Factors Influencing Adherence to Insomnia and Obstructive Sleep Apnea Treatments among Veterans with Mild Traumatic Brain Injury.

OBJECTIVE: To understand factors influencing adherence to recommended treatment for insomnia and obstructive sleep apnea (OSA) among Veterans with mild traumatic brain injury (mTBI). METHOD: Semi-structured interviews (n = 49) with 29 clinical stakeholders and 20 Veterans were conducted. Clinical stakeholders included Veterans Health Administration providers and policymakers involved in the management of mTBI and/or sleep disorders. Veterans included those with a clinician-confirmed mTBI with a recent history of insomnia disorder and/or OSA treatment. Themes were identified using a Descriptive and Interpretive approach. RESULTS: Barriers to sleep disorder treatment adherence included factors associated with the patient (e.g., negative appraisal of treatment benefit), intervention (e.g., side effects), health conditions (e.g., cognitive challenges), health care system (e.g., limited availability of care), and socioeconomic status (e.g., economic instability). Similarly, facilitators of adherence included patient- (e.g., positive appraisal of treatment benefit), intervention- (e.g., flexible delivery format), condition- (e.g., accommodating cognitive impairments), health care system- (e.g., access to adherence support), and socioeconomic-related factors (e.g., social support). CONCLUSIONS: Interviews revealed the multi-faceted nature of factors influencing adherence to sleep disorder treatment among Veterans with mTBI. Findings can inform the development of novel interventions and care delivery models that meet the complex needs of this population.

Factors influencing shared decision-making for insomnia and obstructive sleep apnea treatment among veterans with mild traumatic brain injury.

STUDY OBJECTIVES: We elicited perspectives of clinical stakeholders and Veterans regarding barriers and facilitators to implementing shared decision-making (SDM) for co-morbid mild traumatic brain injury (mTBI) and sleep disorders in the Veterans Health Administration (VHA). We also compared the perspectives of clinical stakeholders and Veterans regarding determinants of SDM. METHODS: Semi-structured interviews were conducted with 29 clinical stakeholders and 20 Veterans (n=49). Clinical stakeholders included VHA providers and policymakers involved in the management of mTBI and/or sleep disorders (insomnia disorder; obstructive sleep apnea [OSA]). Veterans included those with a clinician-confirmed mTBI who received care for insomnia disorder and/or OSA within the past year. Themes were identified using a Descriptive and Interpretive approach to qualitative analysis. We compared results across clinical stakeholders and Veterans. RESULTS: Barriers to implementing SDM were identified by both groups at the patient- (e.g., mTBI sequalae), provider- (e.g., de-prioritization of Veteran preferences), encounter- (e.g., time constraints), and facility-levels (e.g., reduced care access). Similarly, both groups identified facilitators at the patient- (e.g., enhanced trust), provider- (e.g., effective communication), encounter- (e.g., decision support), and facility-levels (e.g., mitigating access barriers). Integrated services and provider discontinuity were factors identified by clinical stakeholders and Veterans alone, respectively. CONCLUSIONS: Our study revealed factors shaping the implementation of SDM at the levels of the patient, provider, encounter, and facility. Findings can inform the development of strategies aimed at implementing SDM for co-morbid mTBI and sleep disorders, promoting patient-centered care and enhancing clinical outcomes.

Patients' Perspectives on Medication-Related Suicide Prevention Interventions Delivered in Emergency Settings.

