Changing Rates of Mental Health Disorders Among Veterans Treated in the VHA During Troop Drawdown, 2007-2013.

Nationally representative data on mental health disorder prevalence are critical to set informed mental health priorities and policies. Data indicating mental health diagnoses within our nation's veteran population treated at the Veterans Health Administration (VHA) are available, but have yet to be examined for changing trends to inform both VHA and community care. We use VHA national program evaluation data from a time of increasing military enrollment (2007) to troop draw down (2013) to examine changes over time in the number of diagnoses in veterans receiving VHA services. The number of veterans in all diagnostic categories increased during our study period with the smallest increase in psychotic disorders (8%) and the largest in posttraumatic stress disorder (71%). Trends in behavioral health diagnoses among veterans have important implications for policy and clinician competencies within VHA and community providers as veteran mental health care needs change.

Comparing the Costs and Acceptability of Three Fidelity Assessment Methods for Assertive Community Treatment.

Successful implementation of evidence-based practices requires valid, yet practical fidelity monitoring. This study compared the costs and acceptability of three fidelity assessment methods: on-site, phone, and expert-scored self-report. Thirty-two randomly selected VA mental health intensive case management teams completed all fidelity assessments using a standardized scale and provided feedback on each. Personnel and travel costs across the three methods were compared for statistical differences. Both phone and expert-scored self-report methods demonstrated significantly lower costs than on-site assessments, even when excluding travel costs. However, participants preferred on-site assessments. Remote fidelity assessments hold promise in monitoring large scale program fidelity with limited resources.

A review of research on smoking behavior in three demographic groups of veterans: women, racial/ethnic minorities, and sexual orientation minorities.

BACKGROUND: Veterans comprise a large segment of the U.S. population and smoke at high rates. One significant way to reduce healthcare costs and improve the health of veterans is to reduce smoking-related illnesses for smokers who have high smoking rates and/or face disproportionate smoking consequences (e.g. women, racial/ethnic minorities, sexual orientation minorities). OBJECTIVES: We reviewed published studies of smoking behavior in three demographic subgroups of veterans - women, racial/ethnic minorities, and sexual orientation minorities - to synthesize current knowledge and identify areas in need of more research. METHODS: A MEDLINE search identified papers on smoking and veterans published through 31 December 2014. RESULTS: Twenty-five studies were identified that focused on gender (n = 17), race/ethnicity (n = 6), or sexual orientation (n = 2). Female and sexual orientation minority veterans reported higher rates of smoking than non-veteran women and sexual orientation majority veterans, respectively. Veterans appeared to be offered VA smoking cessation services equally by gender and race. Few studies examined smoking behavior by race/ethnicity or sexual orientation. Little information was identified examining the outcomes of specific smoking treatments for any group. CONCLUSION: There is a need for more research on all aspects of smoking and quit behavior for women, racial/ethnic minorities, and sexual orientation minority veterans. The high rates of smoking by these groups of veterans suggest that they may benefit from motivational interventions aimed at increasing quit attempts and longer and more intense treatments to maximize outcomes. Learning more about these veterans can help reduce costs for those who experience greater consequences of smoking.

Comparison of Assertive Community Treatment Fidelity Assessment Methods: Reliability and Validity.

Assertive community treatment is known for improving consumer outcomes, but is difficult to implement. On-site fidelity measurement can help ensure model adherence, but is costly in large systems. This study compared reliability and validity of three methods of fidelity assessment (on-site, phone-administered, and expert-scored self-report) using a stratified random sample of 32 mental health intensive case management teams from the Department of Veterans Affairs. Overall, phone, and to a lesser extent, expert-scored self-report fidelity assessments compared favorably to on-site methods in inter-rater reliability and concurrent validity. If used appropriately, these alternative protocols hold promise in monitoring large-scale program fidelity with limited resources.

Training, skills, and leadership experience: The need to expand clinical psychology training as illustrated by psychology leadership stories.

