The role of symptom reduction in improving health-related quality of life through brief cognitive behavioral therapy.

Brief cognitive behavior therapy (bCBT) is effective in reducing symptoms of depression and anxiety disorders and improving health-related quality of life (HRQoL). However, the mechanisms through which cognitive behavior therapy impact HRQoL are not well understood. This study evaluated whether anxiety and depression symptom reduction is a mechanism of treatment for HRQoL outcomes. METHOD: Using secondary data from a multisite, pragmatic, randomized trial, this study evaluated bCBT vs enhanced usual care in 16 VA community-based outpatient clinics. Ordinary least-squares path analysis testing multiple mediators was used to evaluate the role of change in depression and anxiety symptoms in the relationship between treatment condition and HRQoL. RESULTS: Receiving bCBT (vs. enhanced usual care) was significantly negatively associated with change (reduction) in depression and anxiety scores. The indirect effect of treatment on mental HRQoL was significant with change in depression scores as mediator. A similar pattern was observed for physical HRQoL and change in anxiety scores as mediator. CONCLUSION: Findings suggest reduction of depression and anxiety symptoms as a mechanism through which bCBT for depression promoted improvements in HRQoL, with important implications for understanding how CBT impacts functioning, as well as the utility of bCBT in nontraditional mental health settings. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT02466126.

Testing the Impact of a Collaborative, Goal-Setting, and Behavioral Telehealth Intervention on Diabetes Distress: A Randomized Clinical Trial.

Background:Diabetes distress is underrecognized and associated with poor outcomes. This study tested whether a 12-month collaborative, goal-setting, and behavioral telehealth intervention reduced diabetes distress levels.Methods:This is a secondary analysis of the Healthy Outcomes through Patient Empowerment (HOPE) study that included individuals (N = 225) with uncontrolled diabetes and depression living at least 20 miles from a Veteran's Affairs medical center. Participants were randomized to HOPE (intervention) or Enhanced Usual Care (EUC) with education. We evaluated diabetes distress levels as measured by the Problem Areas in Diabetes (PAID) Questionnaire and its four subscales (emotional, diabetes management, social, and treatment distress) at baseline, 6, and 12 months.Results:Between-group analysis revealed greater improvements in HOPE versus EUC for: 6-month PAID total score (p = 0.04), emotional (p = 0.03), and social (p = 0.04) subscales; 12-month PAID total score (p = 0.07) and emotional subscale (p = 0.07). Within-group comparisons showed larger effect sizes for HOPE compared with EUC: 12-month PAID total scores (0.82 vs. 0.54), 6-month emotional burden (0.54 vs. 0.31), and 6-month (0.32 vs. 0.08) and 12-month (0.41 vs. 0.12) social burdens. Repeated-measures analysis evaluating treatment group and time trended toward improvement in PAID overall for HOPE compared with EUC participants, but was not statistically significant (ß = 6.96; SE = 4.35; p = 0.13).Discussion:Clinically meaningful reductions in PAID overall and the emotional and social subscales were observed in HOPE compared with EUC participants.Conclusion:Further evaluation of diabetes telehealth interventions that include other facets related to diabetes distress, including treatment, diabetes management, social, and emotional burdens, is warranted. Clinical Trial Number. NCT01572389; Clinical Trial Registry. https://clinicaltrials.gov/ct2/show/NCT01572389.

Presence of PTSD is Associated with Clinical and Functional Impact in Veterans with Depression Treated in Community-Based Clinics.

Providers in non-traditional mental health settings (e.g., primary care, community medical clinics) face challenges involving patients who often present with multiple mental health conditions, but require rapid assessment and treatment. To help address this challenge, this study characterized differences in health symptom severity and mental health treatment perceptions between depressed Veterans with and without posttraumatic stress disorder (PTSD) served in community medical clinics. Relative to depressed Veterans without PTSD (N = 62), depressed Veterans with PTSD (N = 122) endorsed greater depression, suicidal ideation, anxiety, pain, and insomnia symptoms, as well as lower functioning. Veterans with depression and PTSD also reported greater mental health needs, prior utilization of mental health services, and higher perceived importance of mental health treatment. Results highlight the complexity of comorbid mental health conditions frequently seen in community medical care clinics and suggest that patients with comorbid mental health difficulties may present with a complex array of mental health symptoms.