OBJECTIVE: Encouraging patients at risk for suicide to reduce access to potentially lethal medications and drugs is a key component of evidence-based suicide prevention. However, little research has been done to inform interventions for reducing intentional self-harm. METHODS: Semistructured interviews were conducted with 28 U.S. veterans who sought emergency care from the Veterans Health Administration between 2021 and 2023 to explore veterans' perspectives on medication-related interventions, including opinions on intervention components (e.g., medication return envelopes). Matrix analysis was used to aggregate data into categories, which were predefined by using constructs from the health belief model (e.g., perceived benefits). RESULTS: The participating veterans generally endorsed interventions as acceptable and were particularly supportive of distributing medication return envelopes. However, they often conceptualized these efforts as steps to prevent unintentional overdose or theft-not necessarily to prevent suicide-and rarely indicated that such interventions were appropriate for themselves. Across the interviews, participants identified important facilitators to care, such as ensuring that interventions were convenient and accounted for the perceived cost of disposing medications. Perspectives on engaging family or friends in interventions were mixed. The importance of the interventions was more readily acknowledged among participants with previous opioid use exposure-perspectives that appeared to stem from lived experiences. CONCLUSIONS: This study contributes important foundational knowledge that can be used to inform research and clinical initiatives aimed at preventing medication- and drug-related suicides.

Expanding access to evidence-based psychotherapy in VA settings: implementation of the brief cognitive behavioral therapy for depression program.

Introduction: Evidence-based psychotherapies (EBPs) are effective for mental health conditions, but access to these services remains limited and rural Veterans are particularly underserved. Specialized implementation and dissemination programs are needed to improve access to known EBPs. Methods: The current project sought to improve access to a known EBP-brief Cognitive Behavioral Therapy for depression (Brief CBT). Diverse Veterans and those from rural settings were a focus of this work. Aligned with the RE-AIM framework, a multifaceted implementation program was used to train and support VHA providers in their use of Brief CBT in VHA mental health settings, with specific outreach efforts made to providers at VHA Community-Based Outpatient Clinics (CBOCs) where rural Veterans often receive care. Evaluation included all facets of RE-AIM with a particular focus on adoption, effectiveness, and maintenance. Results: During the first two years, over 40 VHA facilities adopted the program across four regional networks. Eighty-three providers were approached, and 54 (65.1%) providers completed the training and are delivering the intervention. A total of 688 Veterans, 174 rural (25.7%), received 2,186 sessions (average of 3.5 sessions per Veteran). Veterans receiving Brief CBT with elevated depression scores who completed three or more sessions were found to have significant symptom reductions of 4.6 points (first to last available evaluations). Discussion: Implementation efforts of Brief CBT resulted in rapid uptake and significant clinical impact on Veterans. Rural outreach efforts, including targeted training for CBOC providers and use of tele-mental health, enhanced availability of EBP services for rural Veterans.

A pilot of a veteran suicide prevention learning collaborative among community organizations: Initial results and outcomes.

INTRODUCTION: Veteran suicide remains an ongoing public health concern in need of fresh, community-based initiatives. The Department of Veterans Affairs (VA) has built an enterprise-wide integrated behavioral health system that has pioneered numerous suicide prevention methods. However, most Veterans receive healthcare outside the VA, from organizations that may not be equipped to address Veteran suicide risk. One solution is implementing a VA/community suicide prevention learning collaborative to support organizations in implementing suicide prevention best practices for Veterans. Although learning collaboratives have a history of supporting improved patient safety in healthcare systems, to our knowledge, none have focused on Veteran suicide prevention. METHOD: The current quality improvement project sought to pilot a VA/community suicide prevention learning collaborative in the broader Denver and Colorado Springs areas with 13 organizations that served, interacted with, or employed Veterans. RESULTS: The collaborative had a large footprint in the region, with organizations interacting with over 24,000 community members and over 5000 Veterans. Organizations implemented 92 Veteran suicide prevention program components within a 16-month period. Overall, the learning collaborative made significant strides in Veteran suicide prevention. CONCLUSION: Findings suggest that this method facilitates rapid implementation of Veteran suicide prevention practices and may be promising for accelerating uptake within communities.

COVID-19 and Lifetime Experiences of Trauma, Moral Injury, and Institutional Betrayal Among Healthcare Providers.