Training for clinical psychologists is grounded in training models emphasizing clinical work, scholarship, and research. Rigorous competencies, varying by clinical specialty area, guide the specifics of training within domains of knowledge, skills, and aptitudes-with the goal of ensuring well-trained clinical psychologists. Research further illuminates the skills, characteristics, and experiences needed to maximize the effectiveness of clinical care provided by trained clinical psychologists. In addition, data indicate that clinical psychologists spend an average of 20% of their work time in management and leadership activities beyond clinical duties of direct care, requiring expanded and additional skills beyond those formally conceptualized and broadly included in graduate training. We utilize descriptions of three clinical psychologists' leadership journeys to illustrate the gap in training filled by these bootstrapping autodidacts when successes led to promotion to higher levels of responsibility and leadership. Our proposed solution is a call to action. We call for consideration of an expansion of clinical psychology training by (a) overtly translating currently taught clinical skills into needed leadership skills to consistently fill the gap rather than relying on individuals to acquire enough experience to adequately perform the translation themselves, and (b) adding both pragmatic and theoretical leadership skills into an expanded training curriculum. We strongly urge this rethinking and expansion of training to adequately support and foster future clinical psychologists in administrative and other leadership roles. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Social networks and personal loss among young adults with mental illness and their parents: a family perspective.

OBJECTIVE: Study examined perceptions of personal loss due to mental illness and social network characteristics among young adults with a psychiatric disability and their parents. Research directly compared young adults' and parents' reports of personal loss, social network structure and support, and interpersonal loneliness. Relationships between perceived networks, personal loss, and loneliness for adults and parents were examined. METHOD: Sixty young adults diagnosed with schizophrenia or bipolar disorder and their parents from 30 families completed individual, semistructured interviews that assessed social networks, loneliness, and personal loss due to mental illness. RESULTS: Differences between young adults and parents were found in types of personal loss due to mental illness and the structure of their perceived networks. Parents reported larger networks with more family members than did adults, but no significant differences were found in perceptions of social support. Adults and their parents reported similar feelings of loneliness, but a differential pattern of relationships was found between perceived personal loss, network characteristics, and loneliness among adults and their parents. CONCLUSIONS: Study highlights importance of including both adults with psychiatric disability and their parents in family research. Comparing experiences of adults and parents can help to describe disruptions due to mental illness and perceived availability of social resources in the context of family life.

Valued social roles and measuring mental health recovery: examining the structure of the tapestry.

UNLABELLED: The complexity of the concept of mental health recovery often makes it difficult to systematically examine recovery processes and outcomes. The concept of social role is inherent within many acknowledged dimensions of recovery such as community integration, family relationships, and peer support and can deepen our understanding of these dimensions when social roles are operationalized in ways that directly relate to recovery research and practice. OBJECTIVE: This paper reviews seminal social role theories and operationalizes aspects of social roles: role investment, role perception, role loss, and role gain. The paper provides a critical analysis of the ability of social role concepts to inform mental health recovery research and practice. METHOD: PubMed and PsychInfo databases were used for the literature review. RESULTS: A more thorough examination of social role aspects allows for a richer picture of recovery domains that are structured by the concept social roles. Increasing understanding of consumers' investment and changes in particular roles, perceptions of consumers' role performance relative to peers, and consumers' hopes for the future with regards to the different roles that they occupy could generate tangible, pragmatic approaches in addressing complex recovery domains. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: This deeper understanding allows a more nuanced approach to recovery-related movements in mental health system transformation.

Recovery-oriented inpatient mental health care and readmission.

OBJECTIVE: This article examines the relationship between inpatient mental health units' adherence to recovery-oriented care and 30-day patient readmission. METHOD: The sample included patients admitted to one of 34 Veterans Health Administration inpatient mental health units. Recovery-oriented care was assessed using interviews and site visits. Patient characteristics and readmission data were derived from administrative data. FINDINGS: Overall recovery orientation was not associated with readmission. Exploratory analyses found higher scores on a subsample of items pertaining to inpatient therapeutic programming were associated with lower patient readmissions. Additionally, patients with more prior service use and substance abuse or personality disorders were more likely to be readmitted. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: A growing body of literature supports the association between psychotherapeutic services in inpatient units and better patient outcomes. However, further research is needed to examine this association. More work is needed to develop appropriate psychotherapy services for the inpatient setting and support their implementation. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Psychotherapy in mental health clinics of the Department of Veterans Affairs.

