Improving depression management with support from close others: A thematic analysis of individuals with depression and their partners in care.

OBJECTIVES: With support from others, individuals with depression can build skills and implement lifestyle changes that help them manage their illness. The objective of the current study was to understand how the CarePartners for Depression Program, a randomized clinical trial aimed at enhancing the role of caregivers in the management of depression, improved communication and shared understandings of depression among individuals with depression and their close others. METHODS: We conducted in-depth, semi-structured interviews with individuals with depression and their caregivers who participated in the CarePartners program. Interviews were qualitatively coded using a thematic analytic framework. RESULTS: We conducted individual interviews with 39 participants in the CarePartners program, including 18 individuals with depression, 14 out-of-home care partners, and 7 informal caregivers. Three central themes were derived from analyses: (a) The quality of interpersonal relationships influenced the management of depression; (2) having clearly defined roles for CarePartners improved communication between CarePartners and individuals with depression; and (3) shared understanding of depression improved management of depression. DISCUSSION: Our findings established the conditions under which the management of depression was influenced in a dyadic intervention. Dyadic interventions may make it easier for individuals to support patients with depression by fostering communication and collaboration.

The association between lifetime trauma exposure typologies and mental health outcomes among veterans.

We know little about veterans' lifetime trauma exposure patterns and how such patterns are associated with mental health outcomes. This study sought to identify lifetime trauma exposure typologies among veterans and examine associations between these typologies and mental health outcomes. It used baseline data from a national longitudinal mail-based survey of 3,544 veterans and oversampled for women (51.6%) and veterans living in high crime areas (67.6%). Most veterans (94.2%) reported trauma exposure, and 80.1% reported exposure to two or more traumas. Prevalence of mental health outcomes was: 27.7% anxiety, 31.3% depression, 37.9% posttraumatic stress disorder, 44.4% alcohol use disorder, 10.4% suicide attempt, and 33.5% mental health comorbidity. Latent class analysis was used to identify patterns of lifetime trauma exposure and logistic regression was used to examine the odds of mental health outcomes as a function of class membership. Five lifetime trauma exposure typologies emerged: (1) low trauma; (2) high combat and community violence; (3) intimate partner violence trauma; (4) high global physical assault; and (5) high trauma. Classes showed differential associations with mental health outcomes. Findings have implications for clinical practice including informing providers' mental health treatment plans to correspond to each veteran's trauma exposure typology.

Relationship of perceived neighborhood danger with depression and PTSD among veterans: The moderating role of social support and neighborhood cohesion.

Little is known about the impact of perceived neighborhood danger on military veterans' mental health, a population potentially at higher risk for this experience, or whether interpersonal social support and neighborhood cohesion can help buffer against poor mental health. This study examined: (1) the impact of perceived neighborhood danger on depression and posttraumatic stress disorder (PTSD) among veterans; (2) whether interpersonal social support and neighborhood cohesion can mitigate these effects; and (3) how prior trauma history may interact with these factors. Six moderation models were examined using data from 3049 veterans enrolled in the Longitudinal Investigation of Gender, Health, and Trauma study, a mail-based survey that oversampled for veterans in high crime neighborhoods. Most notably, results indicated that perceived neighborhood danger was associated with increased depression and PTSD (all p < .001). Interpersonal social support or neighborhood cohesion mitigated the effect of perceived neighborhood danger on veterans' depression, but, only for those without prior trauma (all p < .011). For trauma-exposed veterans, interpersonal social support was more effective in mitigating the effect of perceived neighborhood danger on depression than neighborhood cohesion (p = .006). Findings help inform interventions to improve the mental health of veterans living in high crime neighborhoods.

Patterns of adverse childhood experiences and cardiovascular risk factors in U.S. adults.