OBJECTIVE: The aim of the study is to increase understanding regarding healthcare provider experiences with psychological trauma, moral injury, and institutional betrayal, both over the lifetime and during the COVID-19 pandemic. METHODS: The study employed a cross-sectional design to understand traumatic experiences, moral injury, and institutional betrayal among medical and mental health providers. Participants were asked to identify an index trauma, and experiences were coded qualitatively using categories for traumatic events, moral injury, and institutional betrayal. RESULTS: Results revealed that experiences of trauma, moral injury, and institutional betrayal were common in relation to the pandemic, as were prepandemic histories of traumatic exposures. Findings indicate that trauma exposure was a work hazard for healthcare providers during the pandemic, which could result in negative long-term mental health outcomes. CONCLUSIONS: Future research is needed to explore potential long-term negative outcomes among healthcare providers.

Massed vs Intensive Outpatient Prolonged Exposure for Combat-Related Posttraumatic Stress Disorder: A Randomized Clinical Trial.

Importance: Improved, efficient, and acceptable treatments are needed for combat-related posttraumatic stress disorder (PTSD). Objective: To determine the efficacy of 2 compressed prolonged exposure (PE) therapy outpatient treatments for combat-related PTSD. Design, Setting, and Participants: This randomized clinical trial was conducted among military personnel and veterans at 4 sites in Texas from 2017 to 2019. Assessors were blinded to conditions. Data were analyzed from November 2020 to October 2022. Interventions: The interventions were massed-PE, which included 15 therapy sessions of 90 minutes each over 3 weeks, vs intensive outpatient program PE (IOP-PE), which included 15 full-day therapy sessions over 3 weeks with 8 treatment augmentations. The IOP-PE intervention was hypothesized to be superior to massed-PE. Main Outcomes and Measures: Coprimary outcomes included the Clinician-Administered PTSD Scale for Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) (DSM-5) (CAPS-5) and the PTSD Checklist for DSM-5 (PCL-5) administered at baseline and posttreatment follow-ups. Measures ranged from 0 to 80, with higher scores indicating greater severity. Diagnostic remission and reliable change were secondary outcomes. Results: Among 319 military personnel and veterans screened, 234 were randomized (mean [SD] age, 39.20 [7.72] years; 182 [78%] male participants), with 117 participants randomized to IOP-PE and 117 participants randomized to massed-PE. A total of 61 participants (26%) were African American, 58 participants (25%) were Hispanic, and 102 participants (44%) were White; 151 participants (65%) were married. Linear mixed-effects models found that CAPS-5 scores decreased in both treatment groups at the 1-month follow-up (IOP-PE: mean difference, -13.85 [95% CI, -16.47 to -11.23]; P < .001; massed-PE: mean difference, -14.13 [95% CI, -16.63 to -11.62]; P < .001). CAPS-5 change scores differed from 1- to 6-month follow-ups (mean difference, 4.44 [95% CI, 0.89 to 8.01]; P = .02). PTSD symptoms increased in massed-PE participants during follow-up (mean difference, 3.21 [95% CI, 0.65 to 5.77]; P = .01), whereas IOP-PE participants maintained treatment gains (mean difference, 1.23 [95% CI, -3.72 to 1.27]; P = .33). PCL-5 scores decreased in both groups from baseline to 1-month follow-up (IOP-PE: mean difference, -21.81 [95% CI, -25.57 to -18.04]; P < .001; massed-PE: mean difference, -19.96 [95% CI, -23.56 to -16.35]; P < .001) and were maintained at 6 months (IOP-PE: mean change, -0.21 [95% CI, -3.47 to 3.06]; P = .90; massed-PE: mean change, 3.02 [95% CI, -0.36 to 6.40]; P = .08). Both groups had notable PTSD diagnostic remission at posttreatment (IOP-PE: 48% [95% CI, 36% to 61%] of participants; massed-PE: 62% [95% CI, 51% to 73%] of participants), which was maintained at 6 months (IOP-PE: 53% [95% CI, 40% to 66%] of participants; massed-PE: 52% [95% CI, 38% to 66%] of participants). Most participants demonstrated reliable change on the CAPS-5 (61% [95% CI, 52% to 69%] of participants) and the PCL-5 (74% [95% CI, 66% to 81%] of participants) at the 1-month follow-up. Conclusions and Relevance: These findings suggest that PE can be adapted into compressed treatment formats that effectively reduce PTSD symptoms. Trial Registration: ClinicalTrials.gov Identifier: NCT03529435.

