Recent trends in the rural-urban suicide disparity among veterans using VA health care.

There is an elevated risk of suicide among people living in rural areas, and the rural-urban disparity in death by suicide is growing in the general United States population. The department of Veterans Affairs (VA) implemented programs targeting rural health in 2007 and suicide prevention in 2008. Rural-urban differences in suicide rates among VA users have not been examined since 2010. We sought to understand whether the rural-urban disparity in suicide risk among VA users decreased during a time of contemporaneous VA efforts to improve access to mental health care for rural Veterans and to improve the effectiveness of mental health services at preventing suicide. We performed a retrospective cohort study examining differences in the raw and adjusted annual suicide rate among rural and urban VA users between 2003 and 2017. All VHA users 2003-2017. Descriptive statistics are presented for all VHA users in 2017. This includes 6,120,355 unique VA users, 32.0% (n = 1,955,935) of whom lived at a rural address. Raw rates of death by suicide were higher in rural VA users than urban VA users overall (33.3 vs. 29.1 deaths per 100,000 population) and across years, but the age, sex, and race-adjusted rates converged in 2005. White VA users had over triple the rate of death by suicide as black VA users, and lived disproportionally in rural areas. The rural-urban suicide disparity among VA users persists. However, the disparity appears to be driven by differences in the racial composition of rural and urban patients, which were not accounted for in prior studies.

Measurement Strategies for Evidence-Based Antidepressants for Posttraumatic Stress Disorder Delivery: Trends and Associations with Patient-Reported Outcomes.

We sought to develop a quality standard for the prescription of antidepressants for posttraumatic stress disorder (PTSD) that is both consistent with the underlying evidence supporting antidepressants as a treatment for PTSD and associated with the best levels of symptom improvement. We quantified antidepressant initiation during the first year of PTSD treatment in a 10-year national cohort of Department of Veterans Affairs (VA) users, and compared outcomes in a subgroup who completed patient-reported outcome measurement (PROM) as part of routine practice. We added progressively stringent measurement requirements. Prescribing quality for PTSD in the VA was stable over time. Use of PROM was rare in the case of antidepressant treatment, limiting our assessment of outcomes.

Associations between Medication Assisted Therapy Services Delivery and Mortality in a National Cohort of Veterans with Posttraumatic Stress Disorder and Opioid Use Disorder.

Objective: Opioid use disorder (OUD) is a notable concern in the United States (US) and strongly associated with mortality. There is a high prevalence of OUD in patients with posttraumatic stress disorder (PTSD) and the mortality associated with OUD may be exacerbated in patients with PTSD. Medication-assisted treatment (MAT) for OUD has become standard of care for OUD and has been shown to reduce mortality. However, there has been little study of MAT and mortality in patients with PTSD and OUD. Methods: We conducted a retrospective cohort study in U.S. veterans who had newly engaged in PTSD treatment, were diagnosed with OUD and were provided MAT for at least one day between 2004 and 2013. We assessed mortality for one year following the index diagnosis date. We calculated all-cause mortality as well as death by external cause, overdose plus suicide, overdose, and suicide rates per 100,000. We used hazard ratios (HR) and 95% confidence intervals (CI) to compare death rates between patients with high versus low adherence to MAT. We evaluated the impact of high versus low exposure to general substance abuse care. We considered a confidence interval that did not cross one to be significant. Results: A total of 5,901 patients met inclusion criteria. Most patients were men and the average age was 43.3 years (SD = 13.8). The all-cause mortality rate was 1,370 per 100,000 patients. High adherence to MAT resulted in a non-significant, decreased risk for death due to all-cause (HR = 0.73, 95% CI [0.47, 1.13]), external cause (HR = 0.71, 95% CI [0.38, 1.35]), and overdose or suicide (HR = 0.66, 95% CI [0.33, 1.35]). Patients with high exposure (≥ 60 days) to general substance abuse care were significantly less likely to die due to external cause (HR = 0.39, 95% CI [0.18, 0.85]) and overdose or suicide (HR = 0.31, 95% CI [0.12, 0.77]). Conclusions: In patients with PTSD and OUD, improved adherence to MAT and greater exposure to general substance abuse care may result in lower mortality. Studies with longer follow-up and larger sample sizes to assess the impact of MAT on suicide are needed to confirm our findings.

