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Denneson LM, Smolenski DJ, McDonald KL, Shull S, Hoffmire CA, Britton PC, Carlson KF, Dobscha SK. Gender differences in risk and resilience for suicidal thoughts and behaviors: A national longitudinal survey study of United States veterans with a recent suicide attempt. J Affect Disord 2024; 360:412-420. [PMID: 38815763 DOI: 10.1016/j.jad.2024.05.133] [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] [Received: 01/10/2024] [Revised: 05/23/2024] [Accepted: 05/25/2024] [Indexed: 06/01/2024]
Abstract
BACKGROUND This study reports on gender differences in psychosocial symptoms and suicidal thoughts and behaviors from the first longitudinal, national survey of veterans with a recent nonfatal suicide attempt to inform women-tailored suicide prevention. METHODS We recruited all female veterans with a documented nonfatal suicide attempt between October 2018 and September 2019 and a stratified matched sample of males. Surveys were administered at baseline, month 6, and month 12; 968 veterans completed the baseline survey with valid gender data. Surveys assessed psychosocial constructs, suicidal ideation severity, and suicidal behavior. Administrative datasets provided healthcare and suicide attempt data during the one year follow up. RESULTS Women retained higher social rejection and institutional betrayal, and lower self-compassion and autonomy than men over follow up. Higher overall self-compassion was associated with lower baseline suicide ideation for both women and men; however, this association was stronger for women (Δ = -0.19; 95 % CI = -0.31, -0.07; d = -0.15). Individuals with higher overall psychological distress had greater odds of a subsequent suicide attempt (AOR = 2.20, 95 % CI = 1.56, 3.11). Social rejection had the strongest association with worsening psychological distress, both within individuals (b = 0.18; 95 % CI = 0.14, 0.23; d = 0.23) and between individuals (b = 0.07; 95 % CI = 0.04, 0.10; d = 0.09). LIMITATIONS Results may not generalize beyond a VHA-utilizing veteran population. CONCLUSIONS Findings from this study inform potential therapeutic targets and topics for future research on tailoring suicide prevention for women veterans. While all veterans may need support reducing distress, women may need additional support in multiple other areas.
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Affiliation(s)
- Lauren M Denneson
- HSR&D Center to Improve Veteran Involvement in Care (CIVIC), VA Portland Health Care System, Portland, OR, USA; Department of Psychiatry, Oregon Health & Science University, Portland, OR, USA.
| | - Derek J Smolenski
- Defense Health Agency, Department of Defense, Silver Spring, MD, USA
| | - Katie L McDonald
- HSR&D Center to Improve Veteran Involvement in Care (CIVIC), VA Portland Health Care System, Portland, OR, USA
| | - Sarah Shull
- HSR&D Center to Improve Veteran Involvement in Care (CIVIC), VA Portland Health Care System, Portland, OR, USA
| | - Claire A Hoffmire
- Rocky Mountain MIRECC, VA Eastern Colorado Health Care System, Aurora, CO, USA
| | - Peter C Britton
- VISN 2 Center of Excellence for Suicide Prevention, VA Finger Lakes Healthcare System, Canandaigua, NY, USA
| | - Kathleen F Carlson
- HSR&D Center to Improve Veteran Involvement in Care (CIVIC), VA Portland Health Care System, Portland, OR, USA; School of Public Health, Oregon Health & Science University, Portland, OR, USA
| | - Steven K Dobscha
- HSR&D Center to Improve Veteran Involvement in Care (CIVIC), VA Portland Health Care System, Portland, OR, USA; Department of Psychiatry, Oregon Health & Science University, Portland, OR, USA
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Reed DE, Fischer IC, Williams RM, Na PJ, Pietrzak RH. Co-occurring Chronic Pain and PTSD Among US Military Veterans: Prevalence, Correlates, and Functioning. J Gen Intern Med 2024:10.1007/s11606-024-08803-w. [PMID: 38780882 DOI: 10.1007/s11606-024-08803-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Accepted: 05/07/2024] [Indexed: 05/25/2024]
Abstract
BACKGROUND The prevalence of co-occurring chronic pain and posttraumatic stress disorder (PTSD) has yet to be established in a nationally representative sample of US veterans, and little is known about the individual contributing roles of these disorders to the psychiatric and functional burden of this comorbidity. OBJECTIVE To determine the prevalence of chronic pain, PTSD, and co-occurring chronic pain and PTSD, and psychiatric comorbidities and psychosocial functioning in these groups. DESIGN Data were analyzed from the National Health and Resilience in Veterans Study, which surveyed a nationally representative sample of US veterans. PARTICIPANTS Veterans (n=4069) were classified into four groups: control (i.e., no PTSD or chronic pain), chronic pain only, PTSD only, and co-occurring chronic pain and PTSD. MAIN MEASURES A probable PTSD diagnosis was established using the PTSD Checklist for DSM-5, and a chronic pain diagnosis using a self-report item that queried health care professional diagnoses. Psychiatric and functional status were assessed using the Patient Health Questionnaire-4, Alcohol Use Disorders Identification Test, Screen of Drug Use, Suicide Behaviors Questionnaire-Revised, Short Form Health Survey-8, Brief Inventory of Psychosocial Functioning, and Medical Outcomes Study Cognitive Functioning Scale. KEY RESULTS A total of 3.8% of veterans reported both probable PTSD and a diagnosis of chronic pain. Relative to veterans with chronic pain alone, those with co-occurring chronic pain and probable PTSD were more likely to screen positive for psychiatric disorders (odds ratios [ORs]=2.59-9.88) and scored lower on measures of psychosocial functioning (Cohen's ds=0.38-1.43). Relative to veterans with probable PTSD only, those with co-occurring chronic pain and probable PTSD were more likely to have attempted suicide (OR=4.79; 95%CI, 1.81-12.69). CONCLUSIONS Results underscore the importance of whole health care that considers a broad range of health and functional domains in the assessment and treatment of co-occurring chronic pain and PTSD in veterans.
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Affiliation(s)
- David E Reed
- Department of Health Systems and Population Health, University of Washington, Seattle, WA, USA.
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Healthcare System, Seattle, WA, USA.
| | - Ian C Fischer
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA
- U.S. Department of Veterans Affairs National Center for Posttraumatic Stress Disorder, VA Connecticut Healthcare System, West Haven, CT, USA
| | - Rhonda M Williams
- Rehabilitation Care Service, Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA, USA
| | - Peter J Na
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA
- VA Connecticut Healthcare System, West Haven, CT, USA
| | - Robert H Pietrzak
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA
- U.S. Department of Veterans Affairs National Center for Posttraumatic Stress Disorder, VA Connecticut Healthcare System, West Haven, CT, USA
- Department of Social and Behavioral Sciences, Yale School of Public Health, New Haven, CT, USA
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3
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Daus M, Lee M, Ujano-De Motta LL, Holstein A, Morgan B, Albright K, Ayele R, McCarthy M, Sjoberg H, Jones CD. Perspectives on supporting Veterans' social needs during hospital to home health transitions: findings from the Transitions Nurse Program. BMC Health Serv Res 2024; 24:520. [PMID: 38658937 PMCID: PMC11043030 DOI: 10.1186/s12913-024-10900-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Accepted: 03/26/2024] [Indexed: 04/26/2024] Open
Abstract
BACKGROUND Veterans who need post-acute home health care (HHC) are at risk for adverse outcomes and unmet social needs. Veterans' social needs could be identified and met by community-based HHC clinicians due to their unique perspective from the home environment, acuity of Veterans they serve, and access to Veterans receiving community care. To understand these needs, we explored clinician, Veteran, and care partner perspectives to understand Veterans' social needs during the transition from hospital to home with skilled HHC. METHODS Qualitative data were collected through individual interviews with Veterans Health Administration (VHA) inpatient & community HHC clinicians, Veterans, and care partners who have significant roles facilitating Veterans' hospital to home with HHC transition. To inform implementation of a care coordination quality improvement intervention, participants were asked about VHA and HHC care coordination and Veterans' social needs during these transitions. Interviews were recorded, transcribed, and analyzed inductively using thematic analysis and results were organized deductively according to relevant transitional care domains (Discharge Planning, Transition to Home, and HHC Delivery). RESULTS We conducted 35 interviews at 4 VHA Medical Centers located in Western, Midwestern, and Southern U.S. regions during March 2021 through July 2022. We organized results by the three care transition domains and related themes by VHA, HHC, or Veteran/care partner perspective. Our themes included (1) how social needs affected access to HHC, (2) the need for social needs screening during hospitalization, (3) delays in HHC for Veterans discharged from community hospitals, and (4) a need for closed-loop communication between VHA and HHC to report social needs. CONCLUSIONS HHC is an underexplored space for Veterans social needs detection. While this research is preliminary, we recommend two steps forward from this work: (1) develop closed-loop communication and education pathways with HHC and (2) develop a partnership to integrate a social risk screener into HHC pathways.
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Affiliation(s)
- Marguerite Daus
- Denver/Seattle Center of Innovation for Veteran-Centered and Value Driven Care, VHA Eastern Colorado Healthcare System, 1700 N Wheeling St, Aurora, CO, 80045, USA.
| | - Marcie Lee
- Denver/Seattle Center of Innovation for Veteran-Centered and Value Driven Care, VHA Eastern Colorado Healthcare System, 1700 N Wheeling St, Aurora, CO, 80045, USA
| | - Lexus L Ujano-De Motta
- Denver/Seattle Center of Innovation for Veteran-Centered and Value Driven Care, VHA Eastern Colorado Healthcare System, 1700 N Wheeling St, Aurora, CO, 80045, USA
| | | | - Brianne Morgan
- Denver/Seattle Center of Innovation for Veteran-Centered and Value Driven Care, VHA Eastern Colorado Healthcare System, 1700 N Wheeling St, Aurora, CO, 80045, USA
| | - Karen Albright
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- OCHIN, Inc., Portland, OR, USA
| | - Roman Ayele
- Denver/Seattle Center of Innovation for Veteran-Centered and Value Driven Care, VHA Eastern Colorado Healthcare System, 1700 N Wheeling St, Aurora, CO, 80045, USA
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Michaela McCarthy
- Denver/Seattle Center of Innovation for Veteran-Centered and Value Driven Care, VHA Eastern Colorado Healthcare System, 1700 N Wheeling St, Aurora, CO, 80045, USA
| | - Heidi Sjoberg
- Denver/Seattle Center of Innovation for Veteran-Centered and Value Driven Care, VHA Eastern Colorado Healthcare System, 1700 N Wheeling St, Aurora, CO, 80045, USA
| | - Christine D Jones
- Denver/Seattle Center of Innovation for Veteran-Centered and Value Driven Care, VHA Eastern Colorado Healthcare System, 1700 N Wheeling St, Aurora, CO, 80045, USA
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
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Fritz JM, Ford I, George SZ, Vinci de Vanegas L, Cope T, Burke CA, Goode AP. Telehealth delivery of physical therapist-led interventions for persons with chronic low back pain in underserved communities: lessons from pragmatic clinical trials. FRONTIERS IN PAIN RESEARCH 2024; 5:1324096. [PMID: 38706872 PMCID: PMC11066221 DOI: 10.3389/fpain.2024.1324096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 04/08/2024] [Indexed: 05/07/2024] Open
Abstract
In this perspective, we present our experience developing and conducting two pragmatic clinical trials investigating physical therapist-led telehealth strategies for persons with chronic low back pain. Both trials, the BeatPain Utah and AIM-Back trials, are part of pragmatic clinical trial collaboratories and are being conducted with persons from communities that experience pain management disparities. Practice guidelines recommend nonpharmacologic care, and advise against opioid therapy, for the primary care management of persons with chronic low back pain. Gaps between these recommendations and actual practice patterns are pervasive, particularly for persons from racial or ethnic minoritized communities, those with fewer economic resources, and those living in rural areas including Veterans. Access barriers to evidence-based nonpharmacologic care, which is often provided by physical therapists, have contributed to these evidence-practice gaps. Telehealth delivery has created new opportunities to overcome access barriers for nonpharmacologic pain care. As a relatively new delivery mode however, telehealth delivery of physical therapy comes with additional challenges related to technology, intervention adaptations and cultural competence. The purpose of this article is to describe the challenges encountered when implementing telehealth physical therapy programs for persons with chronic low back pain in historically underserved communities. We also discuss strategies developed to overcome barriers in an effort to improve access to telehealth physical therapy and reduce pain management disparities. Inclusion of diverse and under-represented communities in pragmatic clinical trials is a critical consideration for improving disparities, but the unique circumstances present in these communities must be considered when developing implementation strategies.
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Affiliation(s)
- Julie M. Fritz
- Department of Physical Therapy & Athletic Training, University of Utah, Salt Lake City, UT, United States
| | - Isaac Ford
- Department of Physical Therapy & Athletic Training, University of Utah, Salt Lake City, UT, United States
| | - Steven Z. George
- Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, NC, United States
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, United States
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, United States
| | - Laura Vinci de Vanegas
- Department of Physical Therapy & Athletic Training, University of Utah, Salt Lake City, UT, United States
| | - Tyler Cope
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, United States
| | - Colleen A. Burke
- Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, NC, United States
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, United States
| | - Adam P. Goode
- Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, NC, United States
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, United States
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, United States
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Doshi TL, Sandbrink F, Cohen SP. Postamputation limb pain in military personnel: separate but equal or separate and never equal? Pain 2024; 165:723-724. [PMID: 38112618 DOI: 10.1097/j.pain.0000000000003095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 08/18/2023] [Indexed: 12/21/2023]
Affiliation(s)
- Tina L Doshi
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - Friedhelm Sandbrink
- Department of Neurology, Washington Veterans Affairs Medical Center, Washington, DC, United States
- Department of Neurology, Uniformed Services University of the Health Sciences, Bethesda, MD, United States
- Department of Neurology, George Washington University School of Medicine, Washington, DC, United States
| | - Steven P Cohen
- Departments of Anesthesiology and Critical Care Medicine, Neurology, Physical Medicine and Rehabilitation and Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, MD, United States
- Department of Physical Medicine and Rehabilitation and Anesthesiology, Walter Reed National Military Medical Center, Uniformed Services University of the Health Sciences, Bethesda, MD, United States
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Kameg B. Prioritizing high quality care for women veterans: The time is now. Arch Psychiatr Nurs 2024; 49:A2-A3. [PMID: 38734463 DOI: 10.1016/j.apnu.2023.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Accepted: 11/24/2023] [Indexed: 05/13/2024]
Affiliation(s)
- Brayden Kameg
- University of Pittsburgh School of Nursing, United States of America.