Leveraging available metadata in VA PTSD clinics and generating benchmarks for clinically significant change.

OBJECTIVE: Measurement-based care is designed to track symptom levels during treatment and leverage clinically significant change benchmarks to improve quality and outcomes. Though the Veterans Health Administration promotes monitoring progress within posttraumatic stress disorder (PTSD) clinical teams, actionability of data is diminished by a lack of population-based benchmarks for clinically significant change. We reported the state of repeated measurement within PTSD clinical teams, generated benchmarks, and examined outcomes based on these benchmarks. METHOD: PTSD Checklist for the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition data were culled from the Corporate Data Warehouse from the pre-COVID-19 year for Veterans who received at least eight sessions in 14 weeks (episode of care [EOC] cohort) and those who received sporadic care (modal cohort). We used the Jacobson and Truax (1991) approach to generate clinically significant change benchmarks at clinic, regional, and national levels and calculated the frequency of cases that deteriorated, were unchanged, improved, or probably recovered, using our generated benchmarks and benchmarks from a recent study, for both cohorts. RESULTS: Both the number of repeated measurements and the cases who had multisession care in the Corporate Data Warehouse were very low. Clinically significant change benchmarks were similar across locality levels. The modal cohort had worse outcomes than the EOC cohort. CONCLUSIONS: National benchmarks for clinically significant change could improve the actionability of assessment data for measurement-based care. Benchmarks created using data from Veterans who received multisession care had better outcomes than those receiving sporadic care. Measurement-based care in PTSD clinical teams is hampered by low rates of repeated assessments of outcome. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Leveraging the ExpandNet framework and operational partnerships to scale-up brief Cognitive Behavioral Therapy in VA primary care clinics.

Evidence-based psychotherapies (EBPs) are underused in health care settings. Aligning implementation of EBPs with the needs of health care leaders (i.e., operational stakeholders) can potentially accelerate their uptake into routine practice. Operational stakeholders (such as hospital leaders, clinical directors, and national program officers) can influence development and oversight of clinical programs as well as policy directives at local, regional, and national levels. Thus, engaging these stakeholders during the implementation and dissemination of EBPs is critical when targeting wider use in health care settings. This article describes how research-operations partnerships were leveraged to increase implementation of an empirically supported psychotherapy - brief Cognitive Behavioral Therapy (brief CBT) - in Veterans Health Administration (VA) primary care settings. The partnered implementation and dissemination efforts were informed by the empirically derived World Health Organization's ExpandNet framework. A steering committee was formed and included several VA operational stakeholders who helped align the brief CBT program with the implementation needs of VA primary care settings. During the first 18 months of the project, partnerships facilitated rapid implementation of brief CBT at eight VA facilities, including training of 12 providers who saw 120 patients, in addition to expanded program elements to better support sustainability (e.g., train-the-trainer procedures).

The Veterans Affairs Patient Safety Center of Inquiry-Suicide Prevention Collaborative: Creating Novel Approaches to Suicide Prevention Among Veterans Receiving Community Services.