Measurement Strategies for Evidence-Based Psychotherapy for Posttraumatic Stress Disorder Delivery: Trends and Associations with Patient-Reported Outcomes.

We sought to develop a quality standard for the delivery of psychotherapy for posttraumatic stress disorder (PTSD) that is both consistent with the underlying evidence supporting psychotherapy as a treatment for PTSD and associated with the best levels of symptom improvement. We quantified psychotherapy receipt during the initial year of PTSD treatment in a 10-year national cohort of Department of Veterans Affairs (VA) users who completed patient-reported outcome measurement as part of routine practice. We added progressively stringent measurement requirements. The most stringent requirement was associated with superior outcomes. Quality of psychotherapy for PTSD in the VA improved over time.

Correction to: Measurement Strategies for Evidence-Based Psychotherapy for Posttraumatic Stress Disorder Delivery: Trends and Associations with Patient-Reported Outcomes.

The original version of this article unfortunately contained a mistake. The co-author name was incorrectly published with the middle initial in the author list.

A Pilot Study of an Intervention to Prevent Suicide After Psychiatric Hospitalization.

A prior meta-analysis found that the World Health Organization Brief Intervention and Contact Program (WHO BIC) significantly reduces suicide risk. WHO BIC has not been studied in high-income countries. We piloted an adapted version of WHO BIC on an inpatient mental health unit in the United States. We assessed the feasibility and acceptability. We also evaluated changes in suicidal ideation, hopelessness, and connectedness using a repeated measures analysis of variance. Of 13 eligible patients, 9 patients enrolled. Patients experienced significant improvements in suicidal ideation, hopelessness, and connectedness at 1 and 3 months (Beck Scale for Suicidal Ideation, F(2,16) = 14.96, p < 0.01; Beck Hopelessness Scale, F(2,16) = 5.88, p < 0.05; perceived burdensomeness subscale, F(2,16) = 10.97, p < 0.013; and thwarted belongingness subscale, F(2,16) = 4.77, p < 0.03). Patients were highly satisfied. An adapted version of WHO BIC may be feasible to implement in a high-resource setting, but trials need to confirm efficacy.

Comparison of US Oncologist Rurality by Practice Setting and Patients Served.

Importance: Studies of the oncology workforce most often classify physician rurality by their practice location, but this could miss the true extent of physicians involved in rural cancer care. Objective: To compare a method for identifying oncology physicians involved in rural cancer care that uses the proportion of rural patients served with the standard method based on practice location. Design, Setting, and Participants: This cross-sectional study used retrospective Centers for Medicare & Medicaid Services encounter data on medical oncologists, radiation oncologists, and surgeons treating Medicare beneficiaries diagnosed with breast, colorectal, or lung cancer from January 1 to December 31, 2019. Data were analyzed from May to September 2023. Main Outcomes and Measures: The standard method of classifying oncologist physician rurality based on practice location was compared with a novel method of classification based on proportion of rural patients served. Results: The study included 27 870 oncology physicians (71.3% male), of whom 835 (3.0%) practiced in a rural location. Physicians practicing in a rural location treated a high proportion of rural patients (median, 50.0% [IQR, 16.7%-100%]). When considering the rurality of physicians' patient panels, 5123 physicians (18.4%) whose patient panel included at least 20% rural patients, 3199 (11.5%) with at least 33% rural patients, and 1996 (7.2%) with at least 50% rural patients were identified. Using a physician's patient panel to classify physician rurality revealed a higher number and greater spread of oncology physicians involved in rural cancer care in the US than the standard method, while maintaining high performance (area under the curve, 0.857) and fair concordance (κ, 0.346; 95% CI, 0.323-0.369) with the method based on practice setting. Conclusions and Relevance: In this cross-sectional study, classifying oncologist rurality by the proportion of rural patients served identified more oncology physicians treating patients living in rural areas than the standard method of practice location and may more accurately capture the rural cancer physician workforce, as many hospitals have historically been located in more urban areas. This new method may be used to improve future studies of rural cancer care delivery.