Adverse Childhood Experiences (ACEs) are associated with poor health yet, we know little about how distinct patterns of ACE types are associated with cardiovascular (cardiovascular (CVD)) risk factors. The current study 1) examined associations of latent ACE classes with modifiable CVD risk factors including high cholesterol, smoking, diabetes, hypertension, high triglycerides, physical inactivity, overweight/obesity, and lifetime depression; and 2) examined the impact of socioeconomic status-related (SES) factors on these relationships. Using a cross-sectional analysis of the National Epidemiologic Survey of Alcohol and Related Conditions-III (n = 36,309) data, four latent classes of ACEs were previously identified: 1) low adversity, 2) primarily household dysfunction, 3) primarily maltreatment, and 4) multiple adversity types. We examined the association of these classes with CVD risk factors in adulthood and subsequently, the same model accounting for SES-related factors. Tobacco smoking, overweight/obesity, and lifetime depression were each associated with higher odds of being in classes 2, 3, and 4 than class 1, respectively. These relationships held after adjusting for SES-related factors. Class 4 was associated with the most CVD risk factors, including high triglycerides and high cholesterol after controlling for SES-related factors. The consistent associations between tobacco smoking, overweight/obesity, and lifetime depression with each adverse ACE profile, even after controlling for SES, suggest behavioural CVD prevention programs should target these CVD risk factors simultaneously.

PTSD and Depression Symptoms Increase Women's Risk for Experiencing Future Intimate Partner Violence.

Psychological distress may impact women's risk for future intimate partner violence (IPV). Yet, limited research has utilized longitudinal research designs and there is a scarcity of research looking at the three most commonly implicated mental health factors-posttraumatic stress disorder (PTSD), depression, and alcohol use-within the same study. Research is especially scarce for women veterans, who experience substantial risk for these mental health concerns and experiencing IPV. This study examined the role of PTSD symptoms, depression symptoms, and alcohol use in increasing risk for experiencing future IPV while simultaneously accounting for the impact of recent IPV experience on subsequent mental health. This study included a sample of 1921 women veterans (Mage = 36.5), who were asked to complete three mail surveys over the course of 8 months as part of a larger longitudinal survey study of US veterans' health and well-being. The survey assessed experiences of IPV, PTSD symptoms (PCL-5), depression symptoms (PHQ-9), and alcohol use (AUDIT-C) at each of the three time points. Results from separate path analysis models provided support for the role of PTSD symptoms and depression symptoms (but not alcohol use) in increasing risk for IPV experience over time. However, the path analysis models provided little support, with the exception of PTSD, for the impact of IPV experience on subsequent mental health symptoms. Findings point to the importance of better understanding the mechanisms by which PTSD and depression symptoms can increase risk for IPV to inform theory and prevention and treatment efforts. Detection and treatment of PTSD and depression symptoms among women may help reduce risk for future violence in intimate relationships.

Association Between Mental Health Conditions and Outpatient Care Fragmentation: a National Study of Older High-Risk Veterans.

BACKGROUND: Healthcare fragmentation may lead to adverse consequences and may be amplified among older, sicker patients with mental health (MH) conditions. OBJECTIVE: To determine whether older Veterans with MH conditions have more fragmented outpatient non-MH care, compared with older Veterans with no MH conditions. DESIGN: Retrospective cohort study using FY2014 Veterans Health Administration (VHA) administrative data linked to Medicare data. PARTICIPANTS: 125,481 VHA patients ≥ 65 years old who were continuously enrolled in Medicare Fee-for-Service Parts A and B and were at high risk for hospitalization. MAIN OUTCOME AND MEASURES: The main outcome was non-MH care fragmentation as measured by (1) non-MH provider count and (2) Usual Provider of Care (UPC), the proportion of care with the most frequently seen non-MH provider. We tested the association between no vs. any MH conditions and outcomes using Poisson regression and fractional regression with logit link, respectively. We also compared Veterans with no MH condition with each MH condition and combinations of MH conditions, adjusting for sociodemographics, comorbidities, and drive-time to VHA specialty care. KEY RESULTS: In total, 47.3% had at least one MH condition. Compared to those without MH conditions, Veterans with MH conditions had less fragmented care, with fewer non-MH providers (IRR = 0.96; 95% CI: 0.96-0.96) and more concentrated care with their usual provider (OR = 1.08 for a higher UPC; 95% CI: 1.07, 1.09) in adjusted models. Secondary analyses showed that those with individual MH conditions (e.g., depression) had fewer non-MH providers (IRR range: 0.86-0.98) and more concentrated care (OR range: 1.04-1.20). A similar pattern was observed when examining combinations of MH conditions (IRR range: 0.80-0.90; OR range: 1.16-1.30). CONCLUSIONS: Contrary to expectations, having a MH condition was associated with less fragmented non-MH care among older, high-risk Veterans. Further research will determine if this is due to different needs, underuse, or appropriate use of healthcare.