BACKGROUND: While the US Department of Veterans Affairs has made significant strides to prevent veteran suicide, efforts have largely targeted veterans actively engaged in and eligible for Veterans Health Administration (VHA) care, which is consistent with the VHA mission. The majority of veterans are not enrolled in VHA care, and many are ineligible for services. Veterans not connected to VHA have experienced an increase in suicides in recent years. OBSERVATIONS: Since 2018, VHA National Center for Patient Safety has funded the Patient Safety Center of Inquiry-Suicide Prevention Collaborative (PSCI-SPC), which has worked to develop, implement, and evaluate practical solutions aimed at curbing the rising suicide rate among veterans not receiving VHA care. PSCI-SPC has 3 guiding objectives: (1) Develop and test a collaborative, organizational structure to connect VHA and community organizations, such as national, local, public, private, nonprofit, and academic partners who provide high-quality and timely health care; (2) Build and test a learning collaborative to facilitate sharing of VHA suicide prevention best practices with community partners to increase availability, consistency, and quality of mental health services for all veterans; and (3) Implement, test, and refine a novel program to provide affordable suicide prevention interventions to veterans with mental health needs, regardless of their use of, or eligibility for, VHA services. This paper details the current progress for this demonstration project. As these objectives are met, PSCI-SPC will create and disseminate products to support broad implementation of these practices to other VA medical centers and the communities they are embedded in. CONCLUSIONS: PSCI-SPC seeks to fill an important gap in veteran health care by serving as a national clinical innovation and dissemination center for best practices in suicide prevention for veterans who receive care in their communities.

Treatment selection among posttraumatic stress disorder (PTSD) specialty care providers in the Veterans Health Administration: A thematic analysis.

OBJECTIVE: Although efforts to implement evidence-based psychotherapies (EBPs) require understanding how providers view and initiate these interventions, little is known regarding provider treatment selection in posttraumatic stress disorder (PTSD) care. The current study examines how specialty PTSD clinic providers within the Veterans Health Administration (VHA) describe reasons for selecting specific psychotherapies in PTSD treatment planning. METHOD: VHA psychotherapists in specialty PTSD care clinics completed a national online survey of treatment attitudes and practices, including an open-ended item inquiring about treatment selection. Thematic analysis was used to develop a framework describing factors in VHA providers' PTSD treatment selection. RESULTS: Of 250 survey participants, 219 provided description of their treatment selection process. Providers identified four domains of factors impacting treatment planning: (1) provider factors (e.g., training), (2) perceived characteristics of the intervention (e.g., structural features), (3) patient factors (e.g., characteristics of the patient and symptom presentation), and (4) organizational context (e.g., VHA policy). Assessment of appropriate treatments for an individual patient was described as resulting from interaction across these domains, particularly perceived fit between patient needs and specific treatments. CONCLUSIONS: Provider decision making has been understudied in implementation science. Although prior research has emphasized the role of organizational context in EBP reach, our findings suggest that other factors are salient when decisions are made at the level of the individual patient. Results suggest that increased attention to treatment selection and focused training in use of decision aids and shared decision making may have utility in increasing uptake, reach, and sustainment of EBPs among VHA PTSD specialty providers. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Treatments Veterans Health Administration PTSD specialty program providers report their patients prefer: The role of training and theoretical orientation.

OBJECTIVE: A growing empirical literature demonstrates that evidence-based psychotherapies (EBPs) for posttraumatic stress disorder (PTSD) are effective for veterans. However, use of EBPs for PTSD in the Veterans Health Administration (VHA) remains low, and providers cite patient preference as a factor impacting EBP utilization. The purpose of this exploratory study was to assess the impact of provider factors such as theoretical orientation, occupation, graduate school training, or completion of VHA EBP training on providers' perceptions of patient preferences. METHOD: VHA providers in PTSD clinical teams were invited to participate in a national survey (n = 229, response rate 28%) assessing provider demographics and perceived patient preferences. RESULTS: Having a cognitive-behavioral therapy (CBT) orientation emerged as a robust predictor of reporting that veterans tend to choose EBPs and a non-CBT orientation that patients choose "other" therapies. VHA EBP training also impacted therapists' report of patient preference for an EBP. CONCLUSIONS: Results suggest that theoretical orientation and VHA EBP training meaningfully impact how providers perceive patient preference for EBP. Efforts to increase EBP engagement among veteran patients may benefit from enhancing both therapist and patient education, as well as shared decision-making skills among non-CBT-oriented providers. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Provider Attitudes and Experience With Measurement-Based Mental Health Care in the VA Implementation Project.

