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1.
J Affect Disord ; 320: 517-524, 2023 Jan 01.
Artigo em Inglês | MEDLINE | ID: mdl-36191645

RESUMO

BACKGROUND: The first goal of this study was to assess longitudinal changes in burnout among psychotherapists prior to (T1) and during the COVID-19 pandemic (T2). The second objective was to assess the effects of job demands, job resources (including organizational support for evidence-based psychotherapies, or EBPs) and pandemic-related stress (T2 only) on burnout. METHOD: Psychotherapists providing EBPs for posttraumatic stress disorder in U.S. Department of Veterans Affairs (VA) facilities completed surveys assessing burnout, job resources, and job demands prior to (T1; n = 346) and during (T2; n = 193) the COVID-19 pandemic. RESULTS: Burnout prevalence increased from 40 % at T1 to 56 % at T2 (p < .001). At T1, stronger implementation climate and implementation leadership (p < .001) and provision of only cognitive processing therapy (rather than use of prolonged exposure therapy or both treatments; p < .05) reduced burnout risk. Risk factors for burnout at T2 included T1 burnout, pandemic-related stress, less control over when and how to deliver EBPs, being female, and being a psychologist rather than social worker (p < .02). Implementation leadership did not reduce risk of burnout at T2. LIMITATIONS: This study involved staff not directly involved in treating COVID-19, in a healthcare system poised to transition to telehealth delivery. CONCLUSION: Organizational support for using EBPs reduced burnout risk prior to but not during the pandemic. Pandemic related stress rather than increased work demands contributed to elevated burnout during the pandemic. A comprehensive approach to reducing burnout must address the effects of both work demands and personal stressors.


Assuntos
Esgotamento Profissional , COVID-19 , Veteranos , Humanos , Feminino , Masculino , COVID-19/epidemiologia , COVID-19/prevenção & controle , Pandemias/prevenção & controle , Psicoterapeutas , Esgotamento Profissional/epidemiologia , Esgotamento Profissional/psicologia , Inquéritos e Questionários , Satisfação no Emprego
2.
J Affect Disord ; 320: 450-460, 2023 Jan 01.
Artigo em Inglês | MEDLINE | ID: mdl-36174789

RESUMO

OBJECTIVE: Sleep disruption is a common complaint among patients with post-traumatic stress disorder (PTSD). Modern technology of activity monitoring (actigraphy) enables extended, objective, unobtrusive recording and measuring of daytime and nighttime activity. We conducted a meta-analysis to investigate the actigraphic sleep patterns in PTSD compared with healthy controls. METHODS: We searched through seven electronic databases from inception to July 2022. Only case-control studies comparing rest-activity variables measured by actigraphy devices between clinically diagnosed PTSD patients and healthy individuals were included. RESULTS: We identified 12 eligible studies comparing 323 PTSD patients and 416 healthy controls. Using a random-effects model, we showed that PTSD patients have significantly lower sleep efficiency (SMD: -0.26, 95 % CI = -0.51 to -0.004, p < .05, I2 = 29.31 %), more fragmented sleep (SMD: 0.52, 95 % CI = 0.17 to 0.87, p < .01, I2 = 0 %), and longer time in bed (SMD: 0.41, 95 % CI = 0.07 to 0.74, p < .05, I2 = 0 %) compared to healthy controls. LIMITATIONS: This study included a limited number of studies. Publication bias was not examined on all variables, which could lead to an overestimation of effect size. Four studies involved veterans, which likely differ from civilians regarding traumatic exposure. CONCLUSION: This meta-analytic review highlighted a pattern of sleep disturbances in PTSD patients compared with non-PTSD individuals. High-quality, large-scale studies are necessary to draw a definitive conclusion regarding the distinctive sleep profile in PTSD. Future research can pay attention to sleep-specific mechanisms underlying PTSD and explore the momentary interactions between sleep-wake variables.


