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Singh K, Timko C, Yu M, Taylor E, Blue-Howells J, Finlay AK. Scoping review of military veterans involved in the criminal legal system and their health and healthcare: 5-year update and map to the Veterans-Sequential Intercept Model. HEALTH & JUSTICE 2024; 12:18. [PMID: 38639813 PMCID: PMC11027330 DOI: 10.1186/s40352-024-00274-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 04/07/2024] [Indexed: 04/20/2024]
Abstract
BACKGROUND A previous scoping review of legal-involved veterans' health and healthcare (1947-2017) identified studies and their limitations. Given the influx of literature published recently, this study aimed to update the previous review and map articles to the Veterans-Sequential Intercept Model (V-SIM) - a conceptual model used by key partners, including Veterans Health Administration, veteran advocates, criminal justice practitioners, and local governments to identify intercept points in the criminal legal system where resources and programming can be provided. Developing an updated resource of literature is essential to inform current research, discover gaps, and highlight areas for future research. METHODS A systematic search of 5 databases identified articles related to legal-involved veterans' health and healthcare published between December 2017 through December 2022. The first and senior authors conducted abstract reviews, full-text reviews, and data extraction of study characteristics. Finally, each article was sorted by the various intercept points from the V-SIM. RESULTS Of 903 potentially relevant articles, 107 peer-reviewed publications were included in this review, most related to mental health (66/107, 62%) and used an observational quantitative study design (95/107, 89%). Although most articles did not explicitly use the V-SIM to guide data collection, analyses, or interpretation, all could be mapped to this conceptual model. Half of the articles (54/107, 50%) collected data from intercept 5 (Community Corrections and Support Intercept) of the V-SIM. No articles gathered data from intercepts 0 (Community and Emergency Services Intercept), 1 (Law Enforcement Intercept), or 2 (Initial Detention and Court Hearings Intercept). CONCLUSIONS There were 107 articles published in the last five years compared to 190 articles published in 70 years covered in the last review, illustrating the growing interest in legal-involved veterans. The V-SIM is widely used by front-line providers and clinical leadership, but not by researchers to guide their work. By clearly tying their research to the V-SIM, researchers could generate results to help guide policy and practice at specific intercept points. Despite the large number of publications, research on prevention and early intervention for legal-involved veterans is lacking, indicating areas of great need for future studies.
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Affiliation(s)
- Kreeti Singh
- Center for Innovation to Implementation, VA Palo Alto Health Care System, 795 Willow Road (152-MPD), Menlo Park, CA, 94025, USA.
| | - Christine Timko
- Center for Innovation to Implementation, VA Palo Alto Health Care System, 795 Willow Road (152-MPD), Menlo Park, CA, 94025, USA
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, 291 Campus Drive, Li Ka Shing Building, Stanford, CA, 94305, USA
| | - Mengfei Yu
- Center for Innovation to Implementation, VA Palo Alto Health Care System, 795 Willow Road (152-MPD), Menlo Park, CA, 94025, USA
| | - Emmeline Taylor
- Center for Innovation to Implementation, VA Palo Alto Health Care System, 795 Willow Road (152-MPD), Menlo Park, CA, 94025, USA
- Department of Psychology, University of Colorado, Columbine Hall 4th Floor, 1420 Austin Bluffs Pkwy, Colorado Springs, CO, 80918, USA
| | - Jessica Blue-Howells
- Department of Veterans Affairs, Veterans Justice Programs, 810 Vermont Avenue, Washington DC, NW, 20420, USA
| | - Andrea K Finlay
- Center for Innovation to Implementation, VA Palo Alto Health Care System, 795 Willow Road (152-MPD), Menlo Park, CA, 94025, USA
- Department of Veterans Affairs, National Center on Homelessness Among Veterans, 795 Willow Road, Menlo Park, CA, 94025, USA
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Betancourt CA, Goldberg DG, Hawks BA, Kitsantas P. Perspectives of homeless veterans living with substance use disorders (SUD) and mental illness. Heliyon 2023; 9:e20364. [PMID: 37767504 PMCID: PMC10520805 DOI: 10.1016/j.heliyon.2023.e20364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 09/19/2023] [Accepted: 09/20/2023] [Indexed: 09/29/2023] Open
Abstract
Upon returning home from the military, America's veterans face complex challenges such as homelessness and substance use disorders (SUD). Veterans who have experienced SUDs and homelessness are more likely to struggle with depression and suicidal behaviors. This study aims to understand homeless veterans' lived experiences of their everyday life and social interactions. We used semi-structured interviews to conduct a phenomenological study of 14 homeless veterans with known SUDs living in the Baltimore-Washington D.C. Metropolitan area. A Social-Ecological Model (SEM) was used to create themes, a priori, then used open coding analytic methods to identify emerging themes. Two-thirds of veterans used illicit drugs or abused alcohol, and nearly all reported a history of depression or anxiety. Suicidal behaviors were present in a third of all veterans. We found that veteran homelessness and substance use are strongly associated with emotional and physical trauma suffered while on active duty. Consequently, once homeless, a veteran's community may encourage and exacerbate SUDs, thus impeding a path toward sobriety. Homeless veterans who have struggled with SUDs and later experience a death in their family often relapse to substance use. Deeply exploring a veteran's relationships with family, friends, and their immediate community may reveal opportunities to address these issues using healthcare and community interventions.