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7
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Growdon ME, Jing B, Morris EJ, Deardorff WJ, Boscardin WJ, Byers AL, Boockvar KS, Steinman MA. Which older adults are at highest risk of prescribing cascades? A national study of the gabapentinoid-loop diuretic cascade. J Am Geriatr Soc 2024. [PMID: 38547357 DOI: 10.1111/jgs.18892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Revised: 02/16/2024] [Accepted: 03/03/2024] [Indexed: 04/11/2024]
Abstract
BACKGROUND Prescribing cascades are important contributors to polypharmacy. Little is known about which older adults are at highest risk of experiencing prescribing cascades. We explored which older veterans are at highest risk of the gabapentinoid (including gabapentin and pregabalin)-loop diuretic (LD) cascade, given the dramatic increase in gabapentinoid prescribing in recent years. METHODS Using Veterans Affairs and Medicare claims data (2010-2019), we performed a prescription sequence symmetry analysis (PSSA) to assess loop diuretic initiation before and after gabapentinoid initiation among older veterans (≥66 years). To identify the cascade, we calculated the adjusted sequence ratio (aSR), which assesses the temporality of LD relative to gabapentinoid initiation. To explore high-risk groups, we used multivariable logistic regression with prescribing order modeled as a binary dependent variable. We calculated adjusted odds ratios (aORs), measuring the extent to which factors are associated with one prescribing order versus another. RESULTS Of 151,442 veterans who initiated a gabapentinoid, there were 1,981 patients who initiated a LD within 6 months after initiating a gabapentinoid compared to 1,599 patients who initiated a LD within 6 months before initiating a gabapentinoid. In the gabapentinoid-LD group, the mean age was 73 years, 98% were male, 13% were Black, 5% were Hispanic, and 80% were White. Patients in each group were similar across patient and health utilization factors (standardized mean difference <0.10 for all comparisons). The aSR was 1.23 (95% CI: 1.13, 1.34), strongly suggesting the cascade's presence. People age ≥85 years were less likely to have the cascade (compared to 66-74 years; aOR 0.74, 95% CI: 0.56-0.96), and people taking ≥10 medications were more likely to have the cascade (compared to 0-4 drugs; aOR 1.39, 95% CI: 1.07-1.82). CONCLUSIONS Among older adults, those who are younger and taking many medications may be at higher risk of the gabapentinoid-LD cascade, contributing to worsening polypharmacy and potential drug-related harms. We did not identify strong predictors of this cascade, suggesting that prescribing cascade prevention efforts should be widespread rather than focused on specific subgroups.
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Affiliation(s)
- Matthew E Growdon
- Division of Geriatrics, University of California, San Francisco, San Francisco, California, USA
- San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
| | - Bocheng Jing
- Division of Geriatrics, University of California, San Francisco, San Francisco, California, USA
- San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
| | - Earl J Morris
- Department of Pharmaceutical Outcomes & Policy, University of Florida College of Pharmacy, Gainesville, Florida, USA
- Center for Drug Evaluation and Safety, University of Florida, Gainesville, Florida, USA
| | - W James Deardorff
- Division of Geriatrics, University of California, San Francisco, San Francisco, California, USA
- San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
| | - W John Boscardin
- Division of Geriatrics, University of California, San Francisco, San Francisco, California, USA
- San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California, USA
| | - Amy L Byers
- Division of Geriatrics, University of California, San Francisco, San Francisco, California, USA
- San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
- Department of Psychiatry, Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, California, USA
| | - Kenneth S Boockvar
- Division of Gerontology, Geriatrics, and Palliative Care, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Michael A Steinman
- Division of Geriatrics, University of California, San Francisco, San Francisco, California, USA
- San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
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8
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Na PJ, Fischer IC, Petrakis IL, Pietrzak RH. Problematic Alcohol Use Trajectories in U.S. Military Veterans during a Public Health Crisis: Results from a 3-year, Nationally Representative, Longitudinal Study. Psychiatr Q 2024; 95:157-171. [PMID: 38319532 DOI: 10.1007/s11126-024-10067-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/29/2024] [Indexed: 02/07/2024]
Abstract
A growing number of studies have examined alcohol use during the COVID-19 pandemic. However, few longitudinal studies evaluated the prevalence and correlates of different trajectories of problematic alcohol use in vulnerable segments of the population, such as US veterans, over the 3-year course of the COVID-19 pandemic. Data were analyzed from the National Health and Resilience in Veterans Study, a nationally representative, longitudinal study of 2,441 US veterans. Latent growth mixture modeling was used to identify the trajectories and correlates of problematic alcohol use. Four trajectories were identified: consistent (N = 170, weighted 7.2%), decreasing (N = 38, weighted 2.2%), increasing (N = 22, weighted 1.2%), and low (N = 2,211, weighted 89.4%) problematic alcohol use. Greater household income, pre-pandemic drug use disorder (DUD), lower social support, and COVID-19 infection to self or non-household members were associated with an increasing relative to decreasing problematic alcohol use trajectory. Greater household income, adverse childhood experiences (ACEs), pre-pandemic DUD, lower social support, and greater COVID-related social restriction stress were associated with an increasing relative to a low problematic alcohol use trajectory. Younger age, male sex, ACEs, pre-pandemic DUD, lower pre-pandemic and greater decline in protective psychosocial characteristics, COVID-19 infection to non-household member, and lower COVID-related financial stress were associated with a consistent relative to a low problematic alcohol use trajectory. Overall, pre-pandemic greater income, DUD, and lower social support were associated with an increase in problematic alcohol use among US veterans during the COVID-19 pandemic. Results may help inform prevention efforts to mitigate problematic alcohol use during prolonged crises in this population.
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Affiliation(s)
- Peter J Na
- VA Connecticut Healthcare System, West Haven, CT, USA.
- Department of Psychiatry, Yale School of Medicine, 300 George Street, Suite 901, New Haven, CT, 06511, USA.
| | - Ian C Fischer
- Department of Psychiatry, Yale School of Medicine, 300 George Street, Suite 901, New Haven, CT, 06511, USA
- National Center for PTSD, VA Connecticut Healthcare System, West Haven, CT, USA
| | - Ismene L Petrakis
- VA Connecticut Healthcare System, West Haven, CT, USA
- Department of Psychiatry, Yale School of Medicine, 300 George Street, Suite 901, New Haven, CT, 06511, USA
- National Center for PTSD, VA Connecticut Healthcare System, West Haven, CT, USA
| | - Robert H Pietrzak
- Department of Psychiatry, Yale School of Medicine, 300 George Street, Suite 901, New Haven, CT, 06511, USA
- National Center for PTSD, VA Connecticut Healthcare System, West Haven, CT, USA
- Department of Social and Behavioral Sciences, Yale School of Public Health, New Haven, CT, USA
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9
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Jackson GL, Fix GM, White BS, Cutrona SL, Reardon CM, Damschroder LJ, Burns M, DeLaughter K, Opra Widerquist MA, Arasim M, Lindquist J, Gifford AL, King HA, Kaitz J, Jasuja GK, Hogan TP, Lopez JCF, Henderson B, Fitzgerald BA, Goetschius A, Hagan D, McCoy C, Seelig A, Nevedal A. Diffusion of excellence: evaluating a system to identify, replicate, and spread promising innovative practices across the Veterans health administration. FRONTIERS IN HEALTH SERVICES 2024; 3:1223277. [PMID: 38420338 PMCID: PMC10900518 DOI: 10.3389/frhs.2023.1223277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 11/20/2023] [Indexed: 03/02/2024]
Abstract
Introduction The Veterans Health Administration (VHA) Diffusion of Excellence (DoE) program provides a system to identify, replicate, and spread promising practices across the largest integrated healthcare system in the United States. DoE identifies innovations that have been successfully implemented in the VHA through a Shark Tank style competition. VHA facility and regional directors bid resources needed to replicate promising practices. Winning facilities/regions receive external facilitation to aid in replication/implementation over the course of a year. DoE staff then support diffusion of successful practices across the nationwide VHA. Methods Organized around the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) Framework, we summarize results of an ongoing long-term mixed-methods implementation evaluation of DoE. Data sources include: Shark Tank application and bid details, tracking practice adoptions through a Diffusion Marketplace, characteristics of VHA facilities, focus groups with Shark Tank bidders, structured observations of DoE events, surveys of DoE program participants, and semi-structured interviews of national VHA program office leaders, VHA healthcare system/facility executives, practice developers, implementation teams and facilitators. Results In the first eight Shark Tanks (2016-2022), 3,280 Shark Tank applications were submitted; 88 were designated DoE Promising Practices (i.e., practices receive facilitated replication). DoE has effectively spread practices across the VHA, with 1,440 documented instances of adoption/replication of practices across the VHA. This includes 180 adoptions/replications in facilities located in rural areas. Leadership decisions to adopt innovations are often based on big picture considerations such as constituency support and linkage to organizational goals. DoE Promising Practices that have the greatest national spread have been successfully replicated at new sites during the facilitated replication process, have close partnerships with VHA national program offices, and tend to be less expensive to implement. Two indicators of sustainment indicate that 56 of the 88 Promising Practices are still being diffused across the VHA; 56% of facilities originally replicating the practices have sustained them, even up to 6 years after the first Shark Tank. Conclusion DoE has developed a sustainable process for the identification, replication, and spread of promising practices as part of a learning health system committed to providing equitable access to high quality care.
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Affiliation(s)
- George L. Jackson
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs (VA) Health Care System, Durham, NC, United States
- Advancing Implementation and Improvement Science Program, Peter O’Donnell Jr. School of Public Health, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Gemmae M. Fix
- Center for Healthcare Organization & Implementation Research, Bedford & Boston VA Medical Centers, Bedford and Boston, MA, United States
- Section of General Internal Medicine, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, United States
- Department of Health Law, Policy & Management, Boston University, Boston, MA, United States
| | - Brandolyn S. White
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs (VA) Health Care System, Durham, NC, United States
| | - Sarah L. Cutrona
- Center for Healthcare Organization & Implementation Research, Bedford & Boston VA Medical Centers, Bedford and Boston, MA, United States
- Division of Health Informatics and Implementation Science, Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, MA, United States
| | - Caitlin M. Reardon
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, United States
| | - Laura J. Damschroder
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, United States
| | - Madison Burns
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs (VA) Health Care System, Durham, NC, United States
| | - Kathryn DeLaughter
- Center for Healthcare Organization & Implementation Research, Bedford & Boston VA Medical Centers, Bedford and Boston, MA, United States
| | | | - Maria Arasim
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, United States
| | - Jennifer Lindquist
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs (VA) Health Care System, Durham, NC, United States
| | - Allen L. Gifford
- Center for Healthcare Organization & Implementation Research, Bedford & Boston VA Medical Centers, Bedford and Boston, MA, United States
- Section of General Internal Medicine, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, United States
- Department of Health Law, Policy & Management, Boston University, Boston, MA, United States
| | - Heather A. King
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs (VA) Health Care System, Durham, NC, United States
- Department of Population Health Sciences, Duke University, Durham, NC, United States
- Division of General Internal Medicine, Duke University, Durham, NC, United States
| | - Jenesse Kaitz
- Center for Healthcare Organization & Implementation Research, Bedford & Boston VA Medical Centers, Bedford and Boston, MA, United States
| | - Guneet K. Jasuja
- Center for Healthcare Organization & Implementation Research, Bedford & Boston VA Medical Centers, Bedford and Boston, MA, United States
- Section of General Internal Medicine, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, United States
- Department of Health Law, Policy & Management, Boston University, Boston, MA, United States
| | - Timothy P. Hogan
- Advancing Implementation and Improvement Science Program, Peter O’Donnell Jr. School of Public Health, University of Texas Southwestern Medical Center, Dallas, TX, United States
- Center for Healthcare Organization & Implementation Research, Bedford & Boston VA Medical Centers, Bedford and Boston, MA, United States
| | - Jaifred Christian F. Lopez
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs (VA) Health Care System, Durham, NC, United States
- Department of Population Health Sciences, Duke University, Durham, NC, United States
| | - Blake Henderson
- VHA Innovation Ecosystem, Office of Healthcare Innovation and Learning, United States Veterans Health Administration, Washington, DC, United States
| | - Blaine A. Fitzgerald
- VHA Innovation Ecosystem, Office of Healthcare Innovation and Learning, United States Veterans Health Administration, Washington, DC, United States
| | - Amber Goetschius
- VHA Innovation Ecosystem, Office of Healthcare Innovation and Learning, United States Veterans Health Administration, Washington, DC, United States
| | - Danielle Hagan
- VHA Innovation Ecosystem, Office of Healthcare Innovation and Learning, United States Veterans Health Administration, Washington, DC, United States
| | - Carl McCoy
- VHA Innovation Ecosystem, Office of Healthcare Innovation and Learning, United States Veterans Health Administration, Washington, DC, United States
| | - Alex Seelig
- Agile Six Applications, Inc., San Diego, CA, United States
| | - Andrea Nevedal
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, United States
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10
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Dams GM, Ketchen BR, Burden JL, Smith NB. Effectiveness of residential treatment services for veterans with substance use disorders: A propensity score matching evaluation. Drug Alcohol Depend 2024; 255:111081. [PMID: 38211367 DOI: 10.1016/j.drugalcdep.2024.111081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 12/28/2023] [Accepted: 12/31/2023] [Indexed: 01/13/2024]
Abstract
BACKGROUND Prior reviews of substance use disorder (SUD) treatment have found mixed support for residential level of care but are limited by methodology problems and the ethical concerns of randomizing patients with severe SUD to lower levels of care. METHODS The present study is the first to use a large archival SUD residential sample with a matched comparison group and one-year follow-up period to examine the benefits of residential treatment provided to adults clinically assessed as warranting SUD residential care. We used propensity score matching in our sample (N = 6177) of veterans with a SUD who were screened and accepted for Veterans Affairs (VA) SUD residential treatment between January 1st, 2019 and June 30th, 2019. RESULTS We found evidence that VA SUD residential treatment saves veteran lives with an average 66% all-cause mortality risk reduction during the study period (b = -1.09, exp(b) = 0.34, p <0.001). Medium-to-large residential pre- to post-treatment self-reported mental health and SUD symptom improvements (|SMDrobust| = 0.54-0.93) were sustained by one-year post-screening. These residential treatment improvements were significantly larger than estimated counterfactual outcomes across self-reported SUD and stress disorder symptoms at one-year post-screening (ps <0.001). We found mixed behavioral, service utilization, and other self-reported mental health outcomes. CONCLUSIONS We conclude that VA SUD residential treatment is an effective level of care for veterans warranting residential care particularly for SUD symptom improvements and reductions in mortality risk.
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Affiliation(s)
- Gregory M Dams
- Salem Veterans Affairs Medical Center, Salem, VA, United States; VA Program Evaluation and Resource Center, Menlo Park, CA, United States.
| | | | - Jennifer L Burden
- Department of Veterans Affairs, Veterans Health Administration, Salem, VA, United States
| | - Noelle B Smith
- Department of Psychiatry, Yale School of Medicine, Yale University, United States; VA Northeast Program Evaluation Center, West Haven, CT, United States
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11
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Barr PB, Bigdeli TB, Meyers JL, Peterson RE, Sanchez-Roige S, Mallard TT, Dick DM, Harden KP, Wilkinson A, Graham DP, Nielsen DA, Swann AC, Lipsky RK, Kosten TR, Aslan M, Harvey PD, Kimbrel NA, Beckham JC. Correlates of Risk for Disinhibited Behaviors in the Million Veteran Program Cohort. JAMA Psychiatry 2024; 81:188-197. [PMID: 37938835 PMCID: PMC10633411 DOI: 10.1001/jamapsychiatry.2023.4141] [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] [Received: 03/27/2023] [Accepted: 09/01/2023] [Indexed: 11/10/2023]
Abstract
Importance Many psychiatric outcomes share a common etiologic pathway reflecting behavioral disinhibition, generally referred to as externalizing (EXT) disorders. Recent genome-wide association studies (GWASs) have demonstrated the overlap between EXT disorders and important aspects of veterans' health, such as suicide-related behaviors and substance use disorders (SUDs). Objective To explore correlates of risk for EXT disorders within the Veterans Health Administration (VA) Million Veteran Program (MVP). Design, Setting, and Participants A series of phenome-wide association studies (PheWASs) of polygenic risk scores (PGSs) for EXT disorders was conducted using electronic health records. First, ancestry-specific PheWASs of EXT PGSs were conducted in the African, European, and Hispanic or Latin American ancestries. Next, a conditional PheWAS, covarying for PGSs of comorbid psychiatric problems (depression, schizophrenia, and suicide attempt; European ancestries only), was performed. Lastly, to adjust for unmeasured confounders, a within-family analysis of significant associations from the main PheWAS was performed in full siblings (European ancestries only). This study included the electronic health record data from US veterans from VA health care centers enrolled in MVP. Analyses took place from February 2022 to August 2023 covering a period from October 1999 to January 2020. Exposures PGSs for EXT, depression, schizophrenia, and suicide attempt. Main Outcomes and Measures Phecodes for diagnoses derived from the International Statistical Classification of Diseases, Ninth and Tenth Revisions, Clinical Modification, codes from electronic health records. Results Within the MVP (560 824 patients; mean [SD] age, 67.9 [14.3] years; 512 593 male [91.4%]), the EXT PGS was associated with 619 outcomes, of which 188 were independent of risk for comorbid problems or PGSs (from odds ratio [OR], 1.02; 95% CI, 1.01-1.03 for overweight/obesity to OR, 1.44; 95% CI, 1.42-1.47 for viral hepatitis C). Of the significant outcomes, 73 (11.9%) were significant in the African results and 26 (4.5%) were significant in the Hispanic or Latin American results. Within-family analyses uncovered robust associations between EXT PGS and consequences of SUDs, including liver disease, chronic airway obstruction, and viral hepatitis C. Conclusions and Relevance Results of this cohort study suggest a shared polygenic basis of EXT disorders, independent of risk for other psychiatric problems. In addition, this study found associations between EXT PGS and diagnoses related to SUDs and their sequelae. Overall, this study highlighted the potential negative consequences of EXT disorders for health and functioning in the US veteran population.