A pilot open trial of video telehealth-delivered exposure and response prevention for obsessive-compulsive disorder in rural Veterans.

Exposure and response prevention (ERP) is the gold-standard, evidence-based psychotherapy for obsessive-compulsive disorder (OCD), but few receive it. Video telehealth can increase access to ERP for OCD and may enhance the salience of exposures. This study examined the feasibility, acceptability, and preliminary effectiveness of video telehealth-delivered ERP. We conducted a pilot open trial with 11 Veterans, using mixed quantitative and qualitative methods. Treatment completers (n = 9) had significantly reduced OCD and posttraumatic stress disorder symptoms posttreatment. Patients expressed greater comfort in engaging in ERP at home than in clinics. Therapists reported that seeing patients' home environments helped them understand their symptoms and identify relevant OCD exposures. Results suggest that video telehealth-delivered ERP is feasible and acceptable to patients and therapists and promising for reducing OCD symptoms. Future research should compare its effectiveness to usual care and evaluate patients' preferences for treatment delivery. Abbreviations: ERP: exposure and response prevention; GAD-7: Generalized Anxiety Disorder-7 scale; OCD: obsessive-compulsive disorder; OCI-R: Obsessive-Compulsive Inventory, Revised; PCL-5: PTSD Checklist; PHQ-9: Patient Health Questionnaire; PTSD: posttraumatic stress disorder; VA: epartment of Veterans Affairs; Y-BOCS: Yale-Brown Obsessive Compulsive Scale, self report form.

Risk for depression and suicidal ideation among food insecure US veterans: data from the National Health and Nutrition Examination Study.

BACKGROUND: Suicide and food insecurity (i.e., lack of access to food) are two major issues that affect US Veterans. PURPOSE: Using a US-based sample, we evaluated the association between food insecurity and suicidal ideation among Veterans. Because depression often precedes suicide, we also examined the association between food insecurity and depression. METHODS: Using data from 2630 Veterans who participated in the National Health and Nutrition Examination Survey 2007-2016, we conducted an adjusted linear regression model to evaluate the association between food insecurity (measured using 18-item Household Food Security Survey) and depression (measured using PHQ-9) and an adjusted binary logistic regression model to evaluate the association between food insecurity and suicidal ideation (measured using PHQ-9 Question 9). Models were adjusted for gender, age, income-to-poverty ratio, race/ethnicity, and education level. RESULTS: Of the sample, 11.5% were food insecure, depression scores averaged 2.86 (SD = 4.28), and 3.7% endorsed suicidal ideation. Veterans with marginal (ß = 0.68, 95%CI [0.09,1.28]), low (ß = 1.38, 95%CI [0.70,2.05]) or very low food security (ß = 3.08, 95%CI [2.34, 3.83]) had significantly increased depression scores compared to food secure Veterans. Veterans with low (OR = 2.15, 95%CI [1.08, 4.27]) or very low food security (OR = 3.84, 95%CI [2.05, 7.20]) had significantly increased odds for suicidal ideation compared to food secure Veterans. CONCLUSION: Food insecurity in Veterans is associated with increased depression symptoms and suicidal ideation. This association strengthens as food insecurity worsens. Veterans with food insecurity should be screened for depression and suicidal ideation. Simultaneously, depression treatment plans and suicide prevention programs should consider basic needs like food security.

Food insecurity: Comparing odds between working-age veterans and nonveterans with children.