Assuntos
Transtornos do Sono-Vigília , Transtornos de Estresse Pós-Traumáticos , Veteranos , Humanos , Transtornos de Estresse Pós-Traumáticos/diagnóstico , Transtornos de Estresse Pós-Traumáticos/epidemiologia , Actigrafia , Polissonografia , Sono , Transtornos do Sono-Vigília/epidemiologia , Transtornos do Sono-Vigília/etiologia
3.
J Ambul Care Manage ; 46(1): 45-53, 2023.
Artigo em Inglês | MEDLINE | ID: mdl-36036980

RESUMO

Intensive management programs may improve health care experiences among high-risk and complex patients. We assessed patient experience among (1) prior enrollees (n = 59) of an intensive management program (2014-2018); (2) nonenrollees (n = 356) at program sites; and (3) nonprogram site patients (n = 728), using a patient survey based on the Consumer Assessment of Healthcare Providers and Systems in 2019. Outcomes included patient ratings of patient-centered care; overall health care experience; and satisfaction with their usual outpatient care provider. In multivariate models, enrollees were more satisfied with their current provider versus nonenrollees within program sites (adjusted odds ratio 2.36; 95% confidence interval 1.15-4.85).


Assuntos
United States Department of Veterans Affairs , Veteranos , Estados Unidos , Humanos , Saúde dos Veteranos , Atenção Primária à Saúde , Satisfação do Paciente , Avaliação de Resultados da Assistência ao Paciente
4.
JAMA Health Forum ; 3(11): e224621, 2022 Nov 04.
Artigo em Inglês | MEDLINE | ID: mdl-36318458

RESUMO

This Viewpoint discusses the US Department of Veterans Affairs' decision to offer abortion counseling and care to veterans in cases of rape, incest, and life or health endangerment, and how insights from this decision may be shared with other health care systems.


Assuntos
Aborto Induzido , Veteranos , Gravidez , Feminino , Humanos , Serviços de Planejamento Familiar
5.
JAMA Netw Open ; 5(11): e2241434, 2022 Nov 01.
Artigo em Inglês | MEDLINE | ID: mdl-36367727

RESUMO

Importance: Older adults and individuals with medical comorbidities are at increased risk for severe COVID-19. Several pharmacotherapies demonstrated to reduce the risk of COVID-19-related hospitalization and death have been authorized for use. Objective: To describe factors associated with receipt of outpatient COVID-19 pharmacotherapies in the Veterans Affairs (VA) health care system. Design, Settings, and Participants: This cohort study assessed outpatient veterans with risk factors for severe COVID-19 who tested positive for SARS-CoV-2 during January and February 2022. The setting was the VA health care system, the largest integrated health care system in the US. Exposures: Demographic characteristics, place of residence, underlying medical conditions, and COVID-19 vaccination. Main Outcomes and Measures: The odds of receipt of any COVID-19 pharmacotherapy, including sotrovimab, nirmatrelvir boosted with ritonavir, molnupiravir, or remdesivir were estimated using multivariable logistic regression. Results: Among 111 717 veterans included in this study (median [IQR] age, 60 [46-72] years; 96 482 [86.4%] male, 23 362 [20.9%] Black, 10 740 [9.6%] Hispanic, 75 973 [68.0%] White) who tested positive for SARS-CoV-2 during January to February 2022, 4233 (3.8%) received any COVID-19 pharmacotherapy, including 2870 of 92 396 (3.1%) in January and 1363 of 19 321 (7.1%) in February. Among a subset of 56 285 veterans with documented COVID-19-related symptoms in the 30 days preceding a positive SARS-CoV-2 test, 3079 (5.5%) received any COVID-19 pharmacotherapy. Untreated veterans had a median (IQR) age of 60 (46-71) years and a median (IQR) of 3 (2-5) underlying medical conditions. Veterans receiving any treatment were more likely to be older (aged 65 to 74 years vs 50 to 64 years: adjusted odds ratio [aOR], 1.66 [95% CI, 1.52-1.80]; aged at least 75 years vs 50 to 64 years: aOR, 1.67 [95% CI, 1.53-1.84]) and have a higher number of underlying conditions (at least 5 conditions vs 1 to 2 conditions: aOR, 2.17 [95% CI, 1.98-2.39]). Compared with White veterans, Black veterans (aOR, 0.65 [95% CI, 0.60-0.72]) were less likely to receive treatment; and compared with non-Hispanic veterans, Hispanic veterans (aOR, 0.88 [95% CI, 0.77-0.99]) were less likely to receive treatment. There were 16 546 courses of sotrovimab, nirmatrelvir, and molnupiravir allocated across the VA during this period. Conclusions and Relevance: In this cohort study of veterans who tested positive for SARS-CoV-2 during January and February when supply of outpatient COVID-19 pharmacotherapies was limited, prescription of these pharmacotherapies was underused, and many veterans with risk factors for severe COVID-19 did not receive treatment. Veterans from minority racial and ethnic groups were less likely to receive any pharmacotherapy.