Systematic Review of Dyadic Interventions for Ambulatory Care Sensitive Conditions: Current Evidence and Key Gaps.

OBJECTIVES: Identify non-pharmacological interventions to support patient/caregiver dyads with ACSCs; review the effects of dyadic interventions on health services outcomes; and review the effectiveness of dyadic interventions on patient and caregiver biopsychosocial outcomes. METHODS: A systematic review of randomized controlled trials (RCTs). RESULTS: Twenty-six manuscripts representing 20 unique RCTs (Mean N = 154 patients, 140 caregivers) were eligible. Eleven RCTs examined caregiving in patients with HF, seven with T2DM, one with COPD, and one with mixed ACSCs. Dyadic interventions for ACSCs were diverse in terms of length and content, with most including an educational component. Only 4/26 included studies had a low risk of bias. Interventions were most successful at improving quality of life, clinical health outcomes, health behaviors, and health services outcomes, with fewer improvements in patient mental health outcomes, psychosocial outcomes, relationship outcomes, and caregiver outcomes in general. The largest effect sizes were reported from trials focused on T2DM. CONCLUSIONS: High-quality research with consistent measuring instruments is needed to understand which interventions are associated with improved patient and caregiver outcomes. CLINICAL IMPLICATIONS: There may be clinically relevant benefits to including caregivers in interventions for patients with ACSCs, and clinicians should consider this when devising treatment plans.

Screening for Intimate Partner Violence in Family Mediation: An Examination of Multiple Methodological Approaches Using Item Response Theory.

Many divorcing/separating parties seeking mediation to resolve family-related issues report intimate partner violence (IPV) victimization from the other party in the case. It is imperative that mediation staff screen parties for IPV so they can make informed decisions regarding how to proceed with mediation. Existing IPV screens for mediation have significant limitations. We examined three methodological approaches using item response theory that address these limitations by increasing the efficiency and clinical utility of an existing standardized IPV screen for mediation, the Mediator's Assessment of Safety Issues and Concerns (N = 904 mediating parties). We identified three subsets of items, with initial evidence for their validity, focused on helping mediation staff identify high levels of IPV or parties at risk for potentially negative mediation outcomes or needing specialized safety accommodations in mediation. Clinical recommendations are provided indicating which approach is most promising to be used in mediation settings. Overall, findings help advance understanding of how item response theory methodology can enhance the precision of IPV screening in mediation.

Substance Use, PTSD Symptoms, and Suicidal Ideation Among Veteran Psychiatry Inpatients: A Latent Class Trajectory Analysis.

OBJECTIVE: In this study, we aimed to inform clinical practice by identifying distinct subgroups of U.S. veteran psychiatry inpatients on their alcohol and drug use severity, posttraumatic stress disorder (PTSD) symptoms, and suicidal ideation over time. METHOD: Participants were 406 patients with co-occurring substance use and mental health disorders. A parallel latent growth trajectory model was used to characterize participants' symptom severity across 15 months posttreatment intake. RESULTS: Four distinct classes were identified: 47% "normative improvement," 32% "high PTSD," 11% "high drug use," and 9% "high alcohol use." Eighty percent of the sample had reduced their drinking and drug intake by half from baseline to 3 months, and those levels remained stable from 3 to 15 months. The High PTSD, High Drug Use, and High Alcohol Use classes all reported levels of PTSD symptomatology at baseline consistent with a clinical diagnosis, and symptom levels remained high and stable across all 15 months. The Normative Improvement class showed declining drug and alcohol intake and was the only class exhibiting reductions in PTSD symptomatology over time. High substance use classes showed initial declines in suicidal ideation, then an increase from 9 to 15 months. CONCLUSIONS: The reduction in frequency of drinking and drug use for 80% of the sample was substantial and supports the potential efficacy of current treatment approaches. However, the high and stable levels of PTSD for more than 50% of the sample, as well as the reemergence of suicidal ideation in a sizable subgroup, underscore the difficulty in finding and linking patients to effective interventions to decrease symptomatology over time.