BACKGROUND: Low-income, working-age Veterans with children have risk for food insecurity. Less known is extent to which their risk compares to nonveterans. PURPOSE: To evaluate odds of food insecurity for working-age Veterans with children compared to socioeconomically-matched nonveterans with children. METHOD: We constructed a propensity score-matched cohort using 2011-2014 National Health and Nutrition Examination Survey data. Covariate-adjusted logistic regressions estimated Veterans' odds for overall food insecurity and for each level of severity compared to nonveterans. FINDINGS: We matched 155 Veterans to 310 nonveterans on gender, race/ethnicity, education, income. Models were adjusted for age, marital-status, depression, and listed matched variables. Although Veteran-status had no effect on overall food insecurity (odds ratio = 1.09, 95% confidence interval [0.62,1.93]), Veteran-status increased odds for very low food security (odds ratio = 2.71, 95% confidence interval [1.21, 6.07]). DISCUSSION: Veterans do not have higher odds of food insecurity than non-veterans, but they are more likely to have the more severe very low food security (often associated with hunger) than non-veterans. Investigation of food insecurity's impact on Veteran health/well-being is needed.

The Impact of Integrating Physical Health into a Brief CBT Approach for Medically Ill Veterans.

The current study explored the use and preliminary outcomes of physical health treatment elements integrated into a traditional brief cognitive behavioral therapy (bCBT) approach for medically ill veterans with depression and/or anxiety. Data were collected as part of a pragmatic randomized trial examining patient outcomes of bCBT versus an enhanced usual care condition. bCBT was delivered to participants by Veterans Health Administration (VA) mental health providers in the primary care setting. Using a skill-based approach, providers and participants selected modules from a list of intervention strategies. Modules included Taking Control of Your Physical Health, Using Thoughts to Improve Wellness, Increasing Pleasant Activities, and Learning How to Relax. Skill module use and impact on treatment completion and clinical outcomes were explored for participants randomized to bCBT who received at least one skill module (n = 127). Utilization data showed that participants and providers most commonly selected the physical health module for the first skill session. Receiving the "physical health" and "thoughts" modules earlier in treatment were associated with a higher likelihood of treatment completion (defined as four or more sessions). Preliminary outcome data suggest that the physical health skill module was equally effective or superior to other bCBT skill modules. Results suggest that incorporating physical health elements with a bCBT approach hold the potential to positively impact treatment engagement/completion and may result in improved outcomes for medically ill patient populations.

Integrated Brief Cognitive Behavioral Therapy Improves Illness Intrusiveness in Veterans With Chronic Obstructive Pulmonary Disease.

Background: Progressive illnesses such as chronic obstructive pulmonary disease (COPD) impart a high level of physical and psychological burden. Evidence-based psychotherapies hold the potential to improve perceptions of physical health impairment, yet few studies have documented these effects. Purpose: To evaluate the effect of brief cognitive behavioral therapy (bCBT) on disease-related illness intrusiveness. Methods: Participants were 175 Veterans with COPD and clinically elevated symptoms of depression and/or anxiety enrolled in a larger randomized trial (n = 99 randomized to bCBT, n = 76 to enhanced usual care; EUC). bCBT included up to six treatment sessions and optional booster sessions over a 4-month period. EUC entailed an assessment with documentation in the medical record. Primary outcomes focused on posttreatment changes on the Illness Intrusiveness Rating Scale (IIRS), an established measure of perceived impairment from a chronic health condition. Results: Illness intrusiveness improved for bCBT participants relative to EUC, after controlling for baseline IIRS scores, depression, and anxiety (p = .03, partial η2 = .03). Specific improvement was observed in the Instrumental subscale (p = .02), encompassing improved intrusiveness of COPD on daily activities and daily functioning. IIRS scores improved in the absence of changes in physical functioning. Conclusions: Illness intrusiveness was high among Veterans with COPD but improved over the course of bCBT. Integrated behavioral health interventions hold the potential to reduce disease intrusiveness. The IIRS may be a valuable tool to augment traditional assessment and measurement-based care approaches of behavioral health interventions for medically ill patients.