Telehealth Use Following COVID-19 Within Patient-Sharing Physician Networks at a Rural Comprehensive Cancer Center: Cross-sectional Analysis.

BACKGROUND: In response to the COVID-19 pandemic, cancer centers rapidly adopted telehealth to deliver care remotely. Telehealth will likely remain a model of care for years to come and may not only affect the way oncologists deliver care to their own patients but also the physicians with whom they share patients. OBJECTIVE: This study aimed to examine oncologist characteristics associated with telehealth use and compare patient-sharing networks before and after the COVID-19 pandemic in a rural catchment area with a particular focus on the ties between physicians at the comprehensive cancer center and regional facilities. METHODS: In this retrospective observational study, we obtained deidentified electronic health record data for individuals diagnosed with breast, colorectal, or lung cancer at Dartmouth Health in New Hampshire from 2018-2020. Hierarchical logistic regression was used to identify physician factors associated with telehealth encounters post COVID-19. Patient-sharing networks for each cancer type before and post COVID-19 were characterized with global network measures. Exponential-family random graph models were performed to estimate homophily terms for the likelihood of ties existing between physicians colocated at the hub comprehensive cancer center. RESULTS: Of the 12,559 encounters between patients and oncologists post COVID-19, 1228 (9.8%) were via telehealth. Patient encounters with breast oncologists who practiced at the hub hospital were over twice as likely to occur via telehealth compared to encounters with oncologists who practiced in regional facilities (odds ratio 2.2, 95% CI 1.17-4.15; P=.01). Patient encounters with oncologists who practiced in multiple locations were less likely to occur via telehealth, and this association was statistically significant for lung cancer care (odds ratio 0.26, 95% CI 0.09-0.76; P=.01). We observed an increase in ties between oncologists at the hub hospital and oncologists at regional facilities in the lung cancer network post COVID-19 compared to before COVID-19 (93/318, 29.3%, vs 79/370, 21.6%, respectively), which was also reflected in the lower homophily coefficients post COVID-19 compared to before COVID-19 for physicians being colocated at the hub hospital (estimate: 1.92, 95% CI 1.46-2.51, vs 2.45, 95% CI 1.98-3.02). There were no significant differences observed in breast cancer or colorectal cancer networks. CONCLUSIONS: Telehealth use and associated changes to patient-sharing patterns associated with telehealth varied by cancer type, suggesting disparate approaches for integrating telehealth across clinical groups within this health system. The limited changes to the patient-sharing patterns between oncologists at the hub hospital and regional facilities suggest that telehealth was less likely to create new referral patterns between these types of facilities and rather replace care that would otherwise have been delivered in person. However, this study was limited to the 2 years immediately following the initial outbreak of COVID-19, and longer-term follow-up may uncover delayed effects that were not observed in this study period.

Pilot randomized controlled trial of a brief strategy to prevent suicide after discharge from residential addiction treatment.

INTRODUCTION: Veterans are at greater risk for suicide and veterans with substance use disorder (SUD) have an even greater risk. Little research has looked into brief interventions to prevent suicide in this population in residential substance use treatment programs. METHOD: We conducted a pilot, randomized controlled trial of a brief suicide prevention strategy called Veterans Affairs Brief Intervention and Contact Program (VA BIC) in patients participating in the Residential Recovery Center (RRC) SUD 28-day program and deemed at risk for suicide. We measured changes in symptoms at 1-, 3-, and 6-months. We looked at social connectedness, suicidal ideation, hopelessness, thwarted belongingness, perceived burdensomeness, and treatment engagement. RESULTS: The study enrolled twenty patients. One participant withdrew immediately after baseline. We found that adherence to VA BIC components was high, as 100 % of patients (N = 10) completed 70 % or more of the VA BIC visits. Furthermore, 80 % of intervention group patients (N = 8) completed all VA BIC components. During the six-month follow-up, suicidal ideation improved in patients assigned to VA BIC, while it worsened in the standard care arm. Similarly, patients assigned to VA BIC reported a reduction in perceived burdensomeness over the six-month follow-up period while it worsened in the standard care arm. Additionally, VA BIC may modestly improve treatment engagement in the first month postdischarge. CONCLUSION: We were able to recruit and enroll patients from a residential SUD treatment program into a clinical trial of the VA BIC intervention. Our preliminary results suggest that VA BIC may be useful in reducing suicidal ideation and perceived burdensomeness in patients who are discharged from residential SUD treatment programs and increasing treatment engagement. Future trials of VA BIC should determine whether VA BIC can reduce the risk of suicide in patients who are discharged from residential SUD treatment programs.

