Psychopharmacoepidemiology of antidepressant medications among homeless and unstably housed service users in the Veterans Affairs healthcare system

An Evidence Map of the Women Veterans' Health Literature, 2016 to 2023: A Systematic Review

Importance

Women veterans are the fastest-growing veteran subpopulation in the US. Women veterans often experience military service-related health issues in addition to conditions common to all women. Because women veterans are more likely to receive care in the civilian setting than through the Department of Veterans Affairs (VA), all women's health clinicians should be equipped to provide patient-centered care for women veterans. The health care of women veterans requires evidence-based care informed by population-specific scientific literature. An updated evidence map evaluating women veteran-focused health literature is needed.

Objective

To map the scope and breadth of women veterans' health literature published from 2016 to 2023.

Evidence Review

In this systematic review, MEDLINE, Embase, and CINAHL Complete were searched for eligible articles published from 2016 to 2023. Articles reporting about US women veterans' health outcomes or on the experience of providing care to women veterans were included. Included articles were required to report patient-level outcomes that included either data for only women veterans or reported results separately for women veterans. Articles were grouped by primary focus area based on categories previously established by the VA Women's Health research agendas and prior evidence maps.

Findings

The volume of women veterans' health literature published between 2016 and 2023 of 932 articles was double that of the prior 8 years. The largest portion of this literature was focused on chronic medical conditions (137 articles [15%]), general mental health (203 articles [22%]), and interpersonal violence (121 articles 3[13%]). Areas of greatest growth included reproductive health (physical and mental), pain, suicide, and nonsuicidal self-injury. Additionally, emerging areas of inquiry were found, including military-related toxic exposures and harassment within the health care setting.

Conclusions and Relevance

In this systematic review of literature focused on the health of women veterans, the volume of literature was found to have doubled and expanded in important areas that aligned with VA research priorities. However, despite the growth in research related to women veterans, several important research gaps remain within this field of study. Research addressing health issues pertinent to a growing and aging women veterans' population will require rigorous research and program evaluations.

Performance of the Elixhauser Comorbidity Index in Predicting Mortality Among a National US Sample of Hospitalized Homeless Adults

BACKGROUND

The Elixhauser Comorbidity Index (ECI) is widely used, but its performance in homeless populations has not been evaluated.

OBJECTIVES

Using a national sample of inpatients, this study compared homeless and nonhomeless inpatients on common clinical diagnoses and evaluated ECI performance in predicting mortality among homeless inpatients.

RESEARCH DESIGN

A retrospective study was conducted using 2019 National Inpatient Sample (NIS) data, the largest publicly available all-payer inpatient health care database in the United States.

SUBJECTS

Among 4,347,959 hospitalizations, 78,819 (weighted 1.8%) were identified as homeless.

MEASURES

The ECI consists of 38 medical conditions; homelessness was defined using the International Classification of Diseases Tenth Revision Clinical Modification (ICD-10-CM) diagnostic code, and clinical conditions were based on the Clinical Classifications Software Refined (CCSR) for ICD-10-CM.

RESULTS

Leading clinical diagnoses for homeless inpatients included schizophrenia and other psychotic disorders (13.3%), depressive disorders (9.4%), and alcohol-related disorders (7.2%); leading diagnoses for nonhomeless inpatients were septicemia (10.2%), heart failure (5.2%), and acute myocardial infarction (3.0%). Metastatic cancer and liver disease were the most common ECI diagnoses for both homeless and nonhomeless inpatients. ECI indicators and summary scores were predictive of in-hospital mortality for homeless and nonhomeless inpatients, with all models yielding concordance statistics above 0.80, with better performance found among homeless inpatients.

CONCLUSIONS

These findings underlie the high rates of behavioral health conditions among homeless inpatients and the strong performance of the ECI in predicting in-hospital mortality among homeless inpatients, supporting its continued use as a case-mix control method and predictor of hospital readmissions.

Patterns of Psychiatric Medication Prescriptions for Veterans in Treatment Courts and Other Specialty Courts

Psychiatric medications can serve as important tools for addressing behavioral health issues among criminal justice-involved (CJI) veterans. This study used national data on 12,790 CJI veterans in the U.S. Department of Veterans Affairs (VA) Veterans Justice Outreach program from 2019 to 2020 to compare patterns of psychiatric medication prescriptions among veterans who entered a veterans treatment court (n = 6975), another specialty court (SC; n = 414), or no-SC (n = 5401). Different classes of medications were examined, including antidepressants, stimulants, antipsychotics, benzodiazepines, and medications for substance use disorders. The results showed that 60.2% of the total sample was prescribed a psychiatric medication within 1 year of entering the Veterans Justice Outreach program. There was no significant difference in overall psychiatric prescribing among veterans treatment court, other SC, and no-SC groups, but there were a few differences in certain classes of psychiatric medications. Moreover, about 7.8% of veterans who were in the no-SC group and were prescribed psychiatric medications did not have a psychiatric diagnosis. Veterans who were younger, non-Hispanic white, married, with a VA service-connected disability rating, had a diagnosis of mental and/or substance use disorder, and used more VA health care services were more likely to have been prescribed psychiatric medication. Together, these findings illustrate the essential role of psychiatric medications in courts and programs that serve CJI veterans, as well as the important link between VA service engagement and psychiatric prescriptions.