Delivery of Brief Cognitive Behavioral Therapy for Medically Ill Patients in Primary Care: A Pragmatic Randomized Clinical Trial.

BACKGROUND: Few studies have examined the practical effectiveness and implementation potential of brief psychotherapies that integrate mental and physical health. OBJECTIVE: To determine whether an integrated brief cognitive behavioral therapy (bCBT), delivered by mental health providers in primary care, would improve depression, anxiety and quality of life for medically ill veterans. DESIGN: Pragmatic patient-randomized trial comparing bCBT to enhanced usual care (EUC). PARTICIPANTS: A total of 302 participants with heart failure and/or chronic obstructive pulmonary disease (COPD) with elevated symptoms of depression and/or anxiety were enrolled from two Veterans Health Administration primary care clinics. INTERVENTION: bCBT was delivered to 180 participants by staff mental health providers (n = 19). bCBT addressed physical and emotional health using a modular, skill-based approach. bCBT was delivered in person or by telephone over 4 months. Participants randomized to EUC (n = 122) received a mental health assessment documented in their medical record. MAIN MEASURES: Primary outcomes included depression (Patient Health Questionnaire) and anxiety (Beck Anxiety Inventory). Secondary outcomes included health-related quality of life. Assessments occurred at baseline, posttreatment (4 months), and 8- and 12-month follow-up. KEY RESULTS: Participants received, on average, 3.9 bCBT sessions with 63.3% completing treatment (4+ sessions). bCBT improved symptoms of depression (p = 0.004; effect size, d = 0.33) and anxiety (p < 0.001; d = 0.37) relative to EUC at posttreatment, with effects maintained at 8 and 12 months. Health-related quality of life improved posttreatment for bCBT participants with COPD but not for heart failure. Health-related quality of life outcomes were not maintained at 12 months. CONCLUSIONS: Integrated bCBT is acceptable to participants and providers, appears feasible for delivery in primary care settings and is effective for medically ill veterans with depression and anxiety. Improvements for both depression and anxiety were modest but persistent, and the impact on physical health outcomes was limited to shorter-term effects and COPD participants. Clinical trials.Gov identifier: NCT01149772.

Desired Involvement in Treatment Decisions Among Adults with PTSD Symptoms.

UNLABELLED: Most medical patients want to be involved in decisions about their care. Whether this is true for people with posttraumatic stress disorder (PTSD)-a disorder characterized by avoidance of trauma-related discussions-is unknown. We conducted an online survey assessing preferences for involvement in PTSD treatment decisions (level of control, timing) and information about PTSD treatment (content, format). Adults who screened positive for possible PTSD (N = 301) were recruited from a large online survey panel representative of the U. S. POPULATION: Virtually all respondents (97.3%) desired involvement in treatment decisions; two thirds (67.8%) wanted primary responsibility for decisions. Most (64.2%) wanted 30-60 minutes to learn about treatments and 80.1% wanted at least 1-3 days to consider their options. Respondents expressed more interest in informational content on treatment effectiveness and side effects than any other topic. In-person discussion with a provider was preferred more than other learning formats (e.g., websites, brochures). Results suggested that people with symptoms of PTSD want involvement in decisions about their treatment and want to discuss treatment options with their provider. Providers may wish to prioritize information about effectiveness and side effects, and should expect that many patients will need several days after their visit to make a decision.

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

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

Characteristics of U.S. veterans who begin and complete prolonged exposure and cognitive processing therapy for PTSD.