An implementation and effectiveness study evaluating Conflict Analysis in VA residential substance abuse services: Whole Health informed self-guided online care.

CONTEXT: Whole Health is an emerging healthcare framework that emphasizes wellbeing in place of illness. Conflict Analysis (CA), an online self-guided assessment, leverages innovative diagnostic and therapeutic resources that shares Whole Health objectives, including helping users explore their identity and develop a personalized health plan and helping users develop resources to optimize their health. OBJECTIVES: Paper presents CA implementation-effectiveness study in a Veteran Affairs inpatient substance recovery care. DESIGN: Patients were randomized to CA or mindfulness control. Patients completed Whole Health outcomes measures at baseline, completion (post), and three-week follow-up. Interventions took 2.5 h. Attending psychologist assessed CA protocols and completed outcome evaluation. Due to Coronavirus, recruitment and follow-up were curtailed. SETTING: Study took place in a rural northern New England Veteran Affairs inpatient substance recovery unit. OUTCOME MEASURES: Measures include The Personal Growth Initiative Scale, The Beck Cognitive Insight Scale, Perceived Stress Scale, The Patient Health Questionnaire, Perceived Psychological Wellbeing, and Perceived Therapeutic and Diagnostic Benefit. RESULTS: 12 patients were randomized, 11 completed post measures (CA=5; Mindfulness = 6), and 7 completed follow-up measures (CA=3; Mindfulness=4). CA offered significant Whole Health benefits when compared to control. Additionally, participant and clinician evaluations indicated that CA can be personally relevant, meaningful, and motivate therapeutic growth. Implications include extending CA research and expanding Whole Health related interventions. Although initial results suggest implementation feasibility and Whole Health benefit, more research is necessary to establish CA's utility within inpatient substance recovery care in particular and psychiatric rehabilitation in general.

Influence of contextual factors on death by suicide in rural and urban settings.

PURPOSE: To examine the association between contextual factors, represented by geographic and community health variables, and suicide among rural and urban Department of Veterans Affairs health care users (VA users). METHODS: We performed a retrospective cohort study of 12,700,847 VA users between 2003 and 2017. We assigned contextual factors based on individuals' home address at the ZIP Code (area deprivation), county (sunlight exposure, altitude, and community health), and state level (firearm ownership), using publicly available data sources. We grouped contextual factors by quintiles or prespecified thresholds, depending on the nature of each variable. We obtained mortality data from the National Death Index. We measured the effect of living in a place with the highest versus lowest level of each contextual factor on odds of suicide using logistic regression, adjusting for individual compositional factors abstracted from VA electronic medical records data. We used random forest modeling to build prediction models for suicide based on contextual factors among rural and urban veterans. FINDINGS: Almost all contextual factors we examined were significantly associated with suicide among rural and urban VA users, even after adjusting for individual compositional factors. However, no contextual variables were strong protective or risk factors (0.52.0), and prediction models leveraging these contextual factors had poor accuracy among both rural (0.51, 95% CI: 0.48-0.54) and urban (0.53, 95% CI: 0.51-0.55) VA users. CONCLUSIONS: A wide variety of contextual factors is significantly associated with suicide among rural and urban VA users. However, the factors we measured contributed very little to individual-level suicide risk.

National cross-sectional cohort study of the relationship between quality of mental healthcare and death by suicide.