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Affiliation(s)
- Peter B. Barr
- VA New York Harbor Healthcare System, Brooklyn
- Department of Psychiatry and Behavioral Sciences, SUNY Downstate Health Sciences University, Brooklyn, New York
- Institute for Genomics in Health, SUNY Downstate Health Sciences University, Brooklyn, New York
- Department of Epidemiology and Biostatistics, School of Public Health, SUNY Downstate Health Sciences University, Brooklyn, New York
| | - Tim B. Bigdeli
- VA New York Harbor Healthcare System, Brooklyn
- Department of Psychiatry and Behavioral Sciences, SUNY Downstate Health Sciences University, Brooklyn, New York
- Institute for Genomics in Health, SUNY Downstate Health Sciences University, Brooklyn, New York
- Department of Epidemiology and Biostatistics, School of Public Health, SUNY Downstate Health Sciences University, Brooklyn, New York
| | - Jacquelyn L. Meyers
- VA New York Harbor Healthcare System, Brooklyn
- Department of Psychiatry and Behavioral Sciences, SUNY Downstate Health Sciences University, Brooklyn, New York
- Institute for Genomics in Health, SUNY Downstate Health Sciences University, Brooklyn, New York
- Department of Epidemiology and Biostatistics, School of Public Health, SUNY Downstate Health Sciences University, Brooklyn, New York
| | - Roseann E. Peterson
- VA New York Harbor Healthcare System, Brooklyn
- Department of Psychiatry and Behavioral Sciences, SUNY Downstate Health Sciences University, Brooklyn, New York
- Institute for Genomics in Health, SUNY Downstate Health Sciences University, Brooklyn, New York
| | - Sandra Sanchez-Roige
- Department of Psychiatry, University of California San Diego, La Jolla
- Division of Genetic Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Travis T. Mallard
- Psychiatric and Neurodevelopmental Genetics Unit, Center for Genomic Medicine, Massachusetts General Hospital, Boston
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts
| | - Danielle M. Dick
- Department of Psychiatry, Robert Wood Johnson Medical School, Rutgers University, Piscataway, New Jersey
- Rutgers Addiction Research Center, Rutgers University, Piscataway, New Jersey
| | - K. Paige Harden
- Department of Psychology, University of Texas at Austin, Austin
- Population Research Center, University of Texas at Austin, Austin
| | - Anna Wilkinson
- Michael E. DeBakey VA Medical Center, Houston, Texas
- The University of Texas Health Science Center at Houston, UTHealth Houston School of Public Health, Houston
- Michael and Susan Dell Center for Healthy Living, The University of Texas Health Science Center at Houston, Houston
| | - David P. Graham
- Michael E. DeBakey VA Medical Center, Houston, Texas
- Departments of Psychiatry, Neuroscience, Pharmacology, and Immunology and Rheumatology, Baylor College of Medicine, Houston, Texas
| | - David A. Nielsen
- Michael E. DeBakey VA Medical Center, Houston, Texas
- Departments of Psychiatry, Neuroscience, Pharmacology, and Immunology and Rheumatology, Baylor College of Medicine, Houston, Texas
| | - Alan C. Swann
- Michael E. DeBakey VA Medical Center, Houston, Texas
- Departments of Psychiatry, Neuroscience, Pharmacology, and Immunology and Rheumatology, Baylor College of Medicine, Houston, Texas
| | - Rachele K. Lipsky
- Michael E. DeBakey VA Medical Center, Houston, Texas
- Departments of Psychiatry, Neuroscience, Pharmacology, and Immunology and Rheumatology, Baylor College of Medicine, Houston, Texas
| | - Thomas R. Kosten
- Michael E. DeBakey VA Medical Center, Houston, Texas
- Departments of Psychiatry, Neuroscience, Pharmacology, and Immunology and Rheumatology, Baylor College of Medicine, Houston, Texas
| | - Mihaela Aslan
- Clinical Epidemiology Research Center, VA Connecticut Healthcare System, West Haven, Connecticut
- Yale University School of Medicine, New Haven, Connecticut
| | - Philip D. Harvey
- Research Service, Bruce W. Carter Miami Veterans Affairs Medical Center, Miami, Florida
- University of Miami Miller School of Medicine, Miami, Florida
| | - Nathan A. Kimbrel
- Durham VA Health Care System, Durham, North Carolina
- VA Mid-Atlantic Mental Illness Research, Education and Clinical Center, Durham, North Carolina
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Jean C. Beckham
- Durham VA Health Care System, Durham, North Carolina
- VA Mid-Atlantic Mental Illness Research, Education and Clinical Center, Durham, North Carolina
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina
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12
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Justice AC, Tate JP, Howland F, Gaziano JM, Kelley MJ, McMahon B, Haiman C, Wadia R, Madduri R, Danciu I, Leppert JT, Leapman MS, Thurtle D, Gnanapragasam VJ. Adaption and National Validation of a Tool for Predicting Mortality from Other Causes Among Men with Nonmetastatic Prostate Cancer. Eur Urol Oncol 2024:S2588-9311(23)00289-4. [PMID: 38171965 DOI: 10.1016/j.euo.2023.11.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 10/24/2023] [Accepted: 11/30/2023] [Indexed: 01/05/2024]
Abstract
BACKGROUND An electronic health record-based tool could improve accuracy and eliminate bias in provider estimation of the risk of death from other causes among men with nonmetastatic cancer. OBJECTIVE To recalibrate and validate the Veterans Aging Cohort Study Charlson Comorbidity Index (VACS-CCI) to predict non-prostate cancer mortality (non-PCM) and to compare it with a tool predicting prostate cancer mortality (PCM). DESIGN, SETTING, AND PARTICIPANTS An observational cohort of men with biopsy-confirmed nonmetastatic prostate cancer, enrolled from 2001 to 2018 in the national US Veterans Health Administration (VA), was divided by the year of diagnosis into the development (2001-2006 and 2008-2018) and validation (2007) sets. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Mortality (all cause, non-PCM, and PCM) was evaluated. Accuracy was assessed using calibration curves and C statistic in the development, validation, and combined sets; overall; and by age (<65 and 65+ yr), race (White and Black), Hispanic ethnicity, and treatment groups. RESULTS AND LIMITATIONS Among 107 370 individuals, we observed 24 977 deaths (86% non-PCM). The median age was 65 yr, 4947 were Black, and 5010 were Hispanic. Compared with CCI and age alone (C statistic 0.67, 95% confidence interval [CI] 0.67-0.68), VACS-CCI demonstrated improved validated discrimination (C statistic 0.75, 95% CI 0.74-0.75 for non-PCM). The prostate cancer mortality tool also discriminated well in validation (C statistic 0.81, 95% CI 0.78-0.83). Both were well calibrated overall and within subgroups. Owing to missing data, 18 009/125 379 (14%) were excluded, and VACS-CCI should be validated outside the VA prior to outside application. CONCLUSIONS VACS-CCI is ready for implementation within the VA. Electronic health record-assisted calculation is feasible, improves accuracy over age and CCI alone, and could mitigate inaccuracy and bias in provider estimation. PATIENT SUMMARY Veterans Aging Cohort Study Charlson Comorbidity Index is ready for application within the Veterans Health Administration. Electronic health record-assisted calculation is feasible, improves accuracy over age and Charlson Comorbidity Index alone, and might help mitigate inaccuracy and bias in provider estimation of the risk of non-prostate cancer mortality.
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Affiliation(s)
- Amy C Justice
- VA Connecticut Healthcare, West Haven, CT, USA; Pain Research, Informatics, Multimorbidities, Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT, USA; Department of Medicine, Yale School of Medicine, New Haven, CT, USA; School of Public Health, Yale University, New Haven, CT, USA.
| | - Janet P Tate
- VA Connecticut Healthcare, West Haven, CT, USA; Department of Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Frank Howland
- Wabash College Economics Department, Crawfordsville, IN, USA
| | | | - Michael J Kelley
- Durham VA Health Care System, Durham, NC, USA; Cancer Institute and Department of Medicine, Duke University, Durham, NC, USA
| | | | - Christopher Haiman
- Center for Genetic Epidemiology, USC Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Roxanne Wadia
- Department of Anatomic Pathology and Lab Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Ravi Madduri
- Data Science Learning Division, Argonne Research Library, Lemont, IL, USA
| | - Ioana Danciu
- Oak Ridge National Laboratory, Oak Ridge, TN, USA; Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - John T Leppert
- Department of Urology, Stanford University, Stanford, CA, USA; VA Palo Alto Health Care System, Palo Alto, CA, USA
| | - Michael S Leapman
- VA Connecticut Healthcare, West Haven, CT, USA; Department of Urology, Yale School of Medicine, New Haven, CT, USA
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13
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Hoggatt KJ, Chawla N, Yano EM. Differing time trends for alcohol misuse and alcohol use disorder among Veteran men: A comparison of population surveillance and clinical data. Addict Behav 2024; 148:107862. [PMID: 37734285 DOI: 10.1016/j.addbeh.2023.107862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 08/15/2023] [Accepted: 09/13/2023] [Indexed: 09/23/2023]
Abstract
INTRODUCTION Data on time trends are important to track the health burden of alcohol use disorder (AUD) and plan for alcohol-related healthcare needs. Our aim was to estimate time trends in AUD for male VA patients and to assess whether trends in documented diagnosis rates were similar to trends in unhealthy alcohol use measured through clinical screening or trends in AUD prevalence among US veterans in the general population. MATERIALS AND METHODS We used VA electronic health record data (10/1/2009-9/30/2019) to measure AUD diagnosis rates and clinical alcohol screening data to measure unhealthy alcohol use. We used data from the National Survey on Drug Use and Health to measure AUD prevalence for 2010-2019. We estimated time trends using regression models with year entered as a linear term. RESULTS For male VA patients, AUD diagnosis rates increased overall and for most age groups, Alcohol screening rates increased, but the proportion with unhealthy alcohol use decreased, except among older patients. AUD prevalence for male US veterans decreased by -0.17 percentage points (pp) annually (p = 0.010), reflecting a strong decreasing trend for ages 18-34 years (-1.20 pp per year, p < 0.001). CONCLUSIONS Increasing trends in AUD diagnoses among VA patients are a contrast to the decreasing trends in unhealthy alcohol use and AUD population prevalence among male US veterans. However, differences in trends by age group highlights a need to better understand the process of clinical AUD identification, particularly for younger men.
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Affiliation(s)
- Katherine J Hoggatt
- San Francisco VA Medical Center, 4150 Clement St., 111A1, San Francisco, CA 94121, USA; University of California, San Francisco, 505 Parnassus Ave, San Francisco, CA 94143, USA.
| | - Neetu Chawla
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System, 16111 Plummer Street (Mailcode 152), Sepulveda, CA 91343, USA.
| | - Elizabeth M Yano
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System, 16111 Plummer Street (Mailcode 152), Sepulveda, CA 91343, USA; University of California, Los Angeles (UCLA), Fielding School of Public Health and Geffen School of Medicine, 650 Charles E. Young Drive South, Los Angeles, CA 90095, USA.
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14
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Gray C, Egelfeld J, Vashi A. Access to and accessibility of care for rural Veterans with disabilities: A qualitative evaluation of VA healthcare experiences. Disabil Health J 2024; 17:101515. [PMID: 37620242 DOI: 10.1016/j.dhjo.2023.101515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 07/28/2023] [Accepted: 07/31/2023] [Indexed: 08/26/2023]
Abstract
BACKGROUND Persons with disabilities experience significant physical, attitudinal, and communication-based barriers to accessing care. These challenges are exacerbated for rural-dwelling persons with disabilities. Although US Veterans experience disabilities at a higher rate than non-Veterans and are also more likely to dwell in rural locations, research examining the accessibility of VA care for rural Veterans with disabilities is limited. OBJECTIVES With a focus on access and accessibility, we sought to explore the experiences of rural Veterans with disabilities who receive care at VA. METHODS We conducted 30 qualitative interviews with rural-dwelling Veterans who experience at least one of three types of disabilities: hearing loss, vision loss, and mobility loss. Using a descriptive qualitative approach, we focused on creating a taxonomy of potential access barriers experienced among this population. RESULTS Participants reported experiencing access barriers in five main areas, including policies and operational processes at VA clinics; navigating VA campuses and clinics; limited transportation and parking options; communicating with healthcare personnel and occasional negative interactions; and challenges due to pandemic-related changes in policies and procedures. CONCLUSION These findings suggest that Veterans with disabilities may experience a host of challenges and access barriers while navigating the VA Healthcare system. While these challenges have been reported among individuals with disabilities receiving care in other healthcare settings, they have not been assessed in VA specifically. Given its focus on caring for Veterans with service-aggravated conditions and its commitment to equity and inclusion, addressing access barriers among Veterans with disabilities should be a high priority for VA.
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Affiliation(s)
- Caroline Gray
- Center for Innovation to Implementation, VA Palo Alto Healthcare System, Palo Alto, CA, USA; 795 Willow Rd., C-102, Menlo Park, CA 94025, USA.
| | - Jacqueline Egelfeld
- Center for Innovation to Implementation, VA Palo Alto Healthcare System, Palo Alto, CA, USA; 795 Willow Rd., Menlo Park, CA 94025, USA.
| | - Anita Vashi
- Center for Innovation to Implementation, VA Palo Alto Healthcare System, Palo Alto, CA, USA; 795 Willow Rd., Menlo Park, CA 94025, USA; Department of Emergency Medicine, University of California, 505 Parnassus Ave, San Francisco, CA 94143, USA.
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15
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Friedman DR, Rodgers TD, Kovalick C, Yellapragada S, Szumita L, Weiss ES. Veterans with blood cancers: Clinical trial navigation and the challenge of rurality. J Rural Health 2024; 40:114-120. [PMID: 37389421 DOI: 10.1111/jrh.12773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 03/23/2023] [Accepted: 05/30/2023] [Indexed: 07/01/2023]
Abstract
PURPOSE The proportion of cancer patients who participate in clinical trials (CTs) remains low, despite an understanding of barriers to enrollment. The barrier of rural residence is relevant to Veterans, who more commonly live in rural areas than non-Veterans. In this exploratory study, we aimed to examine geographic factors that could impede CT enrollment and to improve access to CTs for Veterans. METHODS To assess the influence of rurality on the availability of CTs, we performed simulated searches using The Leukemia & Lymphoma Society's Clinical Trial Support Center (LLS CTSC) database. The LLS CTSC provides free CT education and navigation. In the second part of this study, we offered Veterans with blood cancers who received care at the Durham, Salem, Clarksburg, Sioux Falls, and Houston Veterans Administration (VA) Medical Centers referral to the LLS CTSC. FINDINGS In simulated searches, we found significantly lower numbers of CTs open to enrollment in rural areas, compared to urban areas. In actual referrals, 33 Veterans were referred to the LLS CTSC, of which 15 (45%) lived in rural areas. Three Veterans enrolled in CTs. Patients declined referral or did not enroll in CTs for various reasons, including a desire to maintain care within the VA and/or to initiate therapy quickly. CONCLUSIONS We identified "clinical trial deserts," which might hinder access and reduce CT participation for rural Veterans. Referral to the LLS CTSC promoted CT education and enrollment among a highly rural cohort of Veterans receiving care in the VA system.
