A Qualitative Study of Sleep-Wake Disturbance Among Veterans With Post-Acute Moderate to Severe Traumatic Brain Injury.

OBJECTIVE: Examine sleep-wake disturbance (SWD) characteristics, factors, consequences, and management strategies from the perspective of veterans with chronic stage, moderate/severe traumatic brain injury (TBI). SETTING: VA Medical Center, Rocky Mountain. US PARTICIPANTS: Nineteen male veterans with post-acute TBI and SWD in the VA Health Administration. DESIGN: Qualitative descriptive. MEASURES: Semistructured interviews, Ohio State University TBI-Identification Method, Insomnia Severity Index. RESULTS: Two main dimensions emerged: "Messed up sleep" and Surviving and Managing SWD. Sleep-wake disturbance has long-term multidimensional features, etiology, consequences, and practice implications. Although SWD may not be consistently discussed with providers, the problem appears to be pervasive in many aspects of the lives of the informants. Difficulty falling asleep, frequent awakenings, and poor sleep quality were common symptoms that were described as intrusive, isolating, and difficult to self-manage. Veterans discussed a host of physical symptoms, mental health issues, environmental, and behavioral factors that contributed to SWD. Medications, sleep apnea treatment, and self-imposed isolation were frequent management strategies. Veterans expressed a willingness to try new approaches and work with providers. CONCLUSION: Sleep-wake disturbance among veterans with chronic stage TBI is a multidimensional phenomenon with interplay between comorbidities, contributing factors, effects on functioning, and sleep management strategies. Implications for practice include early and routine evaluation, monitoring, and treatment of SWD. Research is needed to test interventions that address SWD and common TBI comorbidities.

Barriers and Facilitators in Providing Community Mental Health Care to Returning Veterans with a History of Traumatic Brain Injury and Co-occurring Mental Health Symptoms.

As Veterans from recent conflicts return from deployments, increasing numbers are seeking care for physical (e.g., history of traumatic brain injury) and mental health (e.g., depression, anxiety) symptoms. Data suggest that only about half of recent Veterans are seeking care within the Veterans Health Administration. As such, providers within the community are likely to require additional training to meet the unique needs of these Veterans and their families. Towards this end, meetings were held with administrators and clinicians at Colorado Community Mental Health Centers (CMHCs) to identify current barriers and facilitators, as they relate to working with Veterans with a history of TBI and co-occurring mental health conditions. On-whole, CMHC employees had limited experience with providing care to the cohort of interest. Additional training will assist with increasing capacity and a web-based toolkit was developed to facilitate the transfer of knowledge ( www.mirecc.va.gov/visn19/tbi_toolkit ).

Cross-cultural adaptation of the Window to Hope: a psychological intervention to reduce hopelessness among U.S. veterans with traumatic brain injury.

PRIMARY OBJECTIVE: To conduct a cross-cultural adaptation of Window to Hope (WtoH), a treatment to reduce hopelessness after traumatic brain injury (TBI), from the Australian civilian context to that of U.S. Veterans. RESEARCH DESIGN: Three-stage mixed-methods approach. METHODS: Stage 1: Consensus conference with stakeholders to revise the manual. Stage 2: Pilot study of the revised manual with US Veterans to examine acceptability, feasibility and fidelity. Stage 3: Review of results with consensus conference attendees and further revisions. RESULTS: Stage 1: Conference attendees reached 100% consensus regarding changes made to the manual. Stage 2: Qualitative results yielded themes that suggest that participants benefitted from the intervention and that multiple factors contributed to successful implementation (Narrative Evaluation of Intervention Interview, User Feedback Survey-Modified, Post-Treatment Interviews). Therapists achieved 100% treatment fidelity. Quantitative results from the Client Satisfaction Questionnaire-8 suggest that the intervention was acceptable. Stage 3: The culturally adapted manual was finalized. CONCLUSIONS: RESULTS of this study suggest that the revised WtoH manual is acceptable and feasible. US therapists exhibited adherence to the protocol. The three-stage methodology was successfully employed to cross-culturally adapt an intervention that is well-suited for a Phase II randomized controlled trial among US military Veterans.

Identification and treatment of TBI and co-occurring psychiatric symptoms among OEF/OIF/OND veterans seeking mental health services within the State of Colorado: establishing consensus for best practices.

This paper highlights the results of a consensus meeting regarding best practices for the assessment and treatment of co-occurring traumatic brain injury (TBI) and mental health (MH) problems among Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn Veterans seeking care in non-Veterans Affairs Colorado community MH settings. Twenty individuals with expertise in TBI screening, assessment, and intervention, as well as the state MH system, convened to establish and review questions and assumptions regarding care for this Veteran population. Unanimous consensus regarding best practices was achieved. Recommendations for improving care for Veterans seeking care in community MH settings are provided.

Listening to Our Patients: Learning About Suicide Risk and Protective Factors From Veterans With HIV/AIDS.

PURPOSE: We sought to gather perspectives of veterans with human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) regarding suicide risk factors, warning signs, and protective factors. We also aimed to modify an existing Veterans Health Administration tool, the Suicide Risk Assessment Guide Pocket Card, for HIV/AIDS provider use. METHODS: Twenty male veterans participated in audio-recorded semistructured interviews that were transcribed and coded for themes. FINDINGS: Veterans highlighted personally relevant psychosocial stressors (i.e., poverty, social isolation and loneliness, and physical health). Although the concept of warning signs did not seem salient to participants, they named indicators of elevated imminent risk for self-directed violence (i.e., "relapse," "not take'n medications," and "miss'n appointments") and few protective factors. No themes emerged regarding recommended pocket card changes. CONCLUSIONS: This sample of veterans identified self-directed violence risks noted in the general population and others with HIV/AIDS, as well as proximal events associated with increased risk. Care providers are encouraged to explore the relevance of noted imminent and persistent indicators of increased risk with veterans seeking care.

Delivering Mental Health Services to OEF/OIF Veterans: A VHA Qualitative Study.

PURPOSE: Veterans Health Administration (VHA) mental health (MH) professionals are providing care to increasing numbers of veterans who served in Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF). This study aimed to describe MH clinicians' views of OEF/OIF veteran needs and how providers meet those needs within a large system of care. DESIGN: Qualitative research methodology, specifically qualitative description, was used to explore VHA MH clinicians' experiences providing MH services to OEF/OIF veterans. METHODS: Thirteen VA MH providers participated in semistructured interviews, which included questions regarding the following areas: psychiatric needs of OEF/OIF veterans; collaboration and referral; needs and resources; and the personal/professional impact of providing services to this cohort. FINDINGS: Themes emerged which highlighted complex challenges faced by OEF/OIF veterans, barriers associated with matching the unique needs of these veterans with existing treatments, and the challenges and rewards associated with providing care to members of this population. CONCLUSIONS: Capturing provider perspectives within MH services suggest potential areas for innovation aimed at providing patient-centered care to this cohort of veterans. Results may also inform future work aimed at meeting the needs of both OEF/OIF veterans and MH providers.