BACKGROUND: Patient safety-based interventions aimed at lethal means restriction are effective at reducing death by suicide in inpatient mental health settings but are more challenging in the outpatient arena. As an alternative approach, we examined the association between quality of mental healthcare and suicide in a national healthcare system. METHODS: We calculated regional suicide rates for Department of Veterans Affairs (VA) Healthcare users from 2013 to 2017. To control for underlying variation in suicide risk in each of our 115 mental health referral regions (MHRRs), we calculated standardised rate ratios (SRRs) for VA users compared with the general population. We calculated quality metrics for outpatient mental healthcare in each MHRR using individual metrics as well as an Overall Quality Index. We assessed the correlation between quality metrics and suicide rates. RESULTS: Among the 115 VA MHRRs, the age-adjusted, sex-adjusted and race-adjusted annual suicide rates varied from 6.8 to 92.9 per 100 000 VA users, and the SRRs varied between 0.7 and 5.7. Mean regional-level adherence to each of our quality metrics ranged from a low of 7.7% for subspecialty care access to a high of 58.9% for care transitions. While there was substantial regional variation in quality, there was no correlation between an overall index of mental healthcare quality and SRR. CONCLUSION: There was no correlation between overall quality of outpatient mental healthcare and rates of suicide in a national healthcare system. Although it is possible that quality was not high enough anywhere to prevent suicide at the population level or that we were unable to adequately measure quality, this examination of core mental health services in a well-resourced system raises doubts that a quality-based approach alone can lower population-level suicide rates.

A virtual, pilot randomized trial of a brief intervention to prevent suicide in an integrated healthcare setting.

OBJECTIVE: Patients who die by suicide are often seen in primary care settings in the weeks leading to their death. There has been little study of brief interventions to prevent suicide in these settings. METHOD: We conducted a virtual, pilot, randomized controlled trial of a brief suicide prevention strategy called Veterans Affairs Brief Intervention and Contact Program (VA BIC) in patients who presented to a primary care mental health walk-in clinic for a new mental health intake appointment and were at risk for suicide. Our primary aim was to assess feasibility. We measured our ability to recruit 20 patients. We measured the proportion of enrolled patients who completed all study assessments. We assessed adherence among patients assigned to VA BIC. RESULTS: Twenty patients were enrolled and 95% (N = 19) completed all study assessments. Among the 10 patients assigned to VA BIC, 90% (N = 9) of patients completed all required intervention visits, and 100% (N = 10) completed ≥70% of the required interventions visits. CONCLUSION: It is feasible to conduct a virtual trial of VA BIC in an integrated care setting. Future research should clarify the role of VA BIC as a suicide prevention strategy in integrated care settings using an adequately powered design. CLINICAL TRIAL REGISTRATION: NCT04054947.

The Effect of Meteorological, Pollution, and Geographic Exposures on Death by Suicide: A Scoping Review.

Suicide is a significant public health concern worldwide and in the United States. Despite the far-reaching impact of suicide, risk factors are still not well understood and efforts to accurately assess risk have fallen short. Current research has highlighted how potentially modifiable environmental exposures (i.e., meteorological, pollution, and geographic exposures) can affect suicide risk. A scoping review was conducted to evaluate the strength of the historical and current literature on the environment's effect on suicide and suicide risk. Three databases (i.e., Medline, Embase, and PsychInfo) were reviewed to identify relevant studies and two authors independently reviewed studies considering pre-determined inclusion criteria. A total of 46 meteorological studies were included as well as 23 pollution studies and 12 geographic studies. Descriptive statistics, including counts, percentages, review of studies' sample size (minimum, maximum, median, and interquartile range), were calculated using Excel and SAS 9.4. Overall, strong evidence supports that exposure to sunlight, temperature, air pollution, pesticides, and high altitude increases suicide risk, although effect sizes range from very small to small.

Patient and Clinical Factors Associated With Response to Medications for Posttraumatic Stress Disorder.