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Affiliation(s)
- Daphne R Friedman
- Durham VA Health Care System, Durham, North Carolina, USA
- Duke University School of Medicine, Durham, North Carolina, USA
| | - Thomas D Rodgers
- Durham VA Health Care System, Durham, North Carolina, USA
- Duke University School of Medicine, Durham, North Carolina, USA
| | | | - Sarvari Yellapragada
- Michael E. DeBakey VA Medical Center, Houston, Texas, USA
- Baylor College of Medicine, Houston, Texas, USA
- Dan L. Duncan Comprehensive Cancer Center
| | - Leah Szumita
- The Leukemia & Lymphoma Society, Rye Brook, New York, USA
| | - Elisa S Weiss
- The Leukemia & Lymphoma Society, Rye Brook, New York, USA
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16
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Ravyts SG, Eshera YM, Griffin SC, Halverson T, Grove JL, Beckham JC, Pugh MJ, Kimbrel NA, Calhoun PS. Sleep Apnea Among Gulf War Veterans: An Examination of VA Utilization Rates, Treatment Initiation, and Health Outcomes. Behav Sleep Med 2023:1-11. [PMID: 38156829 DOI: 10.1080/15402002.2023.2299675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Abstract
OBJECTIVES Obstructive sleep apnea (OSA) among veterans is frequently underdiagnosed and undertreated. The present study sought to: 1) characterize the prevalence and rate of treatment of OSA among VA users and non-users and 2) examine the associations between diagnosed or probable OSA and key physical and mental health outcomes. METHODS Gulf-War I-era Veterans were recruited as part of a national survey assessing mental and physical health concerns, healthcare needs, and healthcare utilization. OSA diagnoses were self-reported while sleep apnea risk was assessed via the STOP-Bang. Veterans also completed questionnaires assessing overall health, pain, depression, PTSD, and psychosocial functioning. RESULTS 1,153 veterans were included in the present analyses (Mean age = 58.81; 21.84% female). Compared to non-VA healthcare users, veterans receiving care at the VA were more likely to have been diagnosed with OSA (p < .001) and report receiving treatment for OSA (p = .005). Compared to veterans at low risk for OSA, veterans at elevated risk reported higher levels of pain (p = .001), depression (p = .02), and poorer psychosocial functioning (p < .001). CONCLUSIONS OSA diagnoses appear to be more common among VA healthcare users. Findings suggest that OSA remains underdiagnosed and associated with important physical and mental health consequences. Additional screening for OSA, especially among non-VA clinics, is warranted.
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Affiliation(s)
- Scott G Ravyts
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Yasmine M Eshera
- Department of Psychological Sciences, Kent State University, Kent, OH, USA
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Sarah C Griffin
- Corporal Michael J. Crescenz Department of Veterans Affairs Medical Center, Philadelphia, PA, USA
- Durham Veterans Affairs Health Care System, Durham, NC, USA
- VA Mid-Atlantic Mental Illness Research, Education, and Clinical Center, Durham, NC, USA
| | - Tate Halverson
- Durham Veterans Affairs Health Care System, Durham, NC, USA
- VA Mid-Atlantic Mental Illness Research, Education, and Clinical Center, Durham, NC, USA
| | - Jeremy L Grove
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Jean C Beckham
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, USA
- Durham Veterans Affairs Health Care System, Durham, NC, USA
- VA Mid-Atlantic Mental Illness Research, Education, and Clinical Center, Durham, NC, USA
| | - Mary J Pugh
- Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT, USA
- Department of Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Nathan A Kimbrel
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, USA
- Durham Veterans Affairs Health Care System, Durham, NC, USA
- VA Mid-Atlantic Mental Illness Research, Education, and Clinical Center, Durham, NC, USA
- VA Health Services Research and Development Center of Innovation to Accelerate Discovery and Practice Transformation, Durham, NC, USA
| | - Patrick S Calhoun
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, USA
- Durham Veterans Affairs Health Care System, Durham, NC, USA
- VA Mid-Atlantic Mental Illness Research, Education, and Clinical Center, Durham, NC, USA
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17
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Kenneally L, Stevens S, Cornelius S, Shiner B, Rice K, Park J, Watts BV, Teja N, Riblet N. Pilot randomized controlled trial of a brief strategy to prevent suicide after discharge from residential addiction treatment. JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2023; 154:209156. [PMID: 37652208 PMCID: PMC10562975 DOI: 10.1016/j.josat.2023.209156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 03/23/2023] [Accepted: 08/28/2023] [Indexed: 09/02/2023]
Abstract
INTRODUCTION Veterans are at greater risk for suicide and veterans with substance use disorder (SUD) have an even greater risk. Little research has looked into brief interventions to prevent suicide in this population in residential substance use treatment programs. METHOD We conducted a pilot, randomized controlled trial of a brief suicide prevention strategy called Veterans Affairs Brief Intervention and Contact Program (VA BIC) in patients participating in the Residential Recovery Center (RRC) SUD 28-day program and deemed at risk for suicide. We measured changes in symptoms at 1-, 3-, and 6-months. We looked at social connectedness, suicidal ideation, hopelessness, thwarted belongingness, perceived burdensomeness, and treatment engagement. RESULTS The study enrolled twenty patients. One participant withdrew immediately after baseline. We found that adherence to VA BIC components was high, as 100 % of patients (N = 10) completed 70 % or more of the VA BIC visits. Furthermore, 80 % of intervention group patients (N = 8) completed all VA BIC components. During the six-month follow-up, suicidal ideation improved in patients assigned to VA BIC, while it worsened in the standard care arm. Similarly, patients assigned to VA BIC reported a reduction in perceived burdensomeness over the six-month follow-up period while it worsened in the standard care arm. Additionally, VA BIC may modestly improve treatment engagement in the first month postdischarge. CONCLUSION We were able to recruit and enroll patients from a residential SUD treatment program into a clinical trial of the VA BIC intervention. Our preliminary results suggest that VA BIC may be useful in reducing suicidal ideation and perceived burdensomeness in patients who are discharged from residential SUD treatment programs and increasing treatment engagement. Future trials of VA BIC should determine whether VA BIC can reduce the risk of suicide in patients who are discharged from residential SUD treatment programs.
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Affiliation(s)
- Lauren Kenneally
- White River Junction VA Medical Center, 215 North Main Street, White River Junction, VT 05009, United States of America
| | - Susan Stevens
- White River Junction VA Medical Center, 215 North Main Street, White River Junction, VT 05009, United States of America; Department of Psychiatry, Geisel School of Medicine, Dartmouth College, 1 Rope Ferry Road, Hanover, NH 03755, United States of America
| | - Sarah Cornelius
- White River Junction VA Medical Center, 215 North Main Street, White River Junction, VT 05009, United States of America; Department of Biomedical Data Science, Dartmouth Institute, Community and Family Medicine, Geisel School of Medicine, Dartmouth College, 1 Rope Ferry Road, Hanover, NH 03755, United States of America
| | - Brian Shiner
- White River Junction VA Medical Center, 215 North Main Street, White River Junction, VT 05009, United States of America; Department of Psychiatry, The Dartmouth Institute, Geisel School of Medicine, Dartmouth College, 1 Rope Ferry Road, Hanover, NH 03755, United States of America; National Center for PTSD, Mental Health Service, White River Junction VA Medical Center, 215 North Main Street, White River Junction, VT 05009, United States of America
| | - Korie Rice
- White River Junction VA Medical Center, 215 North Main Street, White River Junction, VT 05009, United States of America
| | - Jenna Park
- White River Junction VA Medical Center, 215 North Main Street, White River Junction, VT 05009, United States of America
| | - Bradley V Watts
- White River Junction VA Medical Center, 215 North Main Street, White River Junction, VT 05009, United States of America; Department of Psychiatry, Geisel School of Medicine, Dartmouth College, 1 Rope Ferry Road, Hanover, NH 03755, United States of America; Veterans Rural Health Resource Center, White River Junction VA Medical Center, 215 North Main Street, White River Junction, VT 05009, United States of America
| | - Nikhil Teja
- White River Junction VA Medical Center, 215 North Main Street, White River Junction, VT 05009, United States of America; Department of Psychiatry, Geisel School of Medicine, Dartmouth College, 1 Rope Ferry Road, Hanover, NH 03755, United States of America
| | - Natalie Riblet
- White River Junction VA Medical Center, 215 North Main Street, White River Junction, VT 05009, United States of America; Department of Psychiatry, The Dartmouth Institute, Geisel School of Medicine, Dartmouth College, 1 Rope Ferry Road, Hanover, NH 03755, United States of America.
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Parmasad V, Keating J, McKinley L, Evans C, Rubin M, Voils C, Safdar N. Frontline perspectives of C. difficile infection prevention practice implementation within veterans affairs health care facilities: A qualitative study. Am J Infect Control 2023; 51:1124-1131. [PMID: 36977453 DOI: 10.1016/j.ajic.2023.03.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 03/17/2023] [Accepted: 03/19/2023] [Indexed: 03/28/2023]
Abstract
BACKGROUND In 2012, the veteran's affairs (VA) multidrug-resistant organism (MDRO) Program Office launched a national Clostridioides difficile Infection (CDI) Prevention Initiative to address CDI as the most common cause of healthcare associated infections, mandating use of a VA CDI Bundle of prevention practices in inpatient facilities. We draw upon frontline worker perspectives to explore work system barriers and facilitators to the sustained implementation of the VA CDI Bundle using the systems engineering initiative for patient safety (SEIPS) framework. METHODS We interviewed 29 key stakeholders at 4 participating sites between October 2019-July 2021. Participants included infection prevention and control (IPC) leaders, nurses, physicians, and environmental management staff. Interviews were analyzed to identify themes and perceptions of facilitators and barriers to CDI prevention. RESULTS IPC leadership was most likely to know of the specific VA CDI Bundle components. Other participants demonstrated general knowledge of CDI prevention practices, with role-based variation in the depth of awareness of specific practices. Facilitators included leadership support, mandated CDI training and prevention practices, and readily available training from multiple sources. Barriers included limits to communication about facility or unit-level CDI rates, ambiguous communications about CDI prevention practice updates and VA mandates, and role-hierarchies that may limit team members' clinical contributions. DISCUSSION Recommendations include improving centrally-mandated clarity about and standardization of CDI prevention policies, including testing. Regular IPC training updates for all clinical stakeholders are also recommended. CONCLUSIONS A work system analysis using SEIPS identified barriers and facilitators to CDI prevention practices that could be addressed both nationally at the system level and locally at the facility level, specifically in the areas of communication and coordination.
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Affiliation(s)
- Vishala Parmasad
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI; William S. Middleton Memorial Veterans Hospital, Madison, WI.
| | - Julie Keating
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI; William S. Middleton Memorial Veterans Hospital, Madison, WI
| | - Linda McKinley
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI; William S. Middleton Memorial Veterans Hospital, Madison, WI
| | - Charlesnika Evans
- Center of Innovation for Complex Chronic Healthcare (CINCCH), Edward Hines Jr. Veterans Affairs Hospital, Hines
| | - Michael Rubin
- IDEAS 2.0 Center, George E. Whalen VA Medical Center, Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, UT
| | - Corrine Voils
- William S. Middleton Memorial Veterans Hospital, Madison, WI; Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Nasia Safdar
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI; William S. Middleton Memorial Veterans Hospital, Madison, WI
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Chao LL. Examining the current health of Gulf War veterans with the veterans affairs frailty index. Front Neurosci 2023; 17:1245811. [PMID: 37746142 PMCID: PMC10512703 DOI: 10.3389/fnins.2023.1245811] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 08/15/2023] [Indexed: 09/26/2023] Open
Abstract
Introduction Gulf War Illness (GWI) is a chronic, multisymptom (e.g., fatigue, muscle/joint pain, memory and concentration difficulties) condition estimated to affect 25-32% of Gulf War (GW) veterans. Longitudinal studies suggest that few veterans with GWI have recovered over time and that deployed GW veterans may be at increased risks for age-related conditions. Methods We performed a retrospective cohort study to examine the current health status of 703 GW veterans who participated in research studies at the San Francisco VA Health Care System (SFVAHCS) between 2002 and 2018. We used the Veterans Affairs Frailty Index (VA-FI) as a proxy measure of current health and compared the VA-FIs of GW veterans to a group of randomly selected age- and sex-matched, non-GW veterans. We also examined GW veterans' VA-FIs as a function of different GWI case definitions and in relationship to deployment-related experiences and exposures. Results Compared to matched, non-GW veterans, GW veterans had lower VA-FIs (0.10 ± 0.10 vs. 0.12 ± 0.11, p < 0.01). However, the subset of GW veterans who met criteria for severe Chronic Multisymptom Illness (CMI) at the time of the SFVAHCS studies had the highest VA-FI (0.13 ± 0.10, p < 0.001). GW veterans who had Kansas GWI exclusionary conditions had higher VA-FI (0.12 ± 0.12, p < 0.05) than veterans who were Kansas GWI cases (0.08 ± 0.08) and controls (i.e., veterans with little or no symptoms, 0.04 ± 0.06) at the time of the SFVAHCS research studies. The VA-FI was positively correlated with several GW deployment-related exposures, including the frequency of wearing flea collars. Discussion Although GW veterans, as a group, were less frail than non-GW veterans, the subset of GW veterans who met criteria for severe CDC CMI and/or who had Kansas GWI exclusionary conditions at the time of the SFVAHCS research studies were frailest at index date. This suggests that many ongoing studies of GWI that use the Kansas GWI criteria may not be capturing the group of GW veterans who are most at risk for adverse chronic health outcomes.
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Affiliation(s)
- Linda L. Chao
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, CA, United States
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, San Francisco, CA, United States
- San Francisco Veterans Affairs Health Care System, San Francisco, CA, United States
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20
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Reimer RJ, Goncalves A, Soper B, Cadena J, Wilson JL, Gryshuk AL, Suarez P, Osborne TF, Grimes KV, Ray P. An electronic health record cohort of Veterans with amyotrophic lateral sclerosis. Amyotroph Lateral Scler Frontotemporal Degener 2023:1-7. [PMID: 37555559 DOI: 10.1080/21678421.2023.2239300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 07/03/2023] [Accepted: 07/15/2023] [Indexed: 08/10/2023]
Abstract
Objective: To assemble and characterize an electronic health record (EHR) dataset for a large cohort of US military Veterans diagnosed with ALS (Amyotrophic Lateral Sclerosis). Methods: An EHR dataset for 19,662 Veterans diagnosed with ALS between January 1, 2000 to December 31, 2020 was compiled from the Veterans Health Administration (VHA) EHR database by a query for ICD9 diagnosis (335.20) or ICD10 diagnosis (G12.21) for Amyotrophic Lateral Sclerosis. Results: The cohort is predominantly male (98.94%) and white (72.37%) with a median age at disease onset of 68 years and median survival from the date of diagnosis of 590 days. With the designation of ALS as a compensable illness in 2009, there was a subsequent increase in the number of Veterans diagnosed per year in the VHA, but no change in median survival. The cohort included a greater-than-expected proportion of individuals whose branch of service at the time of separation was the Army. Conclusions: The composition of the cohort reflects the VHA population who are at greatest risk for ALS. The greater than expected proportion of individuals whose branch of service at the time of separation was the Army suggests the possibility of a branch-specific risk factor for ALS.