OBJECTIVE: Measurement-based care using patient-reported outcome measures has been shown to improve treatment outcomes for patients with mental illness. Despite wide availability of validated measures, measurement-based care is seldom used in clinical practice. METHODS: The authors conducted a survey of 230 mental health providers across 47 U.S. Department of Veterans Affairs medical centers. The survey measured provider attitudes and self-reported use of various components of measurement-based care. RESULTS: More than half of the providers (58%) reported collecting at least one measure for at least half of their patients. Psychiatrists reported using and sharing results less frequently than social workers, nurses, or psychologists. Psychologists reported the most use and sharing of patient-reported measures. CONCLUSIONS: In this convenience sample of providers, use of measurement-based care was reported to be common and attitudes about the utility of such care were positive. However, professional differences in the use of measurement-based care must be addressed to expand its use.

"I had to somehow still be flexible": exploring adaptations during implementation of brief cognitive behavioral therapy in primary care.

BACKGROUND: Primary care clinics present challenges to implementing evidence-based psychotherapies (EBPs) for depression and anxiety, and frontline providers infrequently adopt these treatments. The current study explored providers' perspectives on fidelity to a manualized brief cognitive behavioral therapy (CBT) as delivered in primary care clinics as part of a pragmatic randomized trial. Data from the primary study demonstrated the clinical effectiveness of the treatment and indicated that providers delivered brief CBT with high fidelity, as evaluated by experts using a standardized rating form. Data presented here explore challenges providers faced during implementation and how they adapted nonessential intervention components to make the protocol "fit" into their clinical practice. METHODS: A multiprofessional group of providers (n = 18) completed a one-time semi-structured interview documenting their experiences using brief CBT in the primary care setting. Data were analyzed via directed content analysis, followed by inductive sorting of interview excerpts to identify key themes agreed upon by consensus. The Dynamic Adaptation Process model provided an overarching framework to allow better understanding and contextualization of emergent themes. RESULTS: Providers described a variety of adaptations to the brief CBT to better enable its implementation. Adaptations were driven by provider skills and abilities (i.e., using flexible content and delivery options to promote treatment engagement), patient-emergent issues (i.e., addressing patients' broader life and clinical concerns), and system-level resources (i.e., maximizing the time available to provide treatment). CONCLUSIONS: The therapeutic relationship, individual patient factors, and system-level factors were critical drivers guiding how providers adapted EBP delivery to improve the "fit" into their clinical practice. Adaptations were generally informed by tensions between the EBP protocol and patient and system needs and were largely not addressed in the EBP protocol itself. Adaptations were generally viewed as acceptable by study fidelity experts and helped to more clearly define delivery procedures to improve future implementation efforts. It is recommended that future EBP implementation efforts examine the concept of fidelity on a continuum rather than dichotomized as adherent/not adherent with focused efforts to understand the context of EBP delivery. TRIAL REGISTRATION: ClinicalTrials.gov, NCT01149772.

The Patient Health Questionnaire depression screener in spinal cord injury.