Objective: Fluoxetine, paroxetine, sertraline, topiramate, and venlafaxine have previously shown efficacy for posttraumatic stress disorder (PTSD) in randomized clinical trials. Two prior studies using Department of Veterans Affairs (VA) medical records data show these medications are also effective in routine practice. Using an expanded retrospective cohort, we assessed the possibility of differential patterns of response based on patient and clinical factors.Methods: We identified 6,839 VA outpatients with clinical diagnoses of PTSD between October 1999 and September 2019 who initiated one of the medications and met pre-specified criteria for treatment duration and dose, combined with baseline and endpoint PTSD checklist (PCL) measurements. We compared 12-week changes in PCL score within clinical subgroups defined by sex, race and ethnicity, and military exposures, as well as comorbidities. Comorbidities were identified using International Classification of Diseases diagnostic codes and grouped according to major diagnostic classifications in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (eg, Psychotic Disorders, Depressive Disorders). We used a propensity score weighting approach to balance covariates among medication arms within each clinical subgroup. In our exploratory analyses using unweighted data for the overall cohort, we built penalized logistic regression models to identify covariates that predicted meaningful improvement.Results: There were no significant differences between medications in our weighted subgroup analyses. In unweighted exploratory analyses, higher baseline PCL scores and concurrent receipt of evidence-based psychotherapy predicted meaningful improvement, while high levels of disability predicted not realizing meaningful improvement.Conclusions: In the largest real-world study of medications for PTSD to date, we did not observe a pattern of differential response among clinical subgroups. All patients taking medications for PTSD, especially those with the highest levels of disability, should consider combined treatment with evidence-based psychotherapy.

Small Area Analysis of Veterans Affairs Mental Health Services Data.

OBJECTIVE: To identify geographic variation in mental health service use in the Department of Veterans Affairs (VA), the authors constructed utilization-based VA mental health service areas (MHSAs) for outpatient treatment and mental health referral regions (MHRRs) for residential and acute inpatient treatment. METHODS: MHSAs are empirically derived geographic groupings of one or more counties containing one or more VA outpatient mental health clinics. For each county within an MHSA, patients received most of their VA-provided outpatient mental health care within that MHSA. MHSAs were aggregated into MHRRs according to where VA users in each MHSA received most of their residential and acute inpatient mental health care. Attribution loyalty was evaluated with the localization index-the fraction of VA users living in each geographic area who used their designated MHSA and MHRR facility. Variation in outpatient mental health visits and in acute inpatient and residential mental health stays was determined for the 2008-2018 period. RESULTS: A total of 441 MHSAs were aggregated to 115 MHRRs (representing 3,909,080 patients with 52,372,303 outpatient mental health visits). The mean±SD localization index was 59.3%±16.4% for MHSAs and 67.8%±12.7% for MHRRs. Adjusted outpatient mental health visits varied from a mean of 0.88 per year in the lowest quintile of MHSAs to 3.14 in the highest. Combined residential and acute inpatient days varied from 0.29 to 1.79 between the lowest and highest quintiles. CONCLUSIONS: MHSAs and MHRRs validly represented mental health utilization patterns in the VA and displayed considerable variation in mental health service provision across different locations.

Longitudinal Examination of COVID-19 Public Health Measures on Mental Health for Rural Patients With Serious Mental Illness.

INTRODUCTION: There is emerging evidence to support that the COVID-19 pandemic and related public health measures may be associated with negative mental health sequelae. Rural populations in particular may fair worse because they share many unique characteristics that may put them at higher risk for adverse outcomes with the pandemic. Yet, rural populations may also be more resilient due to increased sense of community. Little is known about the impact of the pandemic on the mental health and well-being of a rural population pre- and post-pandemic, especially those with serious mental illness. MATERIAL AND METHODS: We conducted a longitudinal, mixed-methods study with assessments preceding the pandemic (between October 2019 and March 2020) and during the stay-at-home orders (between April 23, 2020, and May 4, 2020). Changes in hopelessness, suicidal ideation, connectedness, and treatment engagement were assessed using a repeated-measures ANOVA or Friedman test. RESULTS: Among 17 eligible participants, 11 people were interviewed. Overall, there were no notable changes in any symptom scale in the first 3-5 months before the pandemic or during the stay-at-home orders. The few patients who reported worse symptoms were significantly older (mean age: 71.7 years, SD: 4.0). Most patients denied disruptions to treatment, and some perceived telepsychiatry as beneficial. CONCLUSIONS: Rural patients with serious mental illness may be fairly resilient in the face of the COVID-19 pandemic when they have access to treatment and supports. Longer-term outcomes are needed in rural patients with serious mental illness to better understand the impact of the pandemic on this population.