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Affiliation(s)
- Richard J Reimer
- Department of Neurology and Neurological Sciences, Stanford and Division of Neurology, Stanford University School of Medicine, Veterans Affairs Palo Alto Health Care System, Stanford, CA, USA
| | - Andre Goncalves
- Computational Engineering, Engineering Directorate, Lawrence Livermore National Laboratory, Livermore, CA, USA
| | - Braden Soper
- Center for Applied Scientific Computing, Computing Directorate, Lawrence Livermore National Laboratory, Livermore, CA, USA
| | - Jose Cadena
- Computational Engineering, Engineering Directorate, Lawrence Livermore National Laboratory, Livermore, CA, USA
| | - Jennifer L Wilson
- Department of Bioengineering, University of California, Los Angeles, Los Angeles, CA, USA
| | - Amy L Gryshuk
- Physical and Life Sciences Directorate, Lawrence Livermore National Laboratory, Livermore, CA, USA
| | - Paola Suarez
- National Center for Collaborative Healthcare Innovation, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| | - Thomas F Osborne
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA
- National Center for Collaborative Healthcare Innovation and Division of Radiology, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA, and
| | - Kevin V Grimes
- Department of Chemical and Systems Biology, Stanford University School of Medicine, Stanford, CA, USA
| | - Priyadip Ray
- Computational Engineering, Engineering Directorate, Lawrence Livermore National Laboratory, Livermore, CA, USA
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21
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Hasin DS, Wall MM, Alschuler D, Mannes ZL, Malte C, Olfson M, Keyes KM, Gradus JL, Cerdá M, Maynard CC, Keyhani S, Martins SS, Fink DS, Livne O, McDowell Y, Sherman S, Saxon AJ. Chronic Pain, Cannabis Legalization and Cannabis Use Disorder in Veterans Health Administration Patients, 2005 to 2019. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.07.10.23292453. [PMID: 37503049 PMCID: PMC10370240 DOI: 10.1101/2023.07.10.23292453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/29/2023]
Abstract
Background The risk for cannabis use disorder (CUD) is elevated among U.S. adults with chronic pain, and CUD rates are disproportionately increasing in this group. Little is known about the role of medical cannabis laws (MCL) and recreational cannabis laws (RCL) in these increases. Among U.S. Veterans Health Administration (VHA) patients, we examined whether MCL and RCL effects on CUD prevalence differed between patients with and without chronic pain. Methods Patients with ≥1 primary care, emergency, or mental health visit to the VHA and no hospice/palliative care within a given calendar year, 2005-2019 (yearly n=3,234,382 to 4,579,994) were analyzed using VHA electronic health record (EHR) data. To estimate the role of MCL and RCL enactment in the increases in prevalence of diagnosed CUD and whether this differed between patients with and without chronic pain, staggered-adoption difference-in-difference analyses were used, fitting a linear binomial regression model with fixed effects for state, categorical year, time-varying cannabis law status, state-level sociodemographic covariates, a chronic pain indicator, and patient covariates (age group [18-34, 35-64; 65-75], sex, and race and ethnicity). Pain was categorized using an American Pain Society taxonomy of painful medical conditions. Outcomes In patients with chronic pain, enacting MCL led to a 0·14% (95% CI=0·12%-0·15%) absolute increase in CUD prevalence, with 8·4% of the total increase in CUD prevalence in MCL-enacting states attributable to MCL. Enacting RCL led to a 0·19% (95%CI: 0·16%, 0·22%) absolute increase in CUD prevalence, with 11·5% of the total increase in CUD prevalence in RCL-enacting states attributable to RCL. In patients without chronic pain, enacting MCL and RCL led to smaller absolute increases in CUD prevalence (MCL: 0·037% [95%CI: 0·03, 0·05]; RCL: 0·042% [95%CI: 0·02, 0·06]), with 5·7% and 6·0% of the increases in CUD prevalence attributable to MCL and RCL. Overall, MCL and RCL effects were significantly greater in patients with than without chronic pain. By age, MCL and RCL effects were negligible in patients age 18-34 with and without pain. In patients age 35-64 with and without pain, MCL and RCL effects were significant (p<0.001) but small. In patients age 65-75 with pain, absolute increases were 0·10% in MCL-only states and 0·22% in MCL/RCL states, with 9·3% of the increase in CUD prevalence in MCL-only states attributable to MCL, and 19.4% of the increase in RCL states attributable to RCL. In patients age 35-64 and 65-75, MCL and RCL effects were significantly greater in patients with pain. Interpretation In patients age 35-75, the role of MCL and RCL in the increasing prevalence of CUD was greater in patients with chronic pain than in those without chronic pain, with particularly pronounced effects in patients with chronic pain age 65-75. Although the VHA offers extensive behavioral and non-opioid pharmaceutical treatments for pain, cannabis may seem a more appealing option given media enthusiasm about cannabis, cannabis commercialization activities, and widespread public beliefs about cannabis efficacy. Cannabis does not have the risk/mortality profile of opioids, but CUD is a clinical condition with considerable impairment and comorbidity. Because cannabis legalization in the U.S. is likely to further increase, increasing CUD prevalence among patients with chronic pain following state legalization is a public health concern. The risk of chronic pain increases as individuals age, and the average age of VHA patients and the U.S. general population is increasing. Therefore, clinical monitoring of cannabis use and discussion of the risk of CUD among patients with chronic pain is warranted, especially among older patients. Research in Context Evidence before this study: Only three studies have examined the role of state medical cannabis laws (MCL) and/or recreational cannabis laws (RCL) in the increasing prevalence of cannabis use disorder (CUD) in U.S. adults, finding significant MCL and RCL effects but with modest effect sizes. Effects of MCL and RCL may vary across important subgroups of the population, including individuals with chronic pain. PubMed was searched by DH for publications on U.S. time trends in cannabis legalization, cannabis use disorders (CUD) and pain from database inception until March 15, 2023, without language restrictions. The following search terms were used: (medical cannabis laws) AND (pain) AND (cannabis use disorder); (recreational cannabis laws) AND (pain) AND (cannabis use disorder); (cannabis laws) AND (pain) AND (cannabis use disorder). Only one study was found that had CUD as an outcome, and this study used cross-sectional data from a single year, which cannot be used to determine trends over time. Therefore, evidence has been lacking on whether the role of state medical and recreational cannabis legalization in the increasing US adult prevalence of CUD differed by chronic pain status.Added value of this study: To our knowledge, this is the first study to examine whether the effects of state MCL and RCL on the nationally increasing U.S. rates of adult cannabis use disorder differ by whether individuals experience chronic pain or not. Using electronic medical record data from patients in the Veterans Health Administration (VHA) that included extensive information on medical conditions associated with chronic pain, the study showed that the effects of MCL and RCL on the prevalence of CUD were stronger among individuals with chronic pain age 35-64 and 65-75, an effect that was particularly pronounced in older patients ages 65-75.Implications of all the available evidence: MCL and RCL are likely to influence the prevalence of CUD through commercialization that increases availability and portrays cannabis use as 'normal' and safe, thereby decreasing perception of cannabis risk. In patients with pain, the overall U.S. decline in prescribed opioids may also have contributed to MCL and RCL effects, leading to substitution of cannabis use that expanded the pool of individuals vulnerable to CUD. The VHA offers extensive non-opioid pain programs. However, positive media reports on cannabis, positive online "information" that can sometimes be misleading, and increasing popular beliefs that cannabis is a useful prevention and treatment agent may make cannabis seem preferable to the evidence-based treatments that the VHA offers, and also as an easily accessible option among those not connected to a healthcare system, who may face more barriers than VHA patients in accessing non-opioid pain management. When developing cannabis legislation, unintended consequences should be considered, including increased risk of CUD in large vulnerable subgroups of the population.
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Affiliation(s)
- Deborah S Hasin
- Columbia University Irving Medical Center, 630 West 168th Street, New York, NY 10032, USA
- Columbia University Mailman School of Public Health, 722 W 168th St, New York, NY 10032, USA
- New York State Psychiatric Institute, 1051 Riverside Dr, New York, NY 10032, USA
| | - Melanie M Wall
- Columbia University Irving Medical Center, 630 West 168th Street, New York, NY 10032, USA
- New York State Psychiatric Institute, 1051 Riverside Dr, New York, NY 10032, USA
| | - Dan Alschuler
- New York State Psychiatric Institute, 1051 Riverside Dr, New York, NY 10032, USA
| | - Zachary L Mannes
- New York State Psychiatric Institute, 1051 Riverside Dr, New York, NY 10032, USA
| | - Carol Malte
- Health Services Research & Development (HSR&D) Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, 1660 S Columbian Way, Seattle, WA 98108, USA
- Center of Excellence in Substance Addiction Treatment and Education, VA Puget Sound Health Care System, 1660 S Columbian Way, Seattle, WA 98108, USA
| | - Mark Olfson
- Columbia University Irving Medical Center, 630 West 168th Street, New York, NY 10032, USA
| | - Katherine M Keyes
- Columbia University Mailman School of Public Health, 722 W 168th St, New York, NY 10032, USA
| | - Jaimie L Gradus
- Boston University School of Public Health, 715 Albany St, Boston, MA 02118, USA
| | - Magdalena Cerdá
- New York University, 50 West 4th Street, New York, NY 10012, USA
| | - Charles C Maynard
- Health Services Research & Development (HSR&D) Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, 1660 S Columbian Way, Seattle, WA 98108, USA
- University of Washington, 1400 Ne Campus Parkway, Seattle, WA 98195, USA
| | - Salomeh Keyhani
- San Francisco VA Health System, 4150 Clement St, San Francisco, CA 94121, USA
- University of California at San Francisco, 505 Parnassus Ave, San Francisco, CA 94143, USA
| | - Silvia S Martins
- Columbia University Mailman School of Public Health, 722 W 168th St, New York, NY 10032, USA
| | - David S Fink
- New York State Psychiatric Institute, 1051 Riverside Dr, New York, NY 10032, USA
| | - Ofir Livne
- New York State Psychiatric Institute, 1051 Riverside Dr, New York, NY 10032, USA
| | - Yoanna McDowell
- Center of Excellence in Substance Addiction Treatment and Education, VA Puget Sound Health Care System, 1660 S Columbian Way, Seattle, WA 98108, USA
| | - Scott Sherman
- New York University, 50 West 4th Street, New York, NY 10012, USA
- VA Manhattan Harbor Healthcare, 423 E 23rd St, New York, NY 10010, USA
| | - Andrew J Saxon
- Health Services Research & Development (HSR&D) Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, 1660 S Columbian Way, Seattle, WA 98108, USA
- Center of Excellence in Substance Addiction Treatment and Education, VA Puget Sound Health Care System, 1660 S Columbian Way, Seattle, WA 98108, USA
- University of Washington School of Medicine, 1959 NE Pacific St, Seattle, WA 98195, USA
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Barr PB, Bigdeli TB, Meyers JL, Peterson RE, Sanchez-Roige S, Mallard TT, Dick DM, Paige Harden K, Wilkinson A, Graham DP, Nielsen DA, Swann A, Lipsky RK, Kosten T, Aslan M, Harvey PD, Kimbrel NA, Beckham JC. Correlates of Risk for Disinhibited Behaviors in the Million Veteran Program Cohort. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.03.22.23286865. [PMID: 37034805 PMCID: PMC10081391 DOI: 10.1101/2023.03.22.23286865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/19/2023]
Abstract
Background Many psychiatric outcomes are thought to share a common etiological pathway reflecting behavioral disinhibition, generally referred to as externalizing disorders (EXT). Recent genome-wide association studies (GWAS) have demonstrated the overlap between EXT and important aspects of veterans' health, such as suicide-related behaviors, substance use disorders, and other medical conditions. Methods We conducted a series of phenome-wide association studies (PheWAS) of polygenic scores (PGS) for EXT, and comorbid psychiatric problems (depression, schizophrenia, and suicide attempt) in an ancestrally diverse cohort of U.S. veterans (N = 560,824), using diagnostic codes from electronic health records. We conducted ancestry-specific PheWASs of EXT PGS in the European, African, and Hispanic/Latin American ancestries. To determine if associations were driven by risk for other comorbid problems, we performed a conditional PheWAS, covarying for comorbid psychiatric problems (European ancestries only). Lastly, to adjust for unmeasured confounders we performed a within-family analysis of significant associations from the main PheWAS in full-siblings (N = 12,127, European ancestries only). Results The EXT PGS was associated with 619 outcomes across all bodily systems, of which, 188 were independent of risk for comorbid problems of PGS. Effect sizes ranged from OR = 1.02 (95% CI = 1.01, 1.03) for overweight/obesity to OR = 1.44 (95% CI = 1.42, 1.47) for viral hepatitis C. Of the significant outcomes 73 (11.9%) and 26 (4.5%) were significant in the African and Hispanic/Latin American results, respectively. Within-family analyses uncovered robust associations between EXT and consequences of substance use disorders, including liver disease, chronic airway obstruction, and viral hepatitis C. Conclusion Our results demonstrate a shared polygenic basis of EXT across populations of diverse ancestries and independent of risk for other psychiatric problems. The strongest associations with EXT were for diagnoses related to substance use disorders and their sequelae. Overall, we highlight the potential negative consequences of EXT for health and functioning in the US veteran population.