Concerned others' help utilization and patients' alcohol treatment outcomes.

BACKGROUND: This study of dyads composed of patients in treatment for alcohol use disorders (AUDs) and their Concerned Others (COs) examined (1) COs' attendance at three types of help (educational sessions, treatment sessions with the patient, and treatment sessions without the patient) during a 3-month period after patients' admission, and (2) whether COs' use of help was associated with better treatment outcomes reported by COs about patients, and patients about themselves. METHODS: Dyads (n = 277) were assessed when patients entered AUD treatment and 3 months later (80 %). COs rated their patient's AUD, and patients rated their own AUD, on the Brief Addiction Monitor. At 3-month follow-up, COs answered three items about help (education, treatment with patient, treatment without patient) from their patient's treatment program. Main analyses were analyses of covariance to examine associations between COs' help use and patients' outcomes. RESULTS: At 3-month follow-up, COs who had obtained one type of help were significantly more likely to have also obtained the other two types of help. However, relatively few COs (39 %) obtained any type of help. COs who obtained help rated their patient as having more protection against future substance use. And, when COs had obtained help, patients rated themselves as having less risk of future substance use, and had attended a greater number of AA meetings, than when COs had not obtained help. CONCLUSIONS: Findings suggest that COs' use of help can benefit patients in AUD treatment. Clinicians and researchers should increase the availability and use of help among COs.

Patients With Alcohol Use Disorders and Their Concerned Others: Concordance of Lived Experience as a Moderator of Treatment Outcomes.

OBJECTIVE: Growing up with an adult with an alcohol use disorder (AUD) is common and negatively affects adult functioning. This study examined two questions concerning the lived experience of growing up in a home with AUD. METHOD AND RESULTS: The first question asked how adults entering AUD treatment (n = 402) who had this lived experience (58%) compared to those who did not (42%) on indicators of alcohol use severity. Patients with lived experience reported alcohol use at a younger age, more times having been arrested and charged, and greater risk for future substance use. The second question examined concordance between patients and their concerned others on this lived experience (n = 277 dyads) and patients' treatment outcomes 3 months later. The associations between patients' lived experience and better treatment outcomes were stronger when patients' concerned others had a concordant lived experience. When patient-concerned other dyads reported concordant lived experiences at baseline, patients had lower substance use and risk scores at the 3-month follow-up than when the dyads reported discordant lived experiences with regard to growing up in a home with AUD; effect sizes were small. CONCLUSIONS: Concordance and discordance on this lived experience could be considered in treatment planning for patients with AUD and their concerned others. Providers could ask about each member's childhood and aim interventions at helping dyads discuss their childhoods in ways that validate each other's needs and provide emotional support, without stigmatization. Delivery may consider relationship type (spousal or other) and be in educational or treatment sessions that include the dyad or one member.

An Examination of the Association Between Patient Experience and Quality of Mental Health Care Among Women Veterans.

Improving patient experience is one strategy that may increase the quality of mental health care if better experience is linked to the likelihood of a potentially therapeutic dose (PTD) of treatment. This study sought to examine: (1) the proportion of women veterans who obtained a PTD of mental health treatment; and (2) the association between women's experiences with Veterans Health Administration (VHA) mental health services and obtaining a PTD of mental health treatment. We assessed patient experience via a survey that measured experiences with gender-sensitive care, ease of getting care, perceived quality of care, and extent to which care met needs. We used VHA administrative data to determine mental health utilization across a national sample of 2109 women veterans with episodes of mental health care that included psychotherapy or pharmacotherapy. Results indicated that 71% of women received a PTD. Positive ratings regarding perceived quality of care and whether care met needs were associated with higher odds of receiving a PTD of treatment. Findings provide supporting evidence for the continued necessity  of offering patient-centered mental health care to women veterans. Careful consideration of women veterans' mental health care experiences may be crucial in promoting high value mental health care for this population in VHA.