A systematic review of approaches to improve medication adherence in homeless adults with psychiatric disorders

Introduction

Medication non-adherence is a significant problem among homeless individuals with psychiatric disorders in the United States. We conducted a systematic review to identify strategies to improve psychiatric medication adherence among homeless individuals with psychiatric disorders, including substance use disorders.

Methods

We searched seven databases (MEDLINE, Embase, PsychInfo, Scopus, Web of Science, CDSR, and CENTRAL) and screened 664 studies by title and abstract followed by full-text review. Our inclusion criteria were studies that: involved an intervention for homeless adults with psychiatric disorders, reported a quantitative outcome of medication adherence, and were published in English in a peer-reviewed journal. We rated the relative effectiveness of strategies described in each study using a self-designed scale.

Results

Eleven peer-reviewed studies met criteria for inclusion in this review. Within these studies, there were seven different approaches to improve medication adherence in this population. Three studies were randomized controlled trials (RCTs) and the remaining were observational studies. Outpatient interventions included Assertive Community Treatment, Cell Phone-Assisted Monitoring, Customized Adherence Enhancement plus Long-Acting Injectable Medications, and Homeless-Designated Pharmacy Clinics. Residential, shelter-based, and inpatient interventions included use of the Housing First model, Modified Therapeutic Communities, and Homeless-Designated Inpatient Care. The approaches described in four of the eleven studies were rated as scoring a 3 or higher on a 5-point scale of effectiveness in improving medication adherence; none received 5 points.

Discussion

The interventions with the strongest evidence for improving medication adherence in this population were Assertive Community Treatment, Customized Adherence Enhancement plus Long-Acting Injectable Medications, and Housing First. Overall, studies on this topic required more rigor and focus on medication adherence as an outcome in this population. This review highlights several promising strategies and the need for larger RCTs to determine effective and diverse ways to improve medication adherence among homeless adults with psychiatric disorders.

Quality of Depression Care for Veterans Affairs Primary Care Patients with Experiences of Homelessness

BACKGROUND

Persons who experience homelessness (PEH) have high rates of depression and incur challenges accessing high-quality health care. Some Veterans Affairs (VA) facilities offer homeless-tailored primary care clinics, although such tailoring is not required, within or outside VA. Whether services tailoring enhances care for depression is unstudied.

OBJECTIVE

To determine whether PEH in homeless-tailored primary care settings receive higher quality of depression care, compared to PEH in usual VA primary care.

DESIGN

Retrospective cohort study of depression treatment among a regional cohort of VA primary care patients (2016-2019).

PARTICIPANTS

PEH diagnosed or treated for a depressive disorder.

MAIN MEASURES

The quality measures were timely follow-up care (3 + completed visits with a primary care or mental health specialist provider, or 3 + psychotherapy sessions) within 84 days of a positive PHQ-2 screen result, timely follow-up care within 180 days, and minimally appropriate treatment (4 + mental health visits, 3 + psychotherapy visits, 60 + days antidepressant) within 365 days. We applied multivariable mixed-effect logistic regressions to model differences in care quality for PEH in homeless-tailored versus usual primary care settings.

KEY RESULTS

Thirteen percent of PEH with depressive disorders received homeless-tailored primary care (n = 374), compared to usual VA primary care (n = 2469). Tailored clinics served more PEH who were Black, who were non-married, and who had low income, serious mental illness, and substance use disorders. Among all PEH, 48% received timely follow-up care within 84 days of depression screening, 67% within 180 days, and 83% received minimally appropriate treatment. Quality metric attainment was higher for PEH in homeless-tailored clinics, compared to PEH in usual VA primary care: follow-up within 84 days (63% versus 46%; adjusted odds ratio [AOR] = 1.61, p = .001), follow-up within 180 days (78% versus 66%; AOR = 1.51, p = .003), and minimally appropriate treatment (89% versus 82%; AOR = 1.58, p = .004).

CONCLUSIONS

Homeless-tailored primary care approaches may improve depression care for PEH.