Assuntos
COVID-19 , Veteranos , Masculino , Humanos , Idoso , Pessoa de Meia-Idade , Feminino , SARS-CoV-2 , COVID-19/tratamento farmacológico , Estudos de Coortes , Vacinas contra COVID-19
6.
Eur J Psychotraumatol ; 13(2): 2138059, 2022.
Artigo em Inglês | MEDLINE | ID: mdl-36340009

RESUMO

Background: Experiencing potentially morally injurious events (PMIEs) has been found to be significantly associated with poor mental health outcomes in military personnel/veterans. Currently, no manualised treatment for moral injury-related mental health difficulties for UK veterans exists. This article describes the design, methods and expected data collection of the Restore & Rebuild (R&R) protocol, which aims to develop procedures to treat moral injury related mental ill health informed by a codesign approach. Methods: The study consists of three main stages. First, a systematic review will be conducted to understand the best treatments for the symptoms central to moral injury-related mental ill health (stage 1). Then the R&R manual will be co-designed with the support of UK veteran participants with lived experience of PMIEs as well as key stakeholders who have experience of supporting moral injury affected individuals (stage 2). The final stage of this study is to conduct a pilot study to explore the feasibility and acceptability of the R&R manual (stage 3). Results: Qualitative data will be analysed using thematic analysis. Conclusions: This study was approved by the King's College London's Research Ethics Committee (HR-20/21-20850). The findings will be disseminated in several ways, including publication in academic journals, a free training event and presentation at conferences. By providing information on veteran, stakeholder and clinician experiences, we anticipate that the findings will not only inform the development of an acceptable evidence-based approach for treating moral injury-related mental health problems, but they may also help to inform broader approaches to providing care to trauma exposed military veterans.


Antecedentes: Se ha encontrado que experimentar eventos potencialmente dañinos para la moral (PMIE, por sus siglas en inglés) se asocia significativamente con malos resultados de salud mental en el personal militar/veteranos. Actualmente no existe un tratamiento manualizado para los problemas de salud mental relacionadas con daño moral para los veteranos del Reino Unido. Este artículo describe el diseño, los métodos y la recopilación de datos esperada del protocolo Restore & Rebuild (R&R), que tiene como objetivo desarrollar procedimientos para tratar la salud mental relacionada con el daño moral informado por un enfoque de codiseño.Métodos: El estudio consta de tres etapas principales. Primero, se realizará una revisión sistemática para comprender los mejores tratamientos para los síntomas centrales de la enfermedad mental relacionada con el daño moral (etapa 1). Luego, el manual de R&R se diseñará conjuntamente con el apoyo de participantes veteranos del Reino Unido con experiencia vivida de PMIE, así como con partes interesadas clave que tengan experiencia en el apoyo a las personas afectadas por daño moral (etapa 2). La etapa final de este estudio es realizar un estudio piloto para explorar la factibilidad y aceptabilidad del manual R&R (etapa 3).Resultados: Los datos cualitativos se analizarán mediante análisis temático.Conclusiones: Este estudio fue aprobado por el Comité de Ética en Investigación del King's College London (HR-20/21-20850). Los hallazgos se difundirán de varias maneras, incluida la publicación en revistas académicas, un evento de capacitación gratuito y presentaciones en conferencias. Al proporcionar información sobre las experiencias de veteranos, partes interesadas y médicos, anticipamos que los hallazgos no solo informarán el desarrollo de un enfoque basado en evidencia aceptable para tratar problemas de salud mental relacionados con daño moral, sino que también pueden ayudar a transmitir enfoques más amplios para proporcionar atención a veteranos militares expuestos a traumas.