This retrospective chart-review study examined patient-level correlates of initiation and completion of evidence-based psychotherapy (EBP) for posttraumatic stress disorder (PTSD) among treatment-seeking U.S. veterans. We identified all patients (N = 796) in a large Veterans Affairs PTSD and anxiety clinic who attended at least 1 individual psychotherapy appointment with 1 of 8 providers trained in EBP. Within this group, 91 patients (11.4%) began EBP (either Cognitive Processing Therapy or Prolonged Exposure) and 59 patients (7.9%) completed EBP. The medical records of all EBP patients (n = 91) and a provider-matched sample of patients who received another form of individual psychotherapy (n = 66) were reviewed by 4 independent raters. Logistic regression analyses revealed that Iraq and Afghanistan veterans were less likely to begin EBP than veterans from other service eras, OR = 0.48, 95% CI = [0.24, 0.94], and veterans who were service connected for PTSD were more likely than veterans without service connection to begin EBP, OR = 2.33, 95% CI = [1.09, 5.03]. Among those who began EBP, Iraq and Afghanistan veteran status, OR = 0.09, 95% CI = [0.03, 0.30], and a history of psychiatric inpatient hospitalization, OR = 0.13, 95% CI = [0.03, 0.54], were associated with decreased likelihood of EBP completion.

Brief Cognitive-Behavioral Therapy for Depression in Community Clinics: A Hybrid Effectiveness-Implementation Trial.

OBJECTIVE: The authors examined whether brief cognitive-behavioral therapy (bCBT) for depression, delivered by mental health providers in community-based outpatient clinics (CBOCs) of the Veterans Health Administration, improved depression outcomes and was feasible and acceptable in clinical settings. METHODS: The authors used a type-2 hybrid effectiveness-implementation, patient-randomized trial to compare bCBT with enhanced usual care. Participants (N=189) with moderate symptoms of depression (Patient Health Questionnaire-9 [PHQ-9] score ≥10) were enrolled from CBOCs in the southern United States. bCBT (N=109) consisted of three to six sessions, delivered by mental health providers (N=17) as part of routine clinic practices. Providers received comprehensive training and support to facilitate bCBT delivery. Recipients of enhanced usual care (N=80) were given educational materials and encouraged to discuss treatment options with their primary care provider. The primary effectiveness outcome was PHQ-9-assessed depression symptoms posttreatment (4 months after baseline) and at 8- and 12-month follow-ups. Implementation outcomes focused on bCBT dose received, provider fidelity, and satisfaction with bCBT training and support. RESULTS: bCBT improved depression symptoms (Cohen's d=0.55, p<0.01) relative to enhanced usual care posttreatment, and the improvement was maintained at 8- and 12-month follow-ups (p=0.004). bCBT participants received a mean±SD of 3.7±2.7 sessions (range 0-9), and 64% completed treatment (≥3 sessions). Providers delivered bCBT with fidelity and reported that bCBT training and support were feasible and effective. CONCLUSIONS: bCBT had a modest treatment footprint of approximately four sessions, was acceptable to participants and providers, was feasible for delivery in CBOCs, and produced meaningful sustained improvements in depression.

The case for screening for diabetes distress, depression, and anxiety.

Our goal was to determine the prevalence of anxiety and depression in a sample of U.S. military veterans with type 2 diabetes and elevated diabetes distress (DD). Cross-sectional analyses were conducted. The association between DD and anxiety and depression was assessed with logistic regression. Almost 80% of persons with elevated DD had clinically significant anxiety or depression symptoms. The odds of depression and anxiety increased with DD severity. Given the large overlap of depression and anxiety with elevated DD, we recommend providers screen for all three conditions and, if positive, connect to resources for diabetes self-management and/or clinical treatment.

Evaluation of the Implementation of the FLOW Program for Increasing Access to Mental Health Care.

The FLOW program was designed to facilitate appropriate and safe transitions of patients from specialty mental health (SMH) to primary care (PC) as a method of improving access and reducing appointment burden on veterans who have improved or remitted. In this study, the team evaluated the implementation of FLOW across nine Veterans Affairs (VA) sites using a mixed-methods evaluation in a cluster-randomized stepped wedge trial design. Outcome assessments used data from VA databases, dashboards, and semi-structured interviews and were guided by the Reach, Adoption, Effectiveness, Implementation, and Maintenance (RE-AIM) framework. Across the sites, mean level reach was 1.36% of all specialty mental health patients transitioned to primary care (standard deviation [SD] = 1.05). Mean provider adoption was 10.2% (SD = 8.3%). Approximately 75% of veterans were fully satisfied with their transition and reported shared decision-making in the decision to transition. Rates of transitions did not decrease over the 6-month maintenance period following implementation. These data suggest that FLOW can be successfully implemented and maintained, although there was wide variation in implementation across sites. Future research should examine how to support sites that struggle with implementation.