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Affiliation(s)
- Christian A. Betancourt
- Department of Preventive Medicine and Biostatistics, Uniformed Services University, 4301 Jones Bridge Road, Bethesda, MD, 20814, USA
| | - Debora G. Goldberg
- Department of Health Administration and Policy, George Mason University, 4400 University Drive, Fairfax, VA, 22032, USA
| | - Beth A. Hawks
- Department of Preventive Medicine and Biostatistics, Uniformed Services University, 4301 Jones Bridge Road, Bethesda, MD, 20814, USA
| | - Panagiota Kitsantas
- Department of Population Health and Social Medicine, Florida Atlantic University, 777 Glades Rd, Boca Raton, FL, 33431, USA
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Prescription Opioid Misuse and Suicidal Behaviors Among US Veterans: A Cross-Sectional Study from the 2015-2019 National Survey on Drug Use and Health. J Behav Health Serv Res 2023; 50:150-164. [PMID: 36175748 DOI: 10.1007/s11414-022-09820-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/11/2022] [Indexed: 10/14/2022]
Abstract
Suicide continues to be a serious public health issue for the US veteran population as its prevalence has skyrocketed over the last 15 years. This cross-sectional study estimates the prevalence of suicidal behaviors and prescription opioid misuse among veterans and identifies associations between suicidal behaviors and misuse of prescription opioids using data from the National Survey on Drug Use and Health. The findings show that approximately 3.7% of all veterans in this sample experienced suicidal behaviors, while nearly 3.0% reported misusing prescription opioids. Veterans who misused prescription opioids had a much higher prevalence of suicidal behaviors (16.3%) than veterans who used prescription opioids without misuse (4.8%) and those who did not use prescription opioids at all (2.5%). Opioid misuse is strongly associated with suicidal behaviors among veterans. Immediate substance use and mental health screenings, upon first contact with a healthcare system, are imperative in preventing and reducing suicide rates within this vulnerable population.
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Browne J, Mohamed S. Evaluation of disparities in impact of mental health intensive case management on 6-month symptoms, functioning, and quality of life between black and white veterans diagnosed with schizophrenia. Schizophr Res 2023; 253:68-74. [PMID: 34247886 DOI: 10.1016/j.schres.2021.07.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Revised: 07/01/2021] [Accepted: 07/02/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND Substantial health disparities have been reported between Black and White Americans diagnosed with schizophrenia. The nature and extent of these disparities among individuals receiving services in an equal-access health care system remains understudied. PURPOSE AND AIMS The purpose of this study was to examine disparities in enrollment characteristics, service delivery and clinical outcomes between Black and White veterans diagnosed with schizophrenia who received care in the Veterans Health Administration (VHA), an equal-access health care system. METHODS National program evaluation data from the VHA Intensive Community Mental Health Recovery (ICMHR) program were used to evaluate disparities between 2436 Black and 3565 White veterans who enrolled between 1999 and 2013. Veterans and case managers completed measures of sociodemographic factors, clinical history, clinical characteristics, and justice system involvement at enrollment and six months. Chi square and ANOVAs were used to evaluate enrollment and service delivery differences. Six-month changes were evaluated using multiple regression controlling for potentially confounding baseline characteristics. Effect sizes were evaluated with Cohen's d. RESULTS Results indicated differences between Black and White veterans in clinical history, justice system involvement, and clinical characteristics at enrollment. Minimal differences in service delivery were noted and longitudinal analyses revealed no significant differences between Black and White veterans on the majority of outcomes. CONCLUSION Fewer racial disparities in service use and outcomes were observed in ICMHR than in standard non-VA clinic settings. This study demonstrates that disparities may emerge more strongly from systemic rather than individual-level differences.