Assuntos
Transtornos de Estresse Pós-Traumáticos , Veteranos , Humanos , Transtornos de Estresse Pós-Traumáticos/terapia , Veteranos/psicologia , Saúde Mental , Projetos Piloto , Estudos de Viabilidade , Reino Unido , Revisões Sistemáticas como Assunto
7.
J Dr Nurs Pract ; 15(3): 150-156, 2022 Nov 01.
Artigo em Inglês | MEDLINE | ID: mdl-36351766

RESUMO

Problem: The Advance Practice Registered Nurses (APRNs) employed by the Veterans Health Administration (VHA) lack race-based trauma training for Veterans that have experienced psychological, physiological, and emotional trauma. The VHA is responsible for the health of this culturally diverse patient population with complex health conditions. APRNs without prior military experience may have trouble obtaining an accurate history and physical exam due to their inexperience with the military's cross-cultural environment. This quality improvement pilot project aimed to incorporate race-based trauma training into a new adult geriatric acute care nurse practitioner's (AGACNP) fellowship curriculum. The study question is: In acute geriatric acute care nurse practitiioner's, what are the effects of race-based trauma training on competency and confidence in providing care to Veterans when hospitalized? Methods: A prospective descriptive design utilized a purposeful sample of senior adult-geriatric nurse practitioner (AGNP) students, due to the unforeseen circumstances of not hiring AGACNPs s for this pilot, for the first 6-weeks of a new acute care fellowship pilot program. Outcome measures included evaluating skills in identifying racial differences and confidence in applying culturally sensitive care. Results: Participant (N = 3) self-reported confidence increased by .33 (20%) in providing culturally competent and race-based trauma care, and an improvement in identifying race-based differences by .33 (17%) at completion of the pilot. Implications: Results indicated improvement in confidence and competence when providing race-based trauma care within 6 weeks. Continued training and evaluation throughout the 12-month fellowship are recommended.


Assuntos
Serviços Médicos de Emergência , Profissionais de Enfermagem , Veteranos , Adulto , Humanos , Idoso , Projetos Piloto , Profissionais de Enfermagem/educação , Currículo
8.
JAMA Netw Open ; 5(11): e2242048, 2022 Nov 01.
Artigo em Inglês | MEDLINE | ID: mdl-36374497

RESUMO

Importance: Primary care physicians (PCPs) are significant contributors of early cancer detection, yet few studies have investigated whether consistent primary care translates to improved downstream outcomes. Objective: To evaluate the association of prediagnostic primary care use with metastatic disease at diagnosis and cancer-specific mortality (CSM). Design, Setting, and Participants: This cohort study used databases with primary care and referral linkage from multiple Veterans' Affairs centers from 2004 to 2017 and had a 68-month median follow-up. Analysis was completed between July 2021 and September 2022. Participants included veterans older than 39 years who had been diagnosed with 1 of 12 cancers. Inclusion criteria included known clinical staging, survival follow-up, cause of death, and receiving care at the Veterans Affairs health system (VA). Exposures: Prediagnostic PCP use, measured in the 5 years prior to diagnosis. PCP visits were binned into none (0 visits), some (1-4 visits), and annual (5 visits). Main Outcomes and Measures: Metastatic disease at diagnosis, cancer-specific mortality (CSM) for entire cohort and stratified by tumor subtype. Results: Among 245 425 patients representing 12 tumor subtypes, mean age was 65.8 (9.3) years, and the cohort skewed male (97.6%), and White (76.1%), with higher levels of comorbidity (58.6% with Charlson Comorbidity Index scores ≥2). Compared with no prior visit, some PCP use was associated with 26% decreased odds of metastatic disease at diagnosis (odds ratio [OR], 0.74; 95% CI, 0.71-0.76; P < .001) and 12% reduced risk of CSM (subdistribution hazard ratio [SHR], 0.88; 95% CI, 0.86-0.89; P < .001). Annual PCP use was associated with 39% decreased odds of metastatic disease (OR, 0.61; 95% CI, 0.59-0.63; P < .001) and 21% reduced risk of CSM (SHR, 0.79; 95% CI, 0.77-0.81; P < .001). Among tumor subtypes, prostate cancer had the largest effect size for prior PCP use on metastatic disease at diagnosis (OR for annual use, 0.32; 95% CI, 0.30-0.35; P < .001) and CSM (SHRfor annual use, 0.51; 95% CI, 0.48-0.55; P < .001). Conclusions and Relevance: In this cohort study, increased primary care use before cancer diagnosis was associated with significant decreases in metastatic disease at diagnosis and cancer-related death, with potentially the greatest difference from annual use. PCPs play a vital role in cancer prevention, and additional resources should be allocated to assist these physicians.