A Pilot Randomized Trial of a Brief Intervention to Prevent Suicide After Inpatient Psychiatric Discharge.

OBJECTIVE: Risk for suicide is high after psychiatric hospitalization. The World Health Organization's Brief Intervention and Contact (BIC) program has shown efficacy in preventing suicide. A version adapted for the U.S. Department of Veterans Affairs (VA) was studied to determine preliminary effects. METHODS: Patients receiving psychiatric hospitalization because of acute risk for self-harm were randomly assigned to the VA BIC or standard care alone. Effect sizes (Hedges' g) for suicidal ideation (primary outcome), social connectedness (measured as thwarted belongingness and perceived burdensomeness), hopelessness, and engagement were calculated at 1 and 3 months. RESULTS: Patients were randomly assigned to the VA BIC (N=10) or standard care (N=9). The VA BIC had a medium or large effect on most measures at 1 month (suicidal ideation, g=0.45). Effects diminished at 3 months, except for thwarted belongingness (g=0.81). CONCLUSIONS: The VA BIC had meaningful effects on suicide-related outcomes. The largest effect was seen in the first month.

Diffuse bear-track retina: profound, bilateral, grouped congenital pigmentation of the retinal pigment epithelium in an infant.

Grouped congenital hypertrophy of the retinal pigment epithelium is a conspicuous ocular anomaly wherein highly pigmented, demarcated but flat retinal lesions arise from the retinal pigment epithelium. These lesions ("bear tracks") typically increase in size as they approach the retinal periphery. The discovery of pigmentary lesions in a young infant with a poor red reflex warrants urgent ophthalmological and electrodiagnostic review to exclude serious diagnoses, including an early-onset severe retinal dystrophy. We present the case of a 2-month-old boy with marked bear-tracks over the entirety of each retina, but with normal electrodiagnostic findings, genetics, and visual behavior.

Comparing Medications for DSM-5 PTSD in Routine VA Practice.

OBJECTIVE: Fluoxetine, paroxetine, sertraline, topiramate, and venlafaxine have previously shown efficacy for posttraumatic stress disorder (PTSD). One prior study using US Department of Veterans Affairs (VA) medical records data to compare these agents found no differences in symptom reduction in clinical practice. The current study addresses several weaknesses in that study, including limited standardization of treatment duration, inability to account for prior treatment receipt, use of an outdated symptomatic assessment for PTSD, and lack of functional outcome. METHODS: A total of 834 VA outpatients were identified with DSM-5 clinical diagnoses of PTSD between October 2016 and March 2018 who initiated one of the medications and met prespecified criteria for treatment duration and dose, combined with baseline and endpoint DSM-5 PTSD Checklist (PCL-5) measurements. Twelve-week acute-phase changes in PCL-5 score and remission of PTSD symptoms were compared among patients receiving the different medications, as was use of acute psychiatric services in the subsequent 6-month continuation phase. RESULTS: In the acute phase, patients improved by a mean of 6.8-10.1 points on the PCL-5 and 0.0%-10.9% achieved remission of PTSD symptoms. Those taking venlafaxine were significantly more likely to achieve remission (P = .008 vs fluoxetine and P < .0001 vs paroxetine, sertraline, and topiramate). In the continuation phase, there were no differences in acute psychiatric care use between medications. Those who continued their medication were less likely to use acute psychiatric services (HR = 0.55; P = .03). CONCLUSIONS: There may be an advantage to venlafaxine over other agents in achieving acute-phase remission for DSM-5 PTSD in routine clinical practice, but this finding requires further study. Regardless of the agent chosen, medication cessation during the continuation phase is associated with a higher risk of acute psychiatric care use.