In this study, Department of Veterans Affairs Fiscal Year 2006 national workload data are analyzed to determine use and intensity of outpatient individual and group psychotherapy and, using multivariate analysis, to identify sociodemographic and diagnostic correlates. Results show that among veterans receiving specialty mental health services (n=934,832), average visits numbered 7.9, 64.7% received at least one psychotherapy visit, 94% received individual therapy, and 24.1% received group. Veterans with the most mental health specialty visits of any kind were most likely to receive psychotherapy. Veterans with affective disorders and post-traumatic stress disorder diagnosis were more likely to receive psychotherapy than others. Veterans who are older, male, Black, or psychiatrically hospitalized were less likely to receive psychotherapy. Correlates of receipt of group therapy (i.e., older, Black, male, substance abuse diagnosis, urban residence) tend to be inversely related to receiving individual therapy. We conclude that psychotherapy is widely available at modest levels of intensity in Veterans Affairs.

Recovery-oriented acute inpatient mental health care: Operationalization and measurement.

OBJECTIVE: The current article describes efforts to develop and test a measure of recovery-oriented inpatient care. METHOD: The Recovery-oriented Acute INpatient (RAIN) scale was based on prior literature and current Veterans Health Administration (VHA) policy and resources and further revised based on data collection from 34 VHA acute inpatient units. RESULTS: A final scale of 23, behaviorally anchored items demonstrated a four-factor structure including the following factors: inpatient treatment planning, outpatient treatment planning, group programming, and milieu. While several items require additional revision to address psychometric concerns, the scale demonstrated adequate model fit and was consistent with prior literature on recovery-oriented inpatient care. Conclusions and Implementations for Practice: The RAIN scale represents an important tool for future implementation and empirical study of recovery-oriented inpatient care. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Psychometric examination of care quality measures in VA psychosocial rehabilitation and recovery centers (PRRCs).

The Veterans Health Administration (VHA) developed Psychosocial Rehabilitation and Recovery Centers (PRRCs) to enhance recovery-oriented mental health services to large populations of veterans diagnosed with serious mental illness (e.g., psychotic disorders, bipolar disorder) and significant functional challenges. Psychosocial Rehabilitation and Recovery Centers were designed to support a rehabilitation framework to help veterans obtain needed skills and support to integrate into meaningful, self-determined community roles. This study used data collected as part of VHA's development and implementation of a national system to monitor PRRC performance with the purpose of evaluating the psychometric properties and latent structure of outcome measures used in PRRCs. Baseline self-report data from 5,086 veterans and their assigned PRRC staff providers were collected and reviewed. Exploratory factor analyses were used to evaluate the psychometric properties of the Veteran-Rated Psychiatric Symptom Items (VR-PSI), the Clinician-Rated Psychiatric Symptom Items (CR-PSI), and the Internalized Stigma of Mental Illness 10-item scale (ISMI-10). Four latent factors were identified for the VR-PSI and CR-PSI for the total sample, while the ISMI-10 was reduced to 8-items to assess self-stigma as a unitary measure. All measures demonstrated good psychometric properties. This study provides initial support for the latent factor structures and psychometric properties of measures used to assess national VHA PRRC performance. Implications and limitations are discussed. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Public servant, silent servant: A call to action for advocacy training in public service settings.

Views on what is important in training for psychologists are evolving, reflecting a broadening understanding of the role psychologists can and should play in societal change. Since the development of the scientist-practitioner model after World War II, arguments around training have focused on the appropriate balance between training in the practice of psychology versus training in research related to psychology. Recent calls reflect more radical change to include an advocacy emphasis within the formal coursework of psychology doctoral programs, well articulated by Mallinckrodt, Miles, and Levy (2014) as the tripartite model of Scientist-Practitioner-Advocate. In this paper, we present the argument for expanding a model that incorporates advocacy training into clinical psychology internships and postdoctoral programs and describe why we believe voices for advocacy have been largely silent in public-sector clinical psychology training and practices. We outline how this may be accomplished in public sector training settings, and we articulate a call to action for public servants to speak out so their voice can ignite a passion for advocacy within public sector psychology service and training. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Development and Validation of an Instrument to Measure Staff Perceptions of Recovery Climate and Culture in Mental Health Programs.