Assuntos
Neoplasias , Veteranos , Humanos , Estados Unidos/epidemiologia , Masculino , Idoso , United States Department of Veterans Affairs , Estudos de Coortes , Detecção Precoce de Câncer , Atenção Primária à Saúde , Neoplasias/diagnóstico
12.
Artigo em Inglês | MEDLINE | ID: mdl-36343352

RESUMO

Objective: To evaluate whether a history of suicide attempt increases the odds of receiving clozapine treatment in veterans with schizophrenia or schizoaffective disorder.Methods: Electronic health record data were obtained for veterans with schizophrenia or schizoaffective disorder treated at any US Veterans Affairs Medical Center between January 1, 2000, and January 31, 2021 (N = 134,692). Logistic regression (adjusted and unadjusted) was applied to estimate odds ratios (ORs) for clozapine treatment in suicide attempters relative to nonattempters.Results: 3,407 patients had a documented history of suicide attempt, while 6,867 patients had received clozapine treatment. Also, 9.4% (n = 321) of suicide attempters versus 5.0% (n = 6546) of nonattempters had received clozapine treatment. The odds of being treated with clozapine was approximately 2-fold in patients with a history of suicide attempt in unadjusted (OR = 1.98, 95% CI, 1.76-2.22) and adjusted (OR = 1.91, 95% CI, 1.67-2.15) analyses.Conclusions: Despite the higher odds of clozapine treatment in suicide attempters with schizophrenia or schizoaffective disorder, clozapine was underutilized in the current sample of veterans. Concerted efforts should be made to expand the use of clozapine in patients with schizophrenia or schizoaffective disorder, especially those with a history of suicide attempt.


Assuntos
Antipsicóticos , Clozapina , Transtornos Psicóticos , Esquizofrenia , Veteranos , Humanos , Clozapina/efeitos adversos , Esquizofrenia/tratamento farmacológico , Tentativa de Suicídio , Antipsicóticos/efeitos adversos , Transtornos Psicóticos/tratamento farmacológico , Transtornos Psicóticos/psicologia
13.
J Head Trauma Rehabil ; 37(6): E488-E495, 2022.
Artigo em Inglês | MEDLINE | ID: mdl-36345556

RESUMO

OBJECTIVE: To examine the relationship between neuropsychological functioning and performance-based functional capacity in veterans with a history of mild traumatic brain injury (mTBI), as well as the moderating effects of age and psychiatric symptoms on this relationship. SETTING: Three Veterans Affairs medical centers. PARTICIPANTS: One hundred nineteen Iraq/Afghanistan veterans with a history of mTBI and self-reported cognitive difficulties. DESIGN: Cross-sectional, secondary data analysis of baseline measures in a randomized controlled trial. MAIN MEASURES: The main outcome measure, functional capacity, was assessed using the objective and performance-based University of California San Diego Performance-based Skills Assessment-Brief. A global deficit score (GDS) was created as a composite score for performance on a battery of neuropsychological measures assessing domains of attention, processing speed, executive functioning, and verbal memory performance. Posttraumatic stress disorder (PTSD) symptom severity was assessed using the PTSD Checklist-Military Version, and depressive symptom severity was assessed using the Beck Depression Inventory, Second Edition. RESULTS: Bivariate analyses indicated that worse neuropsychological performance (ie, higher GDS) and greater PTSD symptom severity were associated with worse communication abilities and worse overall functional capacity. Multiple linear regressions demonstrated that GDS and PTSD symptom severity explained 9% of the variance in communication and 10% of the variance in overall functional capacity; however, GDS emerged as the only significant predictor in both regressions. Age, PTSD, and depressive symptom severity did not moderate the relationship between GDS and overall functional capacity. Performance in the verbal learning and memory domain emerged as the strongest neuropsychological predictor of communication and overall functional capacity. CONCLUSIONS: Worse neuropsychological functioning was moderately associated with worse performance-based functional capacity, even when accounting for PTSD symptom severity. Verbal learning and memory was the primary neuropsychological domain driving the relationship with functional capacity; improvement in verbal learning and memory may translate into improved functional capacity.