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Affiliation(s)
- Peter B. Barr
- VA New York Harbor Healthcare System, Brooklyn, NY
- Department of Psychiatry and Behavioral Sciences, SUNY Downstate Health Sciences University, Brooklyn, NY
- Institute for Genomics in Health (IGH), SUNY Downstate Health Sciences University, Brooklyn, NY
- Department of Epidemiology and Biostatistics, School of Public Health, SUNY Downstate Health Sciences University, Brooklyn, NY
| | - Tim B. Bigdeli
- VA New York Harbor Healthcare System, Brooklyn, NY
- Department of Psychiatry and Behavioral Sciences, SUNY Downstate Health Sciences University, Brooklyn, NY
- Institute for Genomics in Health (IGH), SUNY Downstate Health Sciences University, Brooklyn, NY
- Department of Epidemiology and Biostatistics, School of Public Health, SUNY Downstate Health Sciences University, Brooklyn, NY
| | - Jacquelyn L. Meyers
- VA New York Harbor Healthcare System, Brooklyn, NY
- Department of Psychiatry and Behavioral Sciences, SUNY Downstate Health Sciences University, Brooklyn, NY
- Institute for Genomics in Health (IGH), SUNY Downstate Health Sciences University, Brooklyn, NY
- Department of Epidemiology and Biostatistics, School of Public Health, SUNY Downstate Health Sciences University, Brooklyn, NY
| | - Roseann E. Peterson
- VA New York Harbor Healthcare System, Brooklyn, NY
- Department of Psychiatry and Behavioral Sciences, SUNY Downstate Health Sciences University, Brooklyn, NY
- Institute for Genomics in Health (IGH), SUNY Downstate Health Sciences University, Brooklyn, NY
| | - Sandra Sanchez-Roige
- Department of Psychiatry, University of California San Diego, La Jolla, CA, USA
- Division of Genetic Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Travis T. Mallard
- Psychiatric and Neurodevelopmental Genetics Unit, Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Danielle M. Dick
- Department of Psychiatry, Robert Wood Johnson Medical School, Rutgers University, Piscataway, NJ
- Rutgers Addiction Research Center, Rutgers University, Piscataway, NJ
| | - K. Paige Harden
- Department of Psychology, University of Texas at Austin, Austin, TX
- Population Research Center, University of Texas at Austin, Austin, TX
| | - Anna Wilkinson
- Michael E. DeBakey VA Medical Center, Houston, TX
- UTHealth Houston School of Public Health, The University of Texas Health Science Center at Houston, Houston, TX
- Michael and Susan Dell Center for Healthy Living, The University of Texas Health Science Center at Houston, Houston, TX
| | - David P. Graham
- Michael E. DeBakey VA Medical Center, Houston, TX
- Department of Psychiatry, Neuroscience, Pharmacology, and Immunology and Rheumatology, Baylor College of Medicine, Houston, TX
| | - David A. Nielsen
- Michael E. DeBakey VA Medical Center, Houston, TX
- Department of Psychiatry, Neuroscience, Pharmacology, and Immunology and Rheumatology, Baylor College of Medicine, Houston, TX
| | - Alan Swann
- Michael E. DeBakey VA Medical Center, Houston, TX
- Department of Psychiatry, Neuroscience, Pharmacology, and Immunology and Rheumatology, Baylor College of Medicine, Houston, TX
| | - Rachele K. Lipsky
- Michael E. DeBakey VA Medical Center, Houston, TX
- Department of Psychiatry, Neuroscience, Pharmacology, and Immunology and Rheumatology, Baylor College of Medicine, Houston, TX
| | - Thomas Kosten
- Michael E. DeBakey VA Medical Center, Houston, TX
- Department of Psychiatry, Neuroscience, Pharmacology, and Immunology and Rheumatology, Baylor College of Medicine, Houston, TX
| | - Mihaela Aslan
- Clinical Epidemiology Research Center (CERC), VA Connecticut Healthcare System, West Haven, CT
- Yale University School of Medicine, New Haven, CT
| | - Philip D. Harvey
- Research Service, Bruce W. Carter Miami Veterans Affairs (VA) Medical Center, Miami, FL
- University of Miami Miller School of Medicine, Miami, FL
| | - Nathan A. Kimbrel
- Durham VA Health Care System, Durham, NC
- VA Mid-Atlantic Mental Illness Research, Education and Clinical Center, Durham, NC
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC
| | - Jean C. Beckham
- Durham VA Health Care System, Durham, NC
- VA Mid-Atlantic Mental Illness Research, Education and Clinical Center, Durham, NC
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC
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23
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Nichter B, Tsai J, Pietrzak RH. Prevalence, correlates, and mental health burden associated with homelessness in U.S. military veterans. Psychol Med 2023; 53:3952-3962. [PMID: 35301973 PMCID: PMC10317824 DOI: 10.1017/s0033291722000617] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Revised: 02/09/2022] [Accepted: 02/17/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND Homelessness is a major public health problem among U.S. military veterans. However, contemporary, population-based data on the prevalence, correlates, and mental health burden of homelessness among veterans are lacking. METHODS Data were analyzed from the 2019-2020 National Health and Resilience in Veterans Study, a nationally representative survey of veterans (n = 4069). Analyses examined the prevalence and correlates of homelessness, as well as the independent associations between homelessness and current probable psychiatric conditions, suicidality, and functioning. RESULTS The lifetime prevalence of homelessness was 10.2% (95% confidence interval 9.3-11.2). More than 8-of-10 veterans reported experiencing their first episode of homelessness following military service, with a mean of 10.6 years post-discharge until onset (s.d. = 12.6). Adverse childhood experiences (ACEs), cumulative trauma burden, current household income, younger age, and drug use disorder emerged as the strongest correlates of homelessness (49% of total explained variance). Veterans with a history of homelessness had elevated odds of lifetime suicide attempt, attempting suicide two or more times, and past-year suicide ideation [odd ratios (ORs) 1.3-3.1]. They also had higher rates of current probable posttraumatic stress disorder, major depressive, generalized anxiety, and drug use disorders (ORs 1.7-2.4); and scored lower on measures of mental, physical, cognitive, psychosocial functioning (d = 0.11-0.15). CONCLUSIONS One in ten U.S. veterans has experienced homelessness, and these veterans represent a subpopulation at substantially heightened risk for poor mental health and suicide. ACEs were the strongest factor associated with homelessness, thus underscoring the importance of targeting early childhood adversities and their mental health consequences in prevention efforts for homelessness in this population.
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Affiliation(s)
- Brandon Nichter
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
| | - Jack Tsai
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
- U.S. Department of Veterans Affairs, National Center on Homelessness Among Veterans, Tampa, FL, USA
- University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Robert H. Pietrzak
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
- U.S. Department of Veterans Affairs, National Center for Posttraumatic Stress Disorder, VA Connecticut Healthcare System, West Haven, CT, USA
- Department of Social and Behavioral Sciences, Yale School of Public Health, New Haven, CT, USA
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24
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Kamdar N, Khan S, Brostow DP, Spencer L, Roy S, Sisson A, Hundt NE. Association between modifiable social determinants and mental health among post-9/11 Veterans: A systematic review. JOURNAL OF MILITARY, VETERAN AND FAMILY HEALTH 2023; 9:8-26. [PMID: 37886122 PMCID: PMC10601397 DOI: 10.3138/jmvfh-2022-0025] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/28/2023]
Abstract
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.
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Affiliation(s)
- Nipa Kamdar
- Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, United States
| | - Sundas Khan
- Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, United States
| | - Diana P. Brostow
- Veterans Health Administration Rocky Mountain Mental Illness Research Education and Clinical Center, Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, Colorado, United States
| | - Lia Spencer
- Brandeis University, Waltham, Massachusetts, United States
| | - Sharmily Roy
- School of Public Health, University of Texas Health Science Center at Houston, Houston, Texas, United States
| | - Amy Sisson
- The Texas Medical Center Library, Houston, Texas, United States
| | - Natalie E. Hundt
- Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, Texas, United States
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25
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Rustagi AS, Byers AL, Brown JK, Purcell N, Slatore CG, Keyhani S. Lung Cancer Screening Among U.S. Military Veterans by Health Status and Race and Ethnicity, 2017-2020: A Cross-Sectional Population-Based Study. AJPM FOCUS 2023; 2:100084. [PMID: 37790642 PMCID: PMC10546514 DOI: 10.1016/j.focus.2023.100084] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/05/2023]
Abstract
Introduction Veterans are at high risk for lung cancer and are an important group for lung cancer screening. Previous research suggests that lung cancer screening may not be reaching healthier and/or non-White individuals, who stand to benefit most from lung cancer screening. We sought to test whether lung cancer screening is associated with poor health and/or race and ethnicity among veterans. Methods This cross-sectional, population-based study included veterans eligible for lung cancer screening (aged 55-79 years, ≥30 pack-year smoking history, current smokers or quit within 15 years, no previous lung cancer) in the 2017-2020 Behavioral Risk Factor Surveillance System surveys. Exposures were (1) poor health, defined as fair/poor health status and difficulty walking or climbing stairs, aligning with eligibility criteria for a pivotal lung cancer screening trial, and (2) race/ethnicity. The outcome was a receipt of lung cancer screening. All variables were self-reported. Results Of 3,376 lung cancer screening-eligible veterans representing an underlying population of 866,000 individuals, 20.3% (95% CI=17.3, 23.6) had poor health, and 13.7% (95% CI=10.6, 17.5) identified as non-White. Poor health was strongly associated with lung cancer screening (adjusted RR=1.64, 95% CI=1.06, 2.27); one third of veterans screened for lung cancer would not qualify for a pivotal lung cancer screening trial in terms of health. Marked racial disparities were observed among veterans: after adjustment, non-White veterans were 67% less likely to report lung cancer screening than White veterans (adjusted RR=0.33, 95% CI=0.11, 0.66). Conclusions Lung cancer screening is correlated with poorer health and White race/ethnicity among veterans, which may undermine its population-level effectiveness. These results highlight the need to promote lung cancer screening, especially for healthier and/or non-White veterans, an important group of Americans for lung cancer screening.
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Affiliation(s)
- Alison S. Rustagi
- Division of General Internal Medicine, Medical Service, San Francisco Veterans Affairs Health Care System, San Francisco, California
- Department of Medicine, University of California, San Francisco, California
| | - Amy L. Byers
- Department of Medicine, University of California, San Francisco, California
- Research Service, San Francisco Veterans Affairs Health Care System, San Francisco, California
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, California
- Weill Institute for Neurosciences, University of California, San Francisco, California
| | - James K. Brown
- Department of Medicine, University of California, San Francisco, California
- Division of Pulmonary, Critical Care, and Sleep Medicine, Medical Service, San Francisco Veterans Affairs Health Care System, San Francisco, California
| | - Natalie Purcell
- Integrative Health, San Francisco Veterans Affairs Health Care System, San Francisco, California
- Social Behavioral Health Sciences, School of Nursing, University of California, San Francisco, California
| | - Christopher G. Slatore
- National Center for Lung Cancer Screening, Veterans Health Administration, Washington, District of Columbia
- Division of Pulmonary and Critical Care Medicine, VA Portland Health Care System, Portland, Oregon
- Division of Pulmonary & Critical Care Medicine, Department of Medicine, Oregon Health & Science University School of Medicine, Portland, Oregon
| | - Salomeh Keyhani
- Division of General Internal Medicine, Medical Service, San Francisco Veterans Affairs Health Care System, San Francisco, California
- Department of Medicine, University of California, San Francisco, California
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26
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Capitulo K, Olender L. Voices of women veterans: My Life, My Story. Nursing 2023; 53:55-60. [PMID: 37074285 DOI: 10.1097/01.nurse.0000923660.93831.c4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/20/2023]
Abstract
PURPOSE To explore women veterans' experiences by writing short stories of their lives as part of a program, My Life, My Story (MLMS), and qualitatively analyzing the aggregate stories to identify themes, risks, and opportunities for changes in care. METHODS We interviewed women veterans receiving care and/or working at the James J. Peters VA Medical Center in the Bronx, N.Y. Women researchers experienced in the narrative storytelling model, MLMS, wrote participants' short stories. Twenty-two stories were written, aggregated, coded, and reviewed multiple times until saturation; no new themes emerged. The researchers established trustworthiness, consistency, and credibility. RESULTS Themes from data from the stories of women veterans included reasons for choosing a military career, military and postmilitary experiences, psychological and military sexual trauma (MST), access to mental health care and support, antiwomen/misogynistic perceptions, relationships, life after military service, experiences with VA care and services, and future goals. CONCLUSION Women veterans have very different military and postmilitary experiences from men. Given the increasing number of women veterans who experience homelessness, MST, and posttraumatic stress disorder, providers, the healthcare community, and the public need to hear the voices of women veterans, learn about their military experiences, and redesign women veterans' healthcare to better meet their unique needs by improving supportive mental and physical health care services.
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Affiliation(s)
- Kathleen Capitulo
- Kathleen Leask Capitulo is a professor at the Icahn School of Medicine at Mount Sinai and NYU Rory Myers College of Nursing in NYC, N.Y.; professor at Zhengzhou University in Zhengzhou, China; and executive director of the Transcultural Nursing Leadership Institute. She was chief nurse executive at James J. Peters VA, Bronx, N.Y. during this study. Lynda Olender is a distinguished faculty lecturer at Hunter-Bellevue School of Nursing at Hunter College in New York, N.Y. She served as a research and executive consultant at James J. Peters VA Medical Center
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27
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Hasin DS, Wall MM, Choi CJ, Alschuler DM, Malte C, Olfson M, Keyes KM, Gradus JL, Cerdá M, Maynard CC, Keyhani S, Martins SS, Fink DS, Livne O, Mannes Z, Sherman S, Saxon AJ. State Cannabis Legalization and Cannabis Use Disorder in the US Veterans Health Administration, 2005 to 2019. JAMA Psychiatry 2023; 80:380-388. [PMID: 36857036 PMCID: PMC9979011 DOI: 10.1001/jamapsychiatry.2023.0019] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 12/21/2022] [Indexed: 03/02/2023]
Abstract
Importance Cannabis use disorder (CUD) is increasing among US adults. Few national studies have addressed the role of medical cannabis laws (MCLs) and recreational cannabis laws (RCLs) in these increases, particularly in patient populations with high rates of CUD risk factors. Objective To quantify the role of MCL and RCL enactment in the increases in diagnosed CUD prevalence among Veterans Health Administration (VHA) patients from 2005 to 2019. Design, Setting, and Participants Staggered-adoption difference-in-difference analyses were used to estimate the role of MCL and RCL in the increases in prevalence of CUD diagnoses, fitting a linear binomial regression model with fixed effects for state, categorical year, time-varying cannabis law status, state-level sociodemographic covariates, and patient age group, sex, and race and ethnicity. Patients aged 18 to 75 years with 1 or more VHA primary care, emergency department, or mental health visit and no hospice/palliative care within a given calendar year were included. Time-varying yearly state control covariates were state/year rates from American Community Survey data: percentage male, Black, Hispanic, White, 18 years or older, unemployed, income below poverty threshold, and yearly median household income. Analysis took place between February to December 2022. Main Outcomes and Measures As preplanned, International Classification of Diseases, Clinical Modification, ninth and tenth revisions, CUD diagnoses from electronic health records were analyzed. Results The number of individuals analyzed ranged from 3 234 382 in 2005 to 4 579 994 in 2019. Patients were largely male (94.1% in 2005 and 89.0% in 2019) and White (75.0% in 2005 and 66.6% in 2019), with a mean (SD) age of 57.0 [14.4] years. From 2005 to 2019, adjusted CUD prevalences increased from 1.38% to 2.25% in states with no cannabis laws (no CLs), 1.38% to 2.54% in MCL-only enacting states, and 1.39% to 2.56% in RCL-enacting states. Difference-in-difference results indicated that MCL-only enactment was associated with a 0.05% (0.05-0.06) absolute increase in CUD prevalence, ie, that 4.7% of the total increase in CUD prevalence in MCL-only enacting states could be attributed to MCLs, while RCL enactment was associated with a 1.12% (95% CI, 0.10-0.13) absolute increase in CUD prevalence, ie, that 9.8% of the total increase in CUD prevalence in RCL-enacting states could be attributed to RCLs. The role of RCL in the increases in CUD prevalence was greatest in patients aged 65 to 75 years, with an absolute increase of 0.15% (95% CI, 0.13-0.17) in CUD prevalence associated with RCLs, ie, 18.6% of the total increase in CUD prevalence in that age group. Conclusions and Relevance In this study of VHA patients, MCL and RCL enactment played a significant role in the overall increases in CUD prevalence, particularly in older patients. However, consistent with general population studies, effect sizes were relatively small, suggesting that cumulatively, laws affected cannabis attitudes diffusely across the country or that other factors played a larger role in the overall increases in adult CUD. Results underscore the need to screen for cannabis use and CUD and to treat CUD when it is present.