CONTEXT: Although depression is not inevitable following spinal cord injury/dysfunction (SCI/D), it can have a negative impact on rehabilitation. Evidence-based assessment of depression utilizing self-report instruments, such as the Patient Health Questionnaire-9 (PHQ-9), is considered good clinical practice. Although the PHQ-9 has been studied in individuals with SCI/D, little is known about the clinical utility of the Patient Health Questionnaire-2 (PHQ-2). Traditional cutoff scores for the PHQ-2 were examined to explore their operating characteristics as related to PHQ-9 results. METHODS: Archival data were collected for 116 Veterans with SCI/D who completed the PHQ-2 and PHQ-9 as one component of their routine, comprehensive SCI annual evaluation at a Veterans Affairs Medical Center. Logistic regressions were performed to determine the impact of different cutoff scores for the PHQ-2 on the likelihood that participants would endorse clinically significant levels of depressive symptoms on the PHQ-9 (≥10). RESULTS: Using a cutoff score of 3 or greater correctly classified 94.8% of the cases, outperforming the other cutoff scores. A cutoff score of 3 or greater had a sensitivity of 83.3% and specificity of 97.8%, and yielded a positive predictive value of 90.9% and a negative predictive value of 95.7%. CONCLUSION: The PHQ-2 shows promise as a clinically useful screener in the community-residing SCI/D population. Findings regarding the presence of suicidal ideation emphasize the importance of routine screening for depressive symptomatology in the SCI/D population. Future research should investigate the role of the PHQ-2 in clinical decision-making and treatment monitoring.

Delivery of mental health treatment to combat veterans with psychiatric diagnoses and TBI histories.

Traumatic brain injury (TBI) and mental health (MH) disorders are prevalent in combat veterans returning from Afghanistan and/or Iraq (hereafter referred to as returning veterans). Accurate estimates of service utilization for veterans with and without TBI exposure (referred to as TBI history) are imperative in order to provide high quality healthcare to returning veterans. We examined associations between TBI history and MH service utilization in a subsample of returning veterans who were newly diagnosed with posttraumatic stress disorder (PTSD), depression, and/or anxiety in the 2010 fiscal year (N = 55,458). Data were extracted from the Veterans Health Administration (VHA) National Patient Care Database. Veterans with MH diagnoses and TBI histories attended significantly more psychotherapy visits, (M = 8.32 visits, SD = 17.15) and were more likely to attend at least 8 psychotherapy visits, (15.7%) than veterans with MH diagnoses but no TBI history (M = 6.48 visits, SD = 12.12; 10.1% attended at least 8 sessions). PTSD and TBI history, but not depression or anxiety, were associated with a greater number of psychotherapy visits when controlling for demographic and clinical variables. PTSD, anxiety, depression, and TBI history were associated with number of psychotropic medication-management visits. TBI history was related to greater MH service utilization, independent of MH diagnoses. Future research should examine what MH services are being utilized and if these services are helping veterans recover from their disorders.

Models for treating depression in specialty medical settings: a narrative review.

OBJECTIVE: This review answered two questions: (a) what types of specialty medical settings are implementing models for treating depression, and (b) do models for treating depression in specialty medical settings effectively treat depression symptoms? METHOD: We searched Medline/Pubmed to identify articles, published between January 1990 and May 2013, reporting on models for treating depression in specialty medical settings. Included studies had to have adult participants with comorbid medical conditions recruited from outpatient, nonstandard primary care settings. Studies also had to report specific, validated depression measures. RESULTS: Search methods identified nine studies (six randomized controlled trials, one nonrandomized controlled trial and two uncontrolled trials), all representing integrated care for depression, in three specialty settings (oncology, infectious disease, neurology). Most studies (N=7) reported greater reductions in depression among patients receiving integrated care compared to usual care, particularly in oncology clinics. CONCLUSIONS: Integrated care for depression in specialty medical settings can improve depression outcomes. Additional research is needed to understand the effectiveness of incorporating behavioral and/or psychological treatments into existing methods. When developing or selecting a model for treating depression in specialty medical settings, clinicians and researchers will benefit from choosing specific components and measures most relevant to their target populations.

Measuring disability-associated appraisals for veterans with spinal cord injury.