OBJECTIVE: Few existing instruments measure recovery-oriented organizational climate and culture. This study developed, psychometrically assessed, and validated an instrument to measure recovery climate and culture. METHODS: Organizational theory and an evidence-based conceptualization of mental health recovery guided instrument development. Items from existing instruments were reviewed and adapted, and new items were developed as needed. All items were rated by recovery experts. A 35-item instrument was pilot-tested and administered to a national sample of mental health staff in U.S. Department of Veterans Affairs Psychosocial Rehabilitation and Recovery Centers (PRRCs). Analysis entailed an exploratory factor analysis (EFA) and inter-item reliability and scale correlation assessment. Blinded site visits to four PRRCs were performed to validate the instrument. RESULTS: The EFA determined a seven-factor solution for the data. The factors identified were staff expectations, values, leadership, rewards, policies, education and training, and quality improvement. Seven items did not meet retention criteria and were dropped from the final instrument. The instrument exhibited good internal consistency (Cronbach's α=0.81; subscales, α=0.84-0.88). Scale correlations were between 0.16 and 0.61, well below the threshold (α=0.9) for indicating overlapping constructs. Site visitors validated the instrument by correctly identifying high-scoring and low-scoring centers. CONCLUSIONS: These findings provide a psychometrically tested and validated instrument for measuring recovery climate and culture in mental health programs. This instrument can be used in evaluation of mental health services to determine the extent to which programs possess the organizational precursors that drive recovery-oriented service delivery.

A site visit protocol for assessing recovery promotion at the program level: An example from the Veterans Health Administration.

OBJECTIVE: A site visit protocol was developed to assess recovery promotion in the organizational climate and culture of programs for veterans with serious mental illnesses. METHOD: The protocol was pilot-tested in 4 programs: 2 that had scored high on the pilot version of a staff survey measure of program-level recovery promotion and 2 that had scored low. Two-person teams conducted onsite visits and assigned global and organizational domain ratings. Interrater agreement was assessed by examining adjacent agreement and computing weighted kappa. RESULTS: The on-site protocol had good interrater agreement and discriminated between sites that scored high and low on the staff survey. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: This site visit protocol and procedure shows promise for evaluating recovery promotion in milieu-based programs. After further refinement of this tool, adaptations could be developed for accreditation protocols or for program self-assessment and quality improvement efforts. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Ever onward: the personal strivings of young adults coping with serious mental illness and the hopes of their parents.

This longitudinal study examined the personal strivings of young adults coping with mental illness, parents' hopes for their children, and attributes that adults and parents give to their strivings and hopes. Findings are based on separate interviews with a total of 60 young adults diagnosed with schizophrenia or bipolar disorder and their parents from 30 families. Adults and their parents generally expressed similar types of strivings and hopes and were persistent in strivings/hopes reported over a 1-year period. Adults were generally more optimistic than parents, anticipating more success in achieving their strivings with less difficulty and effort. Family agreement about strivings/hopes was significantly related to attribute ratings. Findings are discussed in the context of life span development and models of recovery.

Two Birds, One Stone: Unintended Consequences and a Potential Solution for Problems With Recovery in Mental Health.

Recovery began as a social justice movement. In more recent years, professionals have joined the movement, unintentionally co-opting and mainstreaming the more radical goals of these earlier activist consumer movements. The goals of the patient-centered care movement in general medical care are similar to those of "professional recovery." If mental health professionals instead adopted the language and goals of patient-centered care as a first step toward joining the two movements, the recovery movement could reclaim its social justice roots, and progress would be made toward reducing the duality between physical and mental health care systems. Professionals should return the recovery movement to those with lived experience, adopt the unified language of patient-centered care, and align professional transformation efforts under one holistic movement.

Measuring personal loss among adults coping with serious mental illness.

Psychometric properties of a brief self-report measure of personal loss for adults coping with psychiatric disability are examined. The Personal Loss from Mental Illness Scale (PLMI) is a 20-item measure that assesses overall perceptions and four interrelated aspects of personal loss from mental illness. Using a sample of 158 adults with serious mental illness, the PLMI was found to have a meaningful factor structure, good internal consistency and high test-retest reliability. Construct validity is evidenced by positive correlations between personal loss scores, number of psychiatric hospitalizations, self-reports of loneliness, psychological symptoms, and problems with alcohol. PLMI scores were unrelated to scores on a personal growth measure and negatively correlated with scores on a positive well-being scale. Implications of the PLMI for research on coping, adaptation and recovery from serious mental illness are discussed.