Psychotherapy Utilization, Preferences, and Retention among Women Veterans with Post-traumatic Stress Disorder.

BACKGROUND: Psychotherapy is the gold standard treatment for post-traumatic stress disorder (PTSD), yet psychotherapy use and retention among veterans is low. Little is known about the barriers to care and factors associated with women veterans' PTSD psychotherapy use and retention. Using a nationally representative sample of 986 women Veterans Health Administration primary care users with PTSD and a perceived need for mental health care, we examined 1) the proportion of women who used psychotherapy, 2) retention in psychotherapy among women who used any psychotherapy, and 3) individual factors related to psychotherapy use and retention. METHODS: Women completed a survey on their mental health care experiences. Outpatient mental health care use in the year before the survey was obtained from Veterans Health Administration administrative data. RESULTS: Most women (79.1%) used psychotherapy, and 41.7% of those women had a minimal therapeutic dose of psychotherapy (≥8 visits). Mental health diagnostic comorbidity and being African American/Black or identifying as neither African American/Black nor White were significantly associated with higher psychotherapy use. Mental health diagnostic comorbidity, exposure to military sexual trauma, and receiving treatment aligned with gender-related and group-related preferences were associated with higher psychotherapy retention. Being a parent was associated with lower retention. CONCLUSIONS: Although a significant proportion of women veterans with PTSD are using psychotherapy, retention is enhanced when women are able to obtain treatment aligned with their preferences. Thus, efforts to promote patient-centered, shared decisions regarding mental health treatment options could increase the efficacy and efficiency of treatment for PTSD among women.

Trying Times and Trying Out Solutions: Intimate Partner Violence Screening and Support for Women Veterans During COVID-19.

Initial reports indicate widespread increases in intimate partner violence (IPV) rates during the coronavirus disease 2019 (COVID-19) pandemic. Women veterans are at particular risk for experiencing IPV, and the COVID-19 pandemic and resulting stay-at-home orders may be exacerbating this risk. IPV screening and intervention are an integral part of the care provided to women veterans in the Veteran's Health Administration (VHA). Current changes in healthcare delivery during COVID-19 may present challenges to the VHA's standard methods of initiating IPV screening and intervention with women veterans. We discuss the potential challenges VHA healthcare providers may be encountering when conducting routine IPV screening during the COVID-19 pandemic and when providing resources and support to women veterans experiencing IPV. We describe solutions to these challenges, including existing efforts led by the VHA IPV Assistance Program (IPVAP) as well as additional potential solutions. New ideas and partnerships will be critical for helping the VHA continue to assist women veterans experiencing IPV as the COVID-19 pandemic evolves. Though our focus is on women veterans and the VHA, the challenges and solutions we discuss are likely applicable to other populations experiencing IPV and other health care systems screening for IPV.

Mediator's Assessment of Safety Issues and Concerns (MASIC): reliability and validity of a new intimate partner violence screen.

We investigated reliability and validity of the Mediator's Assessment of Safety Issues and Concerns (MASIC), a screening interview for intimate partner violence and abuse (IPV/A) in family mediation settings. Clients at three family mediation clinics in the United States and Australia (N = 391) provided reports of the other parent's IPV/A. Internal consistency of the total screen was excellent. A confirmatory factor analysis provided evidence that the MASIC assesses seven types of IPV/A: psychological abuse, coercive controlling behaviors, threats of severe violence, physical violence, severe physical violence, sexual violence, and stalking. Sex differences on differing types of violence victimization were generally consistent with previous research. Higher levels of victimization predicted self-reported consequences of abuse (e.g., fear, injuries). More abusive parties, as identified by their partners on the MASIC, had more Protective Orders and No Contact Orders and criminal convictions and crimes potentially related to IPV/A. Results provide initial evidence of the reliability and validity of the MASIC but more research is needed.