A protocol for a randomized controlled trial of exposure and response prevention for veterans with obsessive compulsive disorder.

BACKGROUND: Obsessive compulsive disorder (OCD) is effectively treated with exposure and response prevention (ERP), yet very few veterans receive ERP for OCD within the Veterans Health Administration (VHA). Veterans are a clinically complex population, and no prior research has evaluated the effectiveness of ERP in veterans with OCD or comorbid OCD and posttraumatic stress disorder (PTSD). Given the limited accessibility of ERP-trained providers within VHA, assessment of video telehealth (VTH) delivery of ERP is warranted. METHODS: A sample of 160 veterans with OCD (80 diagnosed with comorbid PTSD) will be randomly assigned to receive up to 16 sessions of ERP or a stress management training control delivered via VTH. Assessments will occur at baseline, posttreatment, and 6-month follow-up. The primary outcome will evaluate the impact of ERP on participants' functioning, and secondary outcomes will include quality of life and OCD symptoms. At posttreatment, qualitative interviews with veterans, clinicians, and administrators will explore barriers and facilitators to treatment delivery, and the implementation potential of ERP. CONCLUSIONS: Results will provide direction for the treatment of OCD and comorbid PTSD in veterans, as well as guidance for future implementation efforts for ERP within VHA. CLINICALTRIALS: gov Identifier:NCT05240924.

Association between modifiable social determinants and mental health among post-9/11 Veterans: A systematic review.

Introduction: As U.S. Veterans reintegrate from active duty to civilian life, many are at risk for negative modifiable social determinants of health. The prevalence of mental health conditions among Veterans is also high. Awareness of the associations between these two factors is growing. This systematic review provides a comprehensive analysis of the current state of knowledge of the associations between modifiable social determinants and mental health among U.S. Veterans. Methods: The authors systematically searched four databases and identified 28 articles representing 25 unique studies that met inclusion criteria. Findings from the studies were extracted and synthesized on the basis of modifiable social determinants. Study quality and risk of bias were assessed using the Methodological Quality Questionnaire. Results: The studies identified in the systematic review examined three modifiable social determinants of health: 1) housing stability, 2) employment and finances, and 3) social support. Although the lack of validity for measures of housing stability, employment, and finances compromised study quality, the overall evidence suggests that Veterans with access to supportive social determinants had better mental health status. Evidence was particularly robust for the association between strong social support and lower symptoms of posttraumatic stress disorder. Discussion: Current evidence suggests the need to consider modifiable social determinants of health when designing mental health interventions. However, more research encompassing a wider range of modifiable social determinants such as food security, education, and transportation and using comprehensive methods and validated instruments is needed. Future research also needs to intentionally include Veterans from diverse racial-ethnic groups.

Characteristics Associated with Persistent Versus Transient Food Insecurity Among US Veterans Screened in the Veterans Health Administration.