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Affiliation(s)
- Deborah S. Hasin
- Columbia University and New York State Psychiatric Institute, New York
| | - Melanie M. Wall
- Columbia University and New York State Psychiatric Institute, New York
| | - C. Jean Choi
- Mental Health Data Science, New York State Psychiatric Institute, New York
| | | | - Carol Malte
- Health Services Research & Development (HSR&D) Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, Washington
- Center of Excellence in Substance Addiction Treatment and Education, VA Puget Sound Health Care System, Seattle, Washington
| | - Mark Olfson
- Columbia University and New York State Psychiatric Institute, New York
| | | | | | | | - Charles C. Maynard
- VA Puget Sound Health Care System and University of Washington, Seattle, Washington
| | - Salomeh Keyhani
- San Francisco VA Health System and University of California at San Francisco, San Francisco
| | | | | | | | | | - Scott Sherman
- VA Manhattan Harbor Healthcare and New York University, New York
| | - Andrew J. Saxon
- VA Puget Sound Health Care System and University of Washington, Seattle, Washington
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28
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Chang CJ, Fischer IC, Depp CA, Norman SB, Livingston NA, Pietrzak RH. A disproportionate burden: Prevalence of trauma and mental health difficulties among sexual minority versus heterosexual U.S. military veterans. J Psychiatr Res 2023; 161:477-482. [PMID: 37086703 DOI: 10.1016/j.jpsychires.2023.03.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 03/21/2023] [Accepted: 03/27/2023] [Indexed: 04/24/2023]
Abstract
This study examined sociodemographic, military, and trauma characteristics, and mental health concerns that differ by sexual orientation in a nationally representative sample of U.S. military veterans. Data were analyzed from 4069 veterans who participated in the National Health and Resilience Veterans Study (NHRVS). Compared with veterans who self-reported as heterosexual (n = 3,491, 94.7%), sexual minority veterans (n = 161, 5.3%) were more likely to be younger, women, Hispanic, unmarried/partnered, have lower household income, and to have enlisted in the military, and served for 4-9 years (relative to 3 or less or 10 or more). After adjusting for demographic variables, sexual minority veterans remained more likely to report childhood sexual abuse (odds ratio [OR] = 2.82), military sexual trauma (OR = 2.29), adverse childhood experiences (Cohen's d = 0.11), current and lifetime drug use disorder (ORs = 3.66 and 2.41, respectively), current alcohol use disorder (OR = 1.62), current and lifetime posttraumatic stress disorder (PTSD; ORs = 2.03 and 1.55, respectively), non-suicidal self-injury (NSSI; OR = 3.19), and future suicide intent (OR = 2.65). Among sexual minority veterans, more years of military service was associated with greater odds of lifetime PTSD, and lower annual household income with greater odds of lifetime drug use disorder and NSSI. Consistent with research in non-veterans, results suggest that sexual minority veterans experience greater trauma and mental health burden relative to their heterosexual peers. They further underscore the importance of interventions that prevent and mitigate adverse mental health outcomes in this population.
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Affiliation(s)
- Cindy J Chang
- VA San Diego Healthcare System, San Diego, CA, USA; Department of Psychiatry, University of California, San Diego, CA, USA.
| | - Ian C Fischer
- National Center for PTSD, VA Connecticut Healthcare System, West Haven, CT, USA; Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
| | - Colin A Depp
- VA San Diego Healthcare System, San Diego, CA, USA; Department of Psychiatry, University of California, San Diego, CA, USA
| | - Sonya B Norman
- VA San Diego Healthcare System, San Diego, CA, USA; Department of Psychiatry, University of California, San Diego, CA, USA; National Center for PTSD, White River Junction, VT, USA
| | - Nicholas A Livingston
- National Center for PTSD, Behavioral Science Division, VA Boston Healthcare System, Boston, MA, USA; Department of Psychiatry, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Robert H Pietrzak
- National Center for PTSD, VA Connecticut Healthcare System, West Haven, CT, USA; Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
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29
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Hahn H, Burkitt KH, Kauth MR, Shipherd JC, Blosnich JR. Primary sources of health care among LGBTQ+ veterans: Findings from the Behavioral Risk Factor Surveillance System. Health Serv Res 2023; 58:392-401. [PMID: 36331086 PMCID: PMC10012229 DOI: 10.1111/1475-6773.14096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVE This study examined the primary source of health care between veterans with lesbian, gay, bisexual, queer and similar identities (LGBTQ+) and non-LGBTQ+ veterans. DATA SOURCES AND STUDY SETTING Veterans (N = 20,497) from 17 states who completed the CDC's Behavioral Risk Factor Surveillance System from 2016 to 2020, including the Sexual Orientation and Gender Identity and Health Care Access modules. STUDY DESIGN We used survey-weighted multiple logistic regression to estimate average marginal effects of the prevalence of utilization of Veteran's Health Administration (VHA)/military health care reported between LGBTQ+ and non-LGBTQ+ veterans. Prevalence estimates were adjusted for age group, sex, race and ethnicity, marital status, educational attainment, employment status, survey year, and US state. DATA COLLECTION METHODS Study data were gathered via computer-assisted telephone interviews with probability-based samples of adults aged 18 and over. Data are publicly available. PRINCIPAL FINDINGS Overall, there was not a statistically significant difference in estimated adjusted prevalence of primary use of VHA/military health care between LGBTQ+ and non-LGBTQ+ veterans (20% vs. 23%, respectively, p = 0.13). When examined by age group, LGBTQ+ veterans aged 34 and younger were significantly less likely to report primary use of VHA/military health care compared to non-LGBTQ+ veterans (25% vs. 44%, respectively; p = 0.009). Similarly, in sex-stratified analyses, fewer female LGBTQ+ veterans than female non-LGBTQ+ veterans reported VHA/military health care as their primary source of care (13% vs. 29%, respectively, p = 0.003). Implications and limitations to these findings are discussed. CONCLUSIONS Female and younger LGBTQ+ veterans appear far less likely to use VHA/military for health care compared to their cisgender, heterosexual peers; however, because of small sample sizes, estimates may be imprecise. Future research should corroborate these findings and identify potential reasons for these disparities.
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Affiliation(s)
- Hunter Hahn
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA.,Department of Psychology, The Ohio State University, Columbus, Ohio, USA
| | - Kelly H Burkitt
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | - Michael R Kauth
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, HSR&D Center of Innovation, Houston, Texas, USA.,Lesbian, Gay, Bisexual, Transgender and Queer (LGBTQ+) Health Program, Office of Patient Care Services, Veterans Health Administration, Washington, DC, USA.,Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, Texas, USA
| | - Jillian C Shipherd
- Lesbian, Gay, Bisexual, Transgender and Queer (LGBTQ+) Health Program, Office of Patient Care Services, Veterans Health Administration, Washington, DC, USA.,Department of Psychiatry, Boston University School of Medicine, Boston, Massachusetts, USA.,National Center for PTSD, VA Boston Healthcare System, Boston, Massachusetts, USA
| | - John R Blosnich
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA.,Suzanne Dworak-Peck School of Social Work, University of Southern California, Los Angeles, California, USA
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30
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Semeah LM, Orozco T, Wang X, Ahonle ZJ, Cowper-Ripley D, Ganesh SP, Wilson LK, Litt ER, Ahern JK, Santos Roman LM, Varma DS, Lee MJ, Novak JR, Jia H. Rural and Urban Home Modification Program Users: A Comparative Study. HERD-HEALTH ENVIRONMENTS RESEARCH & DESIGN JOURNAL 2023; 16:223-235. [PMID: 36727246 DOI: 10.1177/19375867221142627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To understand the sociodemographic, geographical, and clinical characteristics of rural veterans utilizing home modification (HM) healthcare services under the Home Improvement Structural Alterations (HISA) program, to compare these characteristics between rural and urban veteran users, to estimate the costs of HMs performed, and to present distance that users traveled to HISA-prescribing medical facilities within the Veterans Health Administration (VHA). BACKGROUND Accessible housing is in short supply. HMs allow veterans with disabilities (VWDs) to remain living at home rather than enter institutional-type settings. HISA is associated with decreased inpatient hospitalization rates and increased use of preventative healthcare via outpatient clinic visits. Home accessibility provides psychological benefits improving social interactions and interaction with the physical environment. METHODS This retrospective database study analyzes data from the National Prosthetics Patient Database and other medical datasets within the VHA. RESULTS Results provide a profile of and comparison between rural and urban veteran users. HISA users are substantially older compared to younger VWDs. The frequency of bathroom, railing, and wooden ramp HMs differed significantly between rural and urban users (p values < .001). Rural users traveled more miles than urban users to reach a prescribing facility. CONCLUSIONS Older adults and individuals with disabilities have unmet housing needs since accessible housing is in short supply. This HM healthcare service is helping to meet the housing accessibility needs of older veterans, VWDs, older adults, and people with disabilities, in general.
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Affiliation(s)
- Luz M Semeah
- U.S. Department of Veterans Affairs, Washington, DC, USA
| | - Tatiana Orozco
- U.S. Department of Veterans Affairs, Washington, DC, USA
| | - Xinping Wang
- U.S. Department of Veterans Affairs, Washington, DC, USA
| | | | | | | | | | - Eric R Litt
- U.S. Department of Veterans Affairs, Washington, DC, USA
| | - Justin K Ahern
- U.S. Department of Veterans Affairs, Washington, DC, USA
| | | | - Deepthi Satheesa Varma
- University of Florida Department of Epidemiology and Health Policy Research, Gainesville, FL, USA
| | - Mi Jung Lee
- The University of Texas Medical Branch, Galveston, TX, USA
| | | | - Huanguang Jia
- U.S. Department of Veterans Affairs, Washington, DC, USA
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31
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Miller MB, Freeman LK, Aranda A, Shoemaker S, Sisk D, Rubi S, Everson AT, Flores LY, Williams MS, Dorimé-Williams ML, McCrae CS, Borsari B. Prevalence and correlates of alcohol-induced blackout in a diverse sample of veterans. ALCOHOL, CLINICAL & EXPERIMENTAL RESEARCH 2023; 47:395-405. [PMID: 36533546 PMCID: PMC9992316 DOI: 10.1111/acer.15002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 11/16/2022] [Accepted: 12/14/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND Alcohol-induced blackouts have been associated concurrently and prospectively with alcohol-related harm. Although rates of heavy drinking among military samples tend to be comparable or higher than rates among civilian samples, the prevalence and correlates of blackout in the military population are understudied. METHODS Veterans (N = 241, 29% female, 39% Black) reported on their alcohol consumption and mental health as part of a larger health-related study among veterans. In this secondary analysis, we tested theoretically and empirically informed predictors (gender, drinking quantity, and other drug use) and consequences [depression, posttraumatic stress disorder (PTSD)] of alcohol-induced blackout. Given the diversity of the sample, potential roles of racial/ethnic discrimination and drinking to cope in alcohol-induced blackout were also tested. RESULTS Past-year prevalence of alcohol-induced blackout was 53% among veterans who drank alcohol and 68% among those who screened positive for hazardous drinking. Everyday experience of racial discrimination was the strongest concurrent predictor of alcohol-induced blackout. Drinking quantity and use of other drugs were significant correlates only in bivariate models. Controlling for gender, race, drinking quantity, other drug use, and discrimination, blackout frequency was significantly associated with symptoms of depression, but not symptoms of PTSD. Both blackout and racial discrimination were associated with drinking to cope. CONCLUSIONS The prevalence and correlates of alcohol-induced blackout among veterans are largely consistent with those documented in civilian and young adult populations. Among racially diverse groups, racial discrimination may be more strongly associated with mental health symptoms than alcohol consumption or acute alcohol consequences such as blackout.
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Affiliation(s)
- Mary Beth Miller
- Department of Psychiatry, University of Missouri, School of Medicine, 1 Hospital Dr DC067.00, Columbia, MO 65212, USA
- Department of Psychological Sciences, University of Missouri, College of Arts & Sciences, 210 McAlester Hall, Columbia, MO 65211, USA
| | - Lindsey K. Freeman
- Department of Psychiatry, University of Missouri, School of Medicine, 1 Hospital Dr DC067.00, Columbia, MO 65212, USA
- Department of Psychological Sciences, University of Missouri, College of Arts & Sciences, 210 McAlester Hall, Columbia, MO 65211, USA
| | - Amaya Aranda
- Department of Psychiatry, University of Missouri, School of Medicine, 1 Hospital Dr DC067.00, Columbia, MO 65212, USA
- Department of Psychological Sciences, University of Missouri, College of Arts & Sciences, 210 McAlester Hall, Columbia, MO 65211, USA
| | - Sydney Shoemaker
- Department of Psychiatry, University of Missouri, School of Medicine, 1 Hospital Dr DC067.00, Columbia, MO 65212, USA
| | - Delaney Sisk
- Department of Psychiatry, University of Missouri, School of Medicine, 1 Hospital Dr DC067.00, Columbia, MO 65212, USA
| | - Sofia Rubi
- Department of Psychiatry, University of Missouri, School of Medicine, 1 Hospital Dr DC067.00, Columbia, MO 65212, USA
| | - Adam T. Everson
- Department of Psychiatry, University of Missouri, School of Medicine, 1 Hospital Dr DC067.00, Columbia, MO 65212, USA
| | - Lisa Y. Flores
- Department of Psychological Sciences, University of Missouri, College of Arts & Sciences, 210 McAlester Hall, Columbia, MO 65211, USA
| | - Michael S. Williams
- Department of Educational Leadership & Policy Analysis, University of Missouri, College of Education, 202 Hill Hall, Columbia, MO 65211, USA
| | - Marjorie L. Dorimé-Williams
- Department of Educational Leadership & Policy Analysis, University of Missouri, College of Education, 202 Hill Hall, Columbia, MO 65211, USA
| | | | - Brian Borsari
- Mental Health Service, San Francisco VA Health Care System, San Francisco, CA
- Department of Psychiatry and Behavioral Sciences, University of California San Francisco, San Francisco, CA
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32
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Mares JG, Lund BC, Adamowicz JL, Burgess DJ, Rothmiller SJ, Hadlandsmyth K. Differences in chronic pain care receipt among veterans from differing racialized groups and the impact of rural versus urban residence. J Rural Health 2023. [PMID: 36695646 DOI: 10.1111/jrh.12744] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
PURPOSE The current study aimed to identify differences in Veterans Affairs (VA) chronic pain care for Black, Asian, and Hispanic Americans, compared to non-Hispanic White Americans, and examine the intersection of race and rurality. METHODS Using national administrative data, all veterans who presented to the VA for chronic pain in 2018 were included. Demographic and comorbidity variables were built from 2018 data and health care utilization variables from 2019 data. Multivariate log-binomial regression models examined differences between racialized groups, and interactions with rural/urban residence, for each health care utilization variable. FINDINGS The full cohort included 2,135,216 veterans with chronic pain. There were no differences between racialized groups in pain-related primary care visits. Black Americans were less likely to receive pain clinic visits (aRR = 0.87, CI: 0.86-0.88). Rurality further decreased the likelihood of Black Americans visiting a pain clinic. Black, Hispanic, and Asian Americans were more likely to receive pain-related physical therapy visits relative to White Americans. Black and Hispanic Americans were more likely to present to emergency/urgent care for chronic pain. While there were no differences in pain-related primary care visits, the decreased likelihood of pain clinic visits and increased use of emergency department/urgent care among Black Americans could indicate inadequate management of chronic pain. CONCLUSIONS Tailored strategies are needed to provide equitable care that meets the needs of patients from racialized groups while accounting for systemic and cultural factors.