Assuntos
Concussão Encefálica , Transtornos de Estresse Pós-Traumáticos , Veteranos , Humanos , Veteranos/psicologia , Concussão Encefálica/complicações , Concussão Encefálica/diagnóstico , Guerra do Iraque 2003-2011 , Campanha Afegã de 2001- , Estudos Transversais , Transtornos de Estresse Pós-Traumáticos/complicações , Testes Neuropsicológicos
14.
JAMA Netw Open ; 5(11): e2240188, 2022 Nov 01.
Artigo em Inglês | MEDLINE | ID: mdl-36326762

RESUMO

Importance: Reported risk of incident peripheral artery disease (PAD) by sex and race varies significantly and has not been reported in national cohorts among individuals free of baseline PAD. Objective: To evaluate the association of sex and race, as well as prevalent cardiovascular risk factors, with limb outcomes in a national cohort of people with normal baseline ankle-brachial indices (ABIs). Design, setting, and participants: This cohort study was conducted using data from participants in the Veterans Affairs Birth Cohort Study (born 1945-1965), with follow-up data between January 1, 2000, and December 31, 2016. Baseline demographics were collected from 77 041 participants receiving care from the Veterans Health Administration with baseline ABIs of 0.90 to 1.40 and no history of PAD. Data were analyzed from October 2019 through September 2022. Exposures: Sex, race, diabetes, and smoking status. Main Outcomes and Measures: Incident PAD, defined as subsequent ABI less than 0.90, surgical or percutaneous revascularization, or nontraumatic amputation. Results: Of 77 041 participants with normal ABIs (73 822 [95.8%] men; mean [SD] age, 60.2 [5.9] years; 13 080 Black [18.2%] and 54 377 White [75.6%] among 71 911 participants with race and ethnicity data), there were 6692 incident PAD events over a median [IQR] of 3.9 [1.7-6.9] years. Incidence rates were lower for women than men (incidence rates [IRs] per 1000 person-years, 7.4 incidents [95% CI, 6.2-8.8 incidents] vs 19.2 incidents [95% CI, 18.7-19.6 incidents]), with a lower risk of incident PAD (adjusted hazard ratio [aHR], 0.49 [95% CI, 0.41-0.59]). IRs per 1000 person-years of incident PAD were similar for Black and White participants (18.9 incidents [95% CI, 17.9-20.1 incidents] vs 18.8 incidents [95% CI, 18.3-19.4]). Compared with White participants, Black participants had increased risk of total PAD (aHR, 1.09 [95% CI, 1.02-1.16]) and nontraumatic amputation (aHR, 1.20 [95% CI, 1.06-1.36]) but not surgical or percutaneous revascularization (aHR, 1.10 [95% CI, 0.98-1.23]) or subsequent ABI less than 0.90 (aHR, 1.04 [95% CI, 0.95-1.13]). Diabetes (aHR, 1.62 [95% CI, 1.53-1.72]) and smoking (eg, current vs never: aHR, 1.76 [95% CI, 1.64-1.89]) were associated with incident PAD. Incident PAD was rare among individuals without a history of smoking or diabetes (eg, among 632 women: IR per 1000 people-years, 2.1 incidents [95% CI, 1.0-4.5 incidents]) despite an otherwise-high-risk cardiovascular profile (eg, 527 women [83.4%] with hypertension). Conclusions and Relevance: This study found that the risk of PAD was approximately 50% lower in women than men and less than 10% higher for Black vs White participants, while the risk of nontraumatic amputation was 20% higher among Black compared with White participants.


Assuntos
Diabetes Mellitus , Doença Arterial Periférica , Veteranos , Masculino , Feminino , Humanos , Pessoa de Meia-Idade , Índice Tornozelo-Braço , Estudos de Coortes , Doença Arterial Periférica/epidemiologia , Diabetes Mellitus/epidemiologia
15.
BMC Psychiatry ; 22(1): 683, 2022 11 04.
Artigo em Inglês | MEDLINE | ID: mdl-36333686