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Affiliation(s)
- Julia Browne
- Geriatric Research, Education and Clinical Center, Durham VA Health Care System, Durham, NC, USA
| | - Somaia Mohamed
- VA New England Mental Illness, Research, Education and Clinical Center (MIRECC), West Haven CT, USA; Yale School of Medicine, New Haven, CT, USA.
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Browne J, Mohamed S. The Impact of Mental Health Intensive Case Management on Functioning and Clinical Outcomes of Older Black and White Veterans With Serious Mental Illness. Am J Geriatr Psychiatry 2022; 30:1183-1194. [PMID: 35365385 DOI: 10.1016/j.jagp.2022.02.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 02/23/2022] [Accepted: 02/25/2022] [Indexed: 01/25/2023]
Abstract
OBJECTIVES To examine differences in service delivery, functioning, and clinical outcomes between older Black and White veterans participating in a national Veterans Health Administration (VHA) program of intensive case management. DESIGN Secondary analysis of national program evaluation data. SETTING VHA Intensive Community Mental Health Recovery (ICMHR) program. PARTICIPANTS Black (n = 1327) and White (n = 4402) veterans age 55 and older who enrolled in ICMHR between 2000-2013. MEASUREMENTS Measures evaluated sociodemographic factors, service delivery, functioning, and clinical outcomes. ANOVA and chi-squares were used to evaluate differences in enrollment characteristics and service delivery between Black and White veterans. Regression analyses were used to examine changes in outcomes over 6 months controlling for confounding baseline differences and service delivery. Cohen's d of .20 was used as a threshold for a clinically meaningful effect. RESULTS Black veterans were more likely to be diagnosed with schizophrenia, alcohol use disorder, and drug use disorder. Although case managers spent significantly less time with Black veterans, there was no difference in the frequency of contacts. Medication management and substance use treatment were more often provided to Black veterans. Black veterans experienced substantially greater improvement in anxiety/depression than White veterans with a small effect size (Cohen's d =-0.25). Changes in all other outcome measures did not meet criteria for clinically meaningful differences. CONCLUSIONS Black veterans experienced meaningfully greater improvements than White veterans on anxiety/depression but not on other measures. Provision of high-intensity services in an equal-access setting may reduce health disparities between Black and White older adults with serious mental illness.
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Affiliation(s)
- Julia Browne
- Geriatric Research, Education and Clinical Center (JB), Durham VA Health Care System, Durham, NC
| | - Somaia Mohamed
- VA New England Mental Illness Research, Education and Clinical Center, West Haven, CT; Department of Psychiatry, Yale School of Medicine, New Haven, CT.
