailored to SUD treatment providers. We assessed the efficacy of a 2-hour training that featured a suicide prevention training video produced by the Department of Veterans Affairs. The video was based on Treatment Improvement Protocol Number 50 (TIP 50) a practical manual to manage suicide risk produced by the Substance Abuse and Mental Health Services Administration. The training was provided in small groups to 273 SUD treatment providers in 18 states. Results were evaluated using self-report assessments obtained at pre-test, post-test, and 2-month follow-up. Statistically significant changes (p < .001) within subjects were obtained on self-efficacy, knowledge, and frequency of suicide prevention practice behaviors. The positive results together with the brevity of the training and its ease of implementation indicate high potential for widespread adoption and the importance of further study.