RESUMO

BACKGROUND: A wealth of evidence has illustrated that reductions in negative posttrauma cognitions (NPCs) predict improvement in posttraumatic stress disorder (PTSD) symptoms during treatment. Yet, the specific temporal arrangement of changes in these constructs is less well understood. This study examined the temporal association between NPC changes and PTSD symptom changes in two distinct intensive PTSD treatment samples. METHODS: Data from 502 veterans who completed a 3-week CPT-based intensive PTSD treatment program was used to test the extent to which lagged NPC measurement predicted the next occurring PTSD severity measurement using linear mixed effects regression models. PTSD severity was assessed every other day during treatment. NPCs were assessed at three treatment timepoints. A second sample of 229 veterans who completed a 2-week CPT-based intensive PTSD treatment program was used to replicate these findings. RESULTS: Across both intensive PTSD treatment programs, NPCs generally increased from intake the end of the first treatment week, which was followed by gradual decreases in NPCs throughout the rest of both programs. Change in NPCs during both the 3-week (b = .21, p < .001, R2 = .38) and the 2-week programs (b = 0.20, p < .001, R2 = .24) were significant predictors of change in PTSD symptom severity. However, the reverse was true as well, with change in PTSD severity predicting latter change in NPCs during both the 3-week (b = 1.51, p < .001, R2 = .37) and 2-week (b = 1.37, p < .001, R2 = .33) programs, further raising questions about temporality of the association between NPCs and PTSD symptom severity during treatment. CONCLUSIONS: The present study demonstrated that changes in NPCs may not temporally precede changes in PTSD symptom severity in PTSD treatment samples. Instead, we observed earlier PTSD symptom changes and a bidirectional association between the two constructs across both samples. Clinically, the study supports the continued focus on NPCs as an important treatment target as they are an important indicator of successful PTSD treatment, even if they may not be a direct mechanism of treatment-based changes in PTSD severity. Future research should attempt to identify alternative mechanisms of change in CPT.


Assuntos
Transtornos de Estresse Pós-Traumáticos , Veteranos , Humanos , Transtornos de Estresse Pós-Traumáticos/complicações , Transtornos de Estresse Pós-Traumáticos/terapia , Transtornos de Estresse Pós-Traumáticos/diagnóstico , Cognição
16.
Artigo em Inglês | MEDLINE | ID: mdl-36360867

RESUMO

This study explores differences in characteristics and relationship treatment preferences across different levels of intimate partner violence (IPV) among Veterans Affairs (VA) primary care patients. In Fall 2019, we sent a mail-in survey assessing relationship healthcare needs to N = 299 Veterans randomly sampled from 20 northeastern VA primary care clinics (oversampling female and younger Veterans). We compared those reporting past year use or experience of physical/sexual aggression, threats/coercion, or injury (Severe IPV; 21%), to those only reporting yelling and screaming (Verbal Conflict; 51%), and denying any IPV (No IPV; 28%). Participants across groups desired 2-6 sessions of face-to-face support for couples' health and communication. No IPV participants were older and had preferred treatment in primary care. The Verbal Conflict and Severe IPV groups were both flagged by IPV screens and had similar interest in couple treatment and relationship evaluation. The Severe IPV group had higher rates of harms (e.g., depression, alcohol use disorder, relationship dissatisfaction, fear of partner) and higher interest in addressing safety outside of VA. Exploratory analyses suggested differences based on use vs. experience of Severe IPV. Findings highlight ways integrated primary care teams can differentiate services to address dissatisfaction and conflict while facilitating referrals for Severe IPV.


Assuntos
Violência por Parceiro Íntimo , Veteranos , Humanos , Feminino , Agressão , Inquéritos e Questionários , Atenção Primária à Saúde
17.
Psychiatr Q ; 93(4): 1003-1016, 2022 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-36331755

RESUMO

OBJECTIVE: Clinical street outreach programs serve people experiencing unsheltered homelessness, who have been shown to have greater medical and psychiatric comorbidities, and increased social and financial challenges. However, outreach programs may struggle in practice to engage the most vulnerable of these individuals. METHODS: Data from the Veterans Health Administration's (VHA's) Homeless Operations Management System (HOMES) from 2018 to 2019 (N = 101,998) were used to compare sociodemographic, clinical, and financial characteristics of literally homeless veterans contacted through street outreach to those who were self-referred or clinic-referred. RESULTS: Veterans engaged through street outreach reported substantially more days of unsheltered homelessness in the past month (mean (M) = 11.18 days, s.d.=13.8) than the clinic-referred group (M = 6.75 days, s.d.=11.1), and were more likely to have spent the past 30 days unsheltered (RR = 2.23). There were notably few other differences between the groups. CONCLUSION: Despite epidemiologic evidence in the literature showing higher medical, psychiatric, and social and financial vulnerabilities among unsheltered homeless individuals, our street outreach group was not found to be any worse off on such variables than the clinic-referred or self-referred groups, other than increased time unsheltered. Outreach workers seem to engage more unsheltered individuals, but do not necessarily engage those with such severe vulnerabilities. Dedicated outreach program funding, training, and support are needed to support street outreach to those with the most severe problems.