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ElTohamy A, Wang JJ, Chen JA, Stevens C, Liu CH. Association Between College Course Delivery Model and Rates of Psychological Distress During the COVID-19 Pandemic. JAMA Netw Open 2022; 5:e2244270. [PMID: 36449292 PMCID: PMC9713601 DOI: 10.1001/jamanetworkopen.2022.44270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
IMPORTANCE College students in the US have been heavily affected by the COVID-19 pandemic. In addition to increased rates of depression and anxiety, college students have faced unprecedented stressors, such as geographic relocation and abrupt conversion from in-person classes to online classes. OBJECTIVE To study the association between course delivery model and psychological distress among US college students. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional analysis used national data from the American College Health Association-National College Health Assessment III data set. Data were gathered from a web-based survey administered from January to early June 2021 to full-time US college students attending 4-year programs. EXPOSURE Course delivery model was self-reported. MAIN OUTCOMES AND MEASURES Psychological distress was measured using the Kessler Screening Scale for Psychological Distress. RESULTS This study evaluated 59 250 full-time undergraduate students (68.1% women; 51.5% White students; mean [SD] age, 21.2 [4.3] years); 3.5% attended fully in-person classes, 61.2% attended fully online classes, and 35.3% attended a mixed format of in-person and online classes. Students who attended classes fully online reported higher levels of psychological distress than those who attended a mix of online and in-person classes (b = 0.76 [99% CI, 0.64-0.88]; P < .001). This association remained significant after controlling for geographic region, year in school, gender, race and ethnicity, food security, current anxiety and/or depressive disorders, COVID-19 concerns, and residence (living on campus, off campus with family, or other off-campus arrangements) (b = 0.18 [99% CI, 0.04-0.31]; P = .001), as well as time spent socializing with friends (b = 0.13 [99% CI, 0.002-0.26]; P = .009). CONCLUSIONS AND RELEVANCE The findings of this study suggest that mental health professionals may wish to consider the association of course delivery models with mental health outcomes when working with college students. Colleges should be aware of the mental health burden associated with attending fully online classes and consider possible in-person components and supports for students.
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Affiliation(s)
- Abdelrahman ElTohamy
- Harvard Medical School, Boston, Massachusetts
- Department of Psychiatry, Brigham and Women’s Hospital, Boston, Massachusetts
| | | | - Justin A. Chen
- Harvard Medical School, Boston, Massachusetts
- Department of Psychiatry, Massachusetts General Hospital, Boston
| | - Courtney Stevens
- Department of Pediatric Newborn Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Department of Psychology, Willamette University, Salem, Oregon
| | - Cindy H. Liu
- Harvard Medical School, Boston, Massachusetts
- Department of Psychiatry, Brigham and Women’s Hospital, Boston, Massachusetts
- Department of Pediatric Newborn Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
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Loho H, Rosenheck RA. Provision of Mental Health Services in the Veterans Health Administration: A Nationwide Comparison With Other Providers. Psychiatr Serv 2022; 74:472-479. [PMID: 36300285 DOI: 10.1176/appi.ps.202100713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Public interest in developing a national health care system has grown in the United States, but so have concerns that a large system would provide poor care. The Veterans Health Administration (VHA) is the largest national U.S. health care system, and several of its performance measures have been compared with those of non-VHA organizations. However, few studies have compared VHA's overall provision of mental health care services, and this study aimed to fill this gap. METHODS Using 2018 National Mental Health Services Survey data, the authors examined the differences in provision of 45 treatment modalities, specialized services, and dedicated programs between self-identified VHA facilities (N=459), non-VHA facilities that serve only adults (N=3,671), and non-VHA facilities that serve all ages (N=6,378). RESULTS Self-identified VHA facilities offered more services (including more treatment modalities, specialized services, and dedicated programs) (mean±SD=24.2±8.9 services) than both non-VHA adult-only facilities (15.4±6.8; Cohen's d=1.11, p<0.001) and non-VHA all-ages facilities (17.1±6.6; Cohen's d=0.90, p<0.001). Notably, VHA facilities were more likely to offer electroconvulsive therapy and telemedicine. VHA facilities were more likely to offer integrated primary care, chronic illness management, supportive housing, vocational rehabilitation, and psychiatric emergency services, among others. Last, VHA facilities were more likely to offer dedicated treatment programs for patients identifying as lesbian, gay, bisexual, or transgender, as well as for patients with posttraumatic stress disorder, traumatic brain injury, or dementia. CONCLUSIONS VHA facilities offer no fewer and possibly more comprehensive mental health services per facility than do non-VHA facilities, possibly because VHA represents an integrated and centralized health system.