OBJECTIVE: Psychological adjustment following spinal cord injury and disorders (SCI/D) is a complex process. According to the Stress Appraisal and Coping Model, appraisals may mediate the relationship between disability and psychological adjustment. The purpose of the present study was to examine the psychometric properties and clinical utility of a short form of the Appraisals of Disability: Primary and Secondary Scale (ADAPSS-sf), a 6-item measure adapted from the original 33-item ADAPSS questionnaire. DESIGN: As part of routine clinical care at a VA Medical Center, 98 Veterans (96% male, mean age = 56) with SCI/D completed study measures as part of their annual comprehensive SCI/D evaluation. Principal-components analysis was used to examine the factor structure of the ADAPSS-sf. Multivariate linear regressions were used to examine the relationship between appraisals of disability and life satisfaction, controlling for demographics, injury characteristics and depressive symptoms. RESULTS: Demographic and SCI characteristics of the study sample are comparable to a national Veteran sample. Factor analysis revealed a 2-factor structure within the ADAPSS-sf. One factor represented appraisals signifying fear and loss, whereas the second factor represented appraisals reflecting resilience. Linear regressions showed that Veterans' disability-associated appraisals were strongly associated with life satisfaction. CONCLUSIONS: Study findings support the internal validity and a coherent 2-factor structure of the ADAPSS-sf in an outpatient Veteran population with chronic SCI/D. Additional research is warranted to test the clinical utility of the ADAPSS-sf with Veterans with SCI/D.

Identification of Anxiety Symptom Clusters in Patients with COPD: Implications for Assessment and Treatment.

BACKGROUND: Treatment of chronic obstructive pulmonary disease (COPD) is palliative, and quality of life is important. Increased understanding of correlates of quality of life and its domains could help clinicians and researchers better tailor COPD treatments and better support patients engaging in those treatments or other important self-management behaviors. PURPOSE: Anxiety is common in those with COPD; however, overlap of physical and emotional symptoms complicates its assessment. The current study aimed to identify anxiety symptom clusters and to assess the association of these symptom clusters with COPD-related quality of life. METHODS: Participants (N = 162) with COPD completed the Beck Anxiety Inventory (BAI), Chronic Respiratory Disease Questionnaire, Patient Health Questionnaire-9, and Medical Research Council dyspnea scale. Anxiety clusters were identified, using principal component analysis (PCA) on the BAI's 21 items. Anxiety clusters, along with factors previously associated with quality of life, were entered into a multiple regression designed to predict COPD-related quality of life. RESULTS: PCA identified four symptom clusters related to (1) general somatic distress, (2) fear, (3) nervousness, and (4) respiration-related distress. Multiple regression analyses indicated that greater fear was associated with less perceived mastery over COPD (ß = -0.19, t(149) = -2.69, p < 0.01). CONCLUSION: Anxiety symptoms associated with fear appear to be an important indicator of anxiety in patients with COPD. In particular, fear was associated with perceptions of mastery, an important psychological construct linked to disease self-management. Assessing the BAI symptom cluster associated with fear (five items) may be a valuable rapid assessment tool to improve COPD treatment and physical health outcomes.

Mental health utilization among older Veterans with coexisting depression and dementia.

OBJECTIVE: We compared mental health service utilization among older, depressed Veterans (60 years or older) with and without coexisting dementia. METHODS: This retrospective study examined data from the 2010 Veterans Health Administration National Patient Care Database outpatient treatment files of Veterans with a newly recognized diagnosis of depression (N = 177,710). RESULTS: Approximately 48.84% with coexisting depression and dementia and 32.00% with depression only received mental health services within 12 months of diagnosis (p < .0001). Veterans with coexisting depression and dementia were more likely to receive medication-management appointments (33.40% vs 20.62%), individual therapy (13.39% vs 10.91%), and family therapy (3.77% vs 1.19%) than depressed Veterans without dementia. CONCLUSION: In general, Veterans with recently diagnosed depression are significantly underusing Veterans Affairs mental health treatment services. Those Veterans who have comorbid dementia are more likely than those with just depression to be enrolled in mental health treatments. Systemic improvements are needed to increase use of mental health services for older, depressed Veterans.