Assuntos
Pessoas em Situação de Rua , Veteranos , Humanos , Serviços de Saúde , Instituições de Assistência Ambulatorial , Encaminhamento e Consulta
18.
J Anxiety Disord ; 92: 102645, 2022 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-36334317

RESUMO

Although improving residential PTSD care is a priority for the Department of Veterans Affairs, previous evaluations have been limited by a lack of systematic data collection across more than two timepoints. This study used recently available data to assess symptom trajectories in a large, national sample of veterans who engaged in residential PTSD treatment. Group-based trajectory analysis PROC TRAJ was used to identify PTSD residential treatment response in a national cohort of veterans (n = 10,832) and the subset of veterans (n = 6515) receiving evidence-based psychotherapy (EBP). PTSD symptoms were assessed at intake, discharge, and 4-month follow-up. Predictors of trajectory membership were estimated using multinomial models. For the full cohort, a three-group trajectory model provided the best fit with the following identified groups: "Severe/Stable" (51.8%), "Moderate/Rebound" (40.1%), and "Mild/Rebound" (8.1%). For the EBP sub-cohort, a three-group trajectory model was selected with the following groups: "Severe/Stable" (58.5%), "Moderate/Rebound" (34.1%), and "Mild/Rebound" (7.4%). Across all trajectories, psychological distress, pain severity, substance use, Iraq/Afghanistan combat era, non-White race, and treatment dropout were associated with poorer treatment response. In the EBP sub-cohort, homelessness and unemployment at the time of admission were also associated with poorer treatment outcomes to varying degrees. This study demonstrates that residential treatment for PTSD is associated with heterogeneous treatment trajectories which highlight the need to continue to explore and improve residential PTSD treatment outcomes. Our results underscore the importance of obtaining follow-up data and identifying ways to maintain therapeutic gains following discharge.


Assuntos
Transtornos de Estresse Pós-Traumáticos , Veteranos , Estados Unidos , Humanos , Transtornos de Estresse Pós-Traumáticos/terapia , Psicoterapia , Tratamento Domiciliar , Estudos de Coortes
20.
BMJ Open Qual ; 11(4)2022 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-36384879

RESUMO

BACKGROUND: Screening for colorectal cancer (CRC) with faecal immunochemical test (FIT) is effective at reducing CRC mortality. Unfortunately, the COVID-19 pandemic has been associated with deferred care, especially screening for CRC. AIM: We sought to develop a mailed FIT programme (MFP) to increase CRC screening and make recommendations for adoption across the Veterans Health Administration (VHA) and for other large healthcare systems. SETTING: 2 regional VA medical centres in California and Washington state. PARTICIPANTS: 5667 average risk veterans aged 50-75 overdue or due within 90 days for CRC screening. PROGRAMME DESCRIPTION: A multidisciplinary implementation team collaborated to mail an FIT kit to eligible veterans. Both sites mailed a primer postcard, and one site added an automated reminder call. PROGRAMME EVALUATION: We monitored FIT return and positivity rate, as well as impact of the programme on clinical staff. 34% of FIT kits were returned within 90 days and 7.8% were abnormal. DISCUSSION: We successfully implemented a population-based MFP at multiple regional VA sites and recommend that these efforts be spread across VA. Our model of regional leadership, facility champions and using centralised resources can be adaptable to other large healthcare systems. MFPs support catch-up from disrupted care by addressing access to CRC screening, unburden primary care visits and conserve limited procedural resources.


Assuntos
COVID-19 , Neoplasias Colorretais , Veteranos , Humanos , Detecção Precoce de Câncer , Pandemias , Neoplasias Colorretais/diagnóstico , Neoplasias Colorretais/epidemiologia
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