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Affiliation(s)
- Hieronimus Loho
- Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut (Loho, Rosenheck); New England Mental Illness Research, Education and Clinical Center, U.S. Department of Veterans Affairs, West Haven, Connecticut (Rosenheck)
| | - Robert A Rosenheck
- Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut (Loho, Rosenheck); New England Mental Illness Research, Education and Clinical Center, U.S. Department of Veterans Affairs, West Haven, Connecticut (Rosenheck)
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McInnes DK, Dunlap S, Fix GM, Foster MV, Conti J, Roncarati JS, Hyde JK. Longitudinal high-frequency ethnographic interviewing to simulate and prepare for intensive smartphone data collection among veterans with homeless experience. Front Digit Health 2022; 4:897288. [PMID: 36033637 PMCID: PMC9411857 DOI: 10.3389/fdgth.2022.897288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 07/06/2022] [Indexed: 11/24/2022] Open
Abstract
Objective While Veteran homelessness has steadily declined over the last decade, those who continue to be unhoused have complex health and social concerns. Housing instability interferes with access to healthcare, social services, and treatment adherence. Preventing unwanted housing transitions is a public health priority. This study is the first phase of a larger research agenda that aims to test the acceptability and feasibility of smartphone-enabled data collection with veterans experiencing homelessness. In preparation for the development of the smartphone data collection application, we utilized ethnographic methods guided by user-centered design principles to inform survey content, approach to recruitment and enrollment, and design decisions. Methods We used a case study design, selecting a small sample (n = 10) of veterans representing a range of homelessness experiences based on risk and length of time. Participants were interviewed up to 14 times over a 4-week period, using a combination of qualitative methods. Additionally, 2 focus group discussions were conducted. Interviews were audio-recorded and transcribed. Data were synthesized and triangulated through use of rapid analysis techniques. Results All participants had experience using smartphones and all but one owned one at the time of enrollment. Participants described their smartphones as “lifelines” to social network members, healthcare, and social service providers. Social relationships, physical and mental health, substance use, income, and housing environment were identified as being directly and indirectly related to transitions in housing. Over the course of ~30 days of engagement with participants, the research team observed dynamic fluctuations in emotional states, relationships, and utilization of services. These fluctuations could set off a chain of events that were observed to both help participants transition into more stable housing or lead to setbacks and further increase vulnerability and instability. In addition to informing the content of survey questions that will be programmed into the smartphone app, participants also provided a broad range of recommendations for how to approach recruitment and enrollment in the future study and design features that are important to consider for veterans with a range of physical abilities, concerns with trust and privacy, and vulnerability to loss or damage of smartphones. Conclusion The ethnographic approach guided by a user-centered design framework provided valuable data to inform our future smartphone data collection effort. Data were critical to understanding aspects of day-to-day life that important to content development, app design, and approach to data collection.
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Affiliation(s)
- D. Keith McInnes
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, United States
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA, United States
| | - Shawn Dunlap
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, United States
| | - Gemmae M. Fix
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, United States
- Boston University School of Medicine, Section of General Internal Medicine, Boston, MA, United States
| | - Marva V. Foster
- Boston University School of Medicine, Section of General Internal Medicine, Boston, MA, United States
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, MA, United States
- Department of Quality Management, VA Boston Healthcare System, Boston, MA, United States
| | - Jennifer Conti
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, United States
| | - Jill S. Roncarati
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, United States
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, United States
- Boston Health Care for the Homeless Program, Boston, MA, United States
| | - Justeen K. Hyde
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, United States
- Boston University School of Medicine, Section of General Internal Medicine, Boston, MA, United States
- *Correspondence: Justeen K. Hyde