BACKGROUND: Awareness of negative health impacts associated with food insecurity among US veterans is growing. Yet, little research has examined characteristics associated with persistent vs transient food insecurity. OBJECTIVE: Our aim was to investigate characteristics associated with persistent vs transient food insecurity among US veterans. DESIGN: The study used a retrospective, observational design to examine data from Veterans Health Administration electronic medical records. PARTICIPANTS/SETTING: The sample consisted of veterans (n = 64,789) who screened positive for food insecurity in Veterans Health Administration primary care during fiscal years 2018-2020 and were rescreened within 3 to 5 months. MAIN OUTCOME MEASURES: Food insecurity was operationalized using the Veterans Health Administration food insecurity screening question. Transient food insecurity was a positive screen followed by a consecutive negative screen within 3 to 15 months. Persistent food insecurity was a positive screen followed by a consecutive positive screen within 3 to 15 months. STATISTICAL ANALYSES PERFORMED: A multivariable logistic regression model was used to assess characteristics (eg, demographic characteristics, disability rating, homelessness, and physical and mental health conditions) associated with persistent vs transient food insecurity. RESULTS: Veterans with increased odds of persistent vs transient food insecurity included men (adjusted odds ratio [AOR] 1.08; 95% CI 1.01 to 1.15) and those from Hispanic (AOR 1.27; 95% CI 1.18 to 1.37) or Native American (AOR 1.30; 95% CI 1.11 to 1.53) racial and ethnic groups. Psychosis (AOR 1.16; 95% CI 1.06 to 1.26); substance use disorder, excluding tobacco and alcohol (AOR 1.11; 95% CI 1.03 to 1.20); and homelessness (AOR 1.32; 95% CI 1.26 to 1.39) were associated with increased odds of persistent vs transient food insecurity. Veterans who were married (AOR 0.87; 95% CI 0.83 to 0.92) or had a service-connected disability rating of 70% to 99% (AOR 0.85; 95% CI 0.79 to 0.90) or 100% (AOR 0.77; 95% CI 0.71 to 0.83) had lower odds of persistent vs transient food insecurity. CONCLUSIONS: Veterans at risk for persistent vs transient food insecurity may struggle with underlying issues like psychosis, substance use, and homelessness in addition to racial and ethnic inequities and gender differences. More research is needed to understand the characteristics and mechanisms that increase risk for persistent vs transient food insecurity among veterans.

Delivery of Exposure and Response Prevention Among Veterans with Obsessive-Compulsive Disorder.

Veterans with obsessive-compulsive disorder (OCD) often face barriers to receiving evidence-based treatments such as exposure and response prevention (ERP). Through retrospective review of electronic medical records, this study examined the rates of ERP delivery in a national sample of 554 veterans newly diagnosed with OCD in the Veterans Health Administration between 2016 and 2017. Results indicated that only 4% of veterans (n = 22) received any ERP treatment; and, of those, 16 veterans received "true ERP." Veterans who received any ERP were younger than those who did not. ERP was primarily delivered by psychologists in urban facilities along the East and West coasts of the USA. The findings from this study emphasize the need to train more providers to effectively deliver ERP in addition to providing telehealth services to increase access to care for veterans in rural areas.

The impact of veteran support and resources for diabetes (iNSPiRED) on diabetes distress: Results from a randomized, parallel-group trial.

OBJECTIVE: The primary objective of this research was to assess the impact of a novel, peer-directed intervention (iNSPiRED) on diabetes distress (DD) among veterans with type 2 diabetes and DD. Secondary objectives were to assess iNSPiRED's impact on anxiety, depression, and diabetes self-management behaviors. METHOD: A single-blinded, randomized, parallel-group trial was conducted. Participants (n = 218) were recruited through a Veterans Affairs medical center and community agencies in a major metropolitan area from September 2019 through January 2022. Certified mental health peer specialists delivered iNSPiRED, a three-month goal-setting and resource navigation intervention. Outcomes were assessed at baseline, postintervention, and month six. Multilevel random-intercept linear regression models with treatment x time interaction terms were used to assess treatment effects. RESULTS: Frequency of following a healthy eating plan was higher for iNSPiRED vs usual care at month three relative to baseline (B = 0.58; p = 0.03) after adjusting for race and socioeconomic status. No other treatment effects differed significantly from zero (ps ≥ 0.05). CONCLUSION: Peer-directed interventions have the potential to deliver low-cost, highly scalable care. However, based on the largely negative findings of the current study, it is likely that more intense, multimodal interventions are needed to address DD.