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Betancourt CA, Kitsantas P, Goldberg DG, Hawks BA. Substance Use Relapse Among Veterans at Termination of Treatment for Substance Use Disorders. Mil Med 2021; 187:e1422-e1431. [PMID: 34272857 DOI: 10.1093/milmed/usab280] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 06/14/2021] [Accepted: 07/04/2021] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION Military veterans continue to struggle with addiction even after receiving treatment for substance use disorders (SUDs). Identifying factors that may influence SUD relapse upon receiving treatment in veteran populations is crucial for intervention and prevention efforts. The purpose of this study was to examine risk factors that contribute to SUD relapse upon treatment completion in a sample of U.S. veterans using logistic regression and classification tree analysis. MATERIALS AND METHODS Data from the 2017 Treatment Episode Data Set-Discharge (TEDS-D) included 40,909 veteran episode observations. Descriptive statistics and multivariable logistic regression analysis were conducted to determine factors associated with SUD relapse after treatment discharge. Classification trees were constructed to identify high-risk subgroups for substance use after discharge from treatment for SUDs. RESULTS Approximately 94% of the veterans relapsed upon discharge from outpatient or residential SUD treatment. Veterans aged 18-34 years old were significantly less likely to relapse than the 35-64 age group (odds ratio [OR] 0.73, 95% confidence interval [CI]: 0.66, 0.82), while males were more likely than females to relapse (OR 1.55, 95% CI: 1.34, 1.79). Unemployed veterans (OR 1.92, 95% CI: 1.67, 2.22) or veterans not in the labor force (OR 1.29, 95% CI: 1.13, 1.47) were more likely to relapse than employed veterans. Homeless vs. independently housed veterans had 3.26 (95% CI: 2.55, 4.17) higher odds of relapse after treatment. Veterans with one arrest vs. none were more likely to relapse (OR 1.52, 95% CI: 1.19, 1.95). Treatment completion was critical to maintain sobriety, as every other type of discharge led to more than double the odds of relapse. Veterans who received care at 24-hour detox facilities were 1.49 (95% CI: 1.23, 1.80) times more likely to relapse than those at rehabilitative/residential treatment facilities. Classification tree analysis indicated that homelessness upon discharge was the most important predictor in SUD relapse among veterans. CONCLUSION Aside from numerous challenges that veterans face after leaving military service, SUD relapse is intensified by risk factors such as homelessness, unemployment, and insufficient SUD treatment. As treatment and preventive care for SUD relapse is an active field of study, further research on SUD relapse among homeless veterans is necessary to better understand the epidemiology of substance addiction among this vulnerable population. The findings of this study can inform healthcare policy and practices targeting veteran-tailored treatment programs to improve SUD treatment completion and lower substance use after treatment.
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Affiliation(s)
- Christian A Betancourt
- Department of Health Administration and Policy, George Mason University, Fairfax, VA 22030-4444, USA
| | - Panagiota Kitsantas
- Department of Health Administration and Policy, George Mason University, Fairfax, VA 22030-4444, USA
| | - Deborah G Goldberg
- Department of Health Administration and Policy, George Mason University, Fairfax, VA 22030-4444, USA
| | - Beth A Hawks
- Department of Preventive Medicine and Biometrics, Uniformed Services University, Bethesda, MD 20814, USA
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Treatment Differences in Primary and Specialty Settings in Veterans with Major Depression. J Am Board Fam Med 2021; 34:268-290. [PMID: 33832996 PMCID: PMC8439361 DOI: 10.3122/jabfm.2021.02.200475] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 12/01/2020] [Accepted: 12/02/2020] [Indexed: 11/08/2022] Open
Abstract
INTRODUCTION The Veterans Health Administration (VHA) supports the nation's largest primary care-mental health integration (PC-MHI) collaborative care model to increase treatment of mild to moderate common mental disorders in primary care (PC) and refer more severe-complex cases to specialty mental health (SMH) settings. It is unclear how this treatment assignment works in practice. METHODS Patients (n = 2610) who sought incident episode VHA treatment for depression completed a baseline self-report questionnaire about depression severity-complexity. Administrative data were used to determine settings and types of treatment during the next 30 days. RESULTS Thirty-four percent (34.2%) of depressed patients received treatment in PC settings, 65.8% in SMH settings. PC patients had less severe and fewer comorbid depressive episodes. Patients with lowest severity and/or complexity were most likely to receive PC antidepressant medication treatment; those with highest severity and/or complexity were most likely to receive combined treatment in SMH settings. Assignment of patients across settings and types of treatment was stronger than found in previous civilian studies but less pronounced than expected (cross-validated AUC = 0.50-0.68). DISCUSSION By expanding access to evidence-based treatments, VHA's PC-MHI increases consistency of treatment assignment. Reasons for assignment being less pronounced than expected and implications for treatment response will require continued study.
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