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Affiliation(s)
- Jasmine G Mares
- Office of Rural Health, Veterans Rural Resource Center, Iowa City VA Health Care System, Iowa City, Iowa, USA.,Department of Anesthesia, Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA
| | - Brian C Lund
- Office of Rural Health, Veterans Rural Resource Center, Iowa City VA Health Care System, Iowa City, Iowa, USA.,Center for Comprehensive Access and Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, Iowa, USA.,Department of Epidemiology, College of Public Health, University of Iowa, Iowa City, Iowa, USA
| | - Jenna L Adamowicz
- Office of Rural Health, Veterans Rural Resource Center, Iowa City VA Health Care System, Iowa City, Iowa, USA.,Department of Psychological & Brain Sciences, University of Iowa, Iowa City, Iowa, USA
| | - Diana J Burgess
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA.,Center for Care Delivery and Outcomes Research, Veterans Affairs Medical Center, Minneapolis, Minnesota, USA
| | - Shamira J Rothmiller
- Office of Rural Health, Veterans Rural Resource Center, Iowa City VA Health Care System, Iowa City, Iowa, USA.,Center for Comprehensive Access and Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, Iowa, USA.,Department of Counselor Education, University of Iowa, Iowa City, Iowa, USA
| | - Katherine Hadlandsmyth
- Office of Rural Health, Veterans Rural Resource Center, Iowa City VA Health Care System, Iowa City, Iowa, USA.,Department of Anesthesia, Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA.,Center for Comprehensive Access and Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, Iowa, USA
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Smolenski DJ, McDonald KL, Hoffmire CA, Britton PC, Carlson KF, Dobscha SK, Denneson LM. Informing measurement of gender differences in suicide risk and resilience: A national study of United States military veterans. J Clin Psychol 2023; 79:1371-1385. [PMID: 36680761 DOI: 10.1002/jclp.23485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Revised: 11/07/2022] [Accepted: 01/03/2023] [Indexed: 01/22/2023]
Abstract
OBJECTIVE To inform measure selection when examining gender differences in suicide risk, this paper evaluates measure performance for a set of gender-relevant constructs and examines gender differences in mean scores. METHODS A national sample of veterans (n = 968) who had recently attempted suicide (past 6 months) completed measures assessing life experience-, psychosocial-, and health-related constructs. A multigroup latent variable model was used to assess similarity of measurement properties between women and men. RESULTS Metric and scalar invariance indicated that the latent variables functioned similarly between women and men. Women had higher scores on negative coping, institutional betrayal, and social rejection; men had higher scores on self-compassion, autonomy, and suicide ideation. CONCLUSIONS Measurement properties and gender differences in mean values support the use of these measures for research on gender differences. Findings also suggest further investigation of social rejection, institutional betrayal, and negative coping among women veterans at risk for suicide.
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Affiliation(s)
- Derek J Smolenski
- Department of Defense, Defense Health Agency, Silver Spring, Maryland, USA
| | - Katie L McDonald
- HSR&D Center to Improve Veteran Involvement in Care (CIVIC), VA Portland Health Care System, Portland, Oregon, USA
| | - Claire A Hoffmire
- Rocky Mountain MIRECC, VA Eastern Colorado Health Care System, Aurora, Colorado, USA
| | - Peter C Britton
- VISN 2 Center of Excellence for Suicide Prevention, VA Finger Lakes Healthcare System, Canandaigua, New York, USA
| | - Kathleen F Carlson
- HSR&D Center to Improve Veteran Involvement in Care (CIVIC), VA Portland Health Care System, Portland, Oregon, USA.,School of Public Health, Oregon Health & Science University, Portland, Oregon, USA
| | - Steven K Dobscha
- HSR&D Center to Improve Veteran Involvement in Care (CIVIC), VA Portland Health Care System, Portland, Oregon, USA.,Department of Psychiatry, Oregon Health & Science University, Portland, Oregon, USA
| | - Lauren M Denneson
- HSR&D Center to Improve Veteran Involvement in Care (CIVIC), VA Portland Health Care System, Portland, Oregon, USA.,Department of Psychiatry, Oregon Health & Science University, Portland, Oregon, USA
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Tsai J, Kelton K. Service use and barriers to care among homeless veterans: Results from the National Veteran Homeless and Other Poverty Experiences (NV-HOPE) study. JOURNAL OF COMMUNITY PSYCHOLOGY 2023; 51:507-515. [PMID: 35748189 DOI: 10.1002/jcop.22912] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Revised: 05/22/2022] [Accepted: 06/09/2022] [Indexed: 06/15/2023]
Abstract
The objective of this study was to examine type of services U.S. veterans seek when they experience homelessness, characteristics associated with service use, and reasons for not using services. Data from a 2021 nationally representative survey of 1004 low-income U.S. veterans were analyzed with descriptive and multivariable analyses. One-quarter of low-income U.S. veterans with experiences of homelessness reported using homeless services while they were homeless and about 27% reported using U.S. Department of Veterans Affairs (VA) healthcare or benefits while homeless. Black and Hispanic veterans were more likely to use both homeless services and VA services while homeless than veterans of other race/ethnic groups. The most common barriers to services were: veterans felt they did not need help, they did not have information about services, there was stigma and shame, and transportation barriers were encountered. These findings suggest veterans use various VA and community-based homeless and healthcare services, but they do experience barriers that may be improved with better public information and care coordination to improve service uptake among homeless veterans.
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Affiliation(s)
- Jack Tsai
- U.S. Department of Veterans Affairs, National Center on Homelessness among Veterans, Tampa, Florida, USA
- Department of Management, Policy, and Community Health, School of Public Health, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Katherine Kelton
- U.S. Department of Veterans Affairs, National Center on Homelessness among Veterans, Tampa, Florida, USA
- Department of Management, Policy, and Community Health, School of Public Health, University of Texas Health Science Center at Houston, Houston, Texas, USA
- South Central Mental Illness Research Education and Clinical Center (MIRECC), Houston, TX, USA
- South Texas Veterans Health Care System, San Antonio Geriatric Research Education and Clinical Center (GRECC), San Antonio, TX, USA
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Taylor M, Pileggi W, Boland M, Boudreaux-Kelly M, Julian D, Beckstead A. A Perioperative Intervention to Prevent and Treat Emergence Delirium at a Veterans Affairs Medical Center. PATIENT SAFETY 2022. [DOI: 10.33940/med/2022.12.3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Emergence delirium (ED) is a temporary condition associated with a patient awakening from an anesthetic and/or adjunct agent (e.g., sedatives and analgesics). During the condition, patients risk harming themselves or staff by engaging in dangerous behavior, which may include thrashing, kicking, punching, and attempting to exit the bed/table.
A multidisciplinary team at Veterans Affairs Pittsburgh Healthcare System (VAPHS) developed and implemented a multicomponent intervention to reduce the severity and occurrence of ED. The intervention consists of a training component and 21 clinical components. The 21 clinical components are implemented on a patient-by-patient basis and include routine screening for risk factors, enhanced communication among staff, adjusting the environment, following a specific medication strategy, and application of manual restraint (hands-on). The authors provide 15 online Supplemental Materials (S1–S15) to promote replication of the intervention.
To our knowledge, this is the first manuscript that describes this type of multicomponent intervention in sufficient detail to allow others to replicate it. Following implementation of the intervention at VAPHS, perioperative staff reported that they observed a substantial reduction in the occurrence and severity of ED, ED-related patient and staff injuries, and ED-related loss of intravenous access and airway patency. Despite staff’s reported success of the intervention, rigorous research is needed to evaluate the efficacy of the intervention.
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Affiliation(s)
| | | | | | | | - David Julian
- VA Pittsburgh Healthcare System; University of Pittsburgh Medical Center Altoona
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Fink DS, Stohl M, Mannes ZL, Shmulewitz D, Wall M, Gutkind S, Olfson M, Gradus J, Keyhani S, Maynard C, Keyes KM, Sherman S, Martins S, Saxon AJ, Hasin DS. Comparing mental and physical health of U.S. veterans by VA healthcare use: implications for generalizability of research in the VA electronic health records. BMC Health Serv Res 2022; 22:1500. [PMID: 36494829 PMCID: PMC9733218 DOI: 10.1186/s12913-022-08899-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 11/28/2022] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE The Department of Veterans Affairs' (VA) electronic health records (EHR) offer a rich source of big data to study medical and health care questions, but patient eligibility and preferences may limit generalizability of findings. We therefore examined the representativeness of VA veterans by comparing veterans using VA healthcare services to those who do not. METHODS We analyzed data on 3051 veteran participants age ≥ 18 years in the 2019 National Health Interview Survey. Weighted logistic regression was used to model participant characteristics, health conditions, pain, and self-reported health by past year VA healthcare use and generate predicted marginal prevalences, which were used to calculate Cohen's d of group differences in absolute risk by past-year VA healthcare use. RESULTS Among veterans, 30.4% had past-year VA healthcare use. Veterans with lower income and members of racial/ethnic minority groups were more likely to report past-year VA healthcare use. Health conditions overrepresented in past-year VA healthcare users included chronic medical conditions (80.6% vs. 69.4%, d = 0.36), pain (78.9% vs. 65.9%; d = 0.35), mental distress (11.6% vs. 5.9%; d = 0.47), anxiety (10.8% vs. 4.1%; d = 0.67), and fair/poor self-reported health (27.9% vs. 18.0%; d = 0.40). CONCLUSIONS Heterogeneity in veteran sociodemographic and health characteristics was observed by past-year VA healthcare use. Researchers working with VA EHR data should consider how the patient selection process may relate to the exposures and outcomes under study. Statistical reweighting may be needed to generalize risk estimates from the VA EHR data to the overall veteran population.
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Affiliation(s)
- David S. Fink
- grid.413734.60000 0000 8499 1112New York State Psychiatric Institute, New York, NY USA
| | - Malka Stohl
- grid.413734.60000 0000 8499 1112New York State Psychiatric Institute, New York, NY USA
| | - Zachary L. Mannes
- grid.21729.3f0000000419368729Columbia University Mailman School of Public Health, New York, NY USA
| | - Dvora Shmulewitz
- grid.413734.60000 0000 8499 1112New York State Psychiatric Institute, New York, NY USA ,grid.21729.3f0000000419368729Columbia University Mailman School of Public Health, New York, NY USA
| | - Melanie Wall
- grid.413734.60000 0000 8499 1112New York State Psychiatric Institute, New York, NY USA ,grid.21729.3f0000000419368729Columbia University Mailman School of Public Health, New York, NY USA
| | - Sarah Gutkind
- grid.21729.3f0000000419368729Columbia University Mailman School of Public Health, New York, NY USA
| | - Mark Olfson
- grid.413734.60000 0000 8499 1112New York State Psychiatric Institute, New York, NY USA ,grid.21729.3f0000000419368729Columbia University Mailman School of Public Health, New York, NY USA
| | - Jaimie Gradus
- grid.189504.10000 0004 1936 7558Boston University School of Public Health, Boston, MA USA
| | - Salomeh Keyhani
- Veteran Affairs, San Francisco, VA USA ,grid.266102.10000 0001 2297 6811University of California, San Francisco, CA USA
| | - Charles Maynard
- grid.413919.70000 0004 0420 6540Veteran Affairs, Puget Sound Health Care System, Seattle, WA USA ,grid.34477.330000000122986657University of Washington, Seattle, WA USA
| | - Katherine M. Keyes
- grid.21729.3f0000000419368729Columbia University Mailman School of Public Health, New York, NY USA
| | - Scott Sherman
- grid.137628.90000 0004 1936 8753New York University, New York, NY USA
| | - Silvia Martins
- grid.21729.3f0000000419368729Columbia University Mailman School of Public Health, New York, NY USA
| | - Andrew J. Saxon
- grid.413919.70000 0004 0420 6540Veteran Affairs, Puget Sound Health Care System, Seattle, WA USA ,grid.34477.330000000122986657University of Washington, Seattle, WA USA
| | - Deborah S. Hasin
- grid.413734.60000 0000 8499 1112New York State Psychiatric Institute, New York, NY USA ,grid.21729.3f0000000419368729Columbia University Mailman School of Public Health, New York, NY USA ,grid.239585.00000 0001 2285 2675Department of Psychiatry, Columbia University Medical Center, 1051 Riverside Dr., Unit 123, New York, NY 10032 USA
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Guadagnoli L, Mashimo H, Lo WK. Assessment of Post-traumatic Stress Disorder Among Objective Esophageal Motility and Reflux Phenotypes in Symptomatic Veterans. J Clin Psychol Med Settings 2022:10.1007/s10880-022-09920-6. [PMID: 36378471 DOI: 10.1007/s10880-022-09920-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/21/2022] [Indexed: 11/16/2022]
Abstract
Prior research suggests post-traumatic stress disorder (PTSD) is associated with the development of esophageal symptoms. We aimed to evaluate the prevalence of PTSD in veterans with esophageal symptoms, and assess for differences in objective esophageal motility and reflux classifications. Consecutive veterans reporting esophageal symptoms (e.g., dysphagia and reflux) underwent clinical evaluation with standard reflux and motility testing. Relevant demographic, mental health, and clinical esophageal information was gathered. Patients were classified into "PTSD" and "Non-PTSD" groups based on the documentation of a clinician-confirmed diagnosis of PTSD in the medical chart. Of the 273 consecutive veterans (89% men, mean age: 62 years) that met inclusion criteria for the study, 34% had a clinician-confirmed diagnosis of PTSD. Differences existed between PTSD and non-PTSD groups on smoking, bipolar disorder, depression, ADHD, and opiate use. However, no differences existed in objectively determined motility or reflux phenotypes. While PTSD was highly prevalent among our sample of symptomatic veterans, the presence of PTSD was not associated with differences in motility classifications and reflux phenotypes. These findings are consistent with recent research in psychogastroenterology, which suggests psychological processes are important to consider across esophageal classifications.
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Cozier YC, Govender P, Berman JS. Obesity and Sarcoidosis Risk. Chest 2022; 162:954-956. [DOI: 10.1016/j.chest.2022.07.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 07/23/2022] [Indexed: 11/06/2022] Open
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Non-pharmacological Treatment for Chronic Pain in US Veterans Treated Within the Veterans Health Administration: Implications for Expansion in US Healthcare Systems. J Gen Intern Med 2022; 37:3937-3946. [PMID: 35048300 PMCID: PMC8769678 DOI: 10.1007/s11606-021-07370-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 12/16/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Consensus guidelines recommend multimodal chronic pain treatment with increased use of non-pharmacological treatment modalities (NPM), including as first-line therapies. However, with many barriers to NPM uptake in US healthcare systems, NPM use may vary across medical care settings. Military veterans are disproportionately affected by chronic pain. Many veterans receive treatment through the Veterans Health Administration (VHA), an integrated healthcare system in which specific policies promote NPM use. OBJECTIVE To examine whether veterans with chronic pain who utilize VHA healthcare were more likely to use NPM than veterans who do not utilize VHA healthcare. DESIGN Cross-sectional nationally representative study. PARTICIPANTS US military veterans (N = 2,836). MAIN MEASURES In the 2019 National Health Interview Survey, veterans were assessed for VHA treatment, chronic pain (i.e., past 3-month daily or almost daily pain), symptoms of depression and anxiety, substance use, and NPM (i.e., physical therapy, chiropractic/spinal manipulation, massage, psychotherapy, educational class/workshop, peer support groups, or yoga/tai chi). KEY RESULTS Chronic pain (45.2% vs. 26.8%) and NPM use (49.8% vs. 39.4%) were more prevalent among VHA patients than non-VHA veterans. After adjusting for sociodemographic characteristics, psychiatric symptoms, physical health indicators, and use of cigarettes or prescription opioids, VHA patients were more likely than non-VHA veterans to use any NPM (adjusted odds ratio [aOR] = 1.52, 95% CI: 1.07-2.16) and multimodal NPM (aOR = 1.80, 95% CI: 1.12-2.87) than no NPM. Among veterans with chronic pain, VHA patients were more likely to use chiropractic care (aOR = 1.90, 95% CI = 1.12-3.22), educational class/workshop (aOR = 3.02, 95% CI = 1.35-6.73), or psychotherapy (aOR = 4.28, 95% CI = 1.69-10.87). CONCLUSIONS Among veterans with chronic pain, past-year VHA use was associated with greater likelihood of receiving NPM. These findings may suggest that the VHA is an important resource and possible facilitator of NPM. VHA policies may offer guidance for expanding use of NPM in other integrated US healthcare systems.
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Hasin DS, Saxon AJ, Malte C, Olfson M, Keyes KM, Gradus JL, Cerdá M, Maynard CC, Keyhani S, Martins SS, Fink DS, Livne O, Mannes Z, Wall MM. Trends in Cannabis Use Disorder Diagnoses in the U.S. Veterans Health Administration, 2005-2019. Am J Psychiatry 2022; 179:748-757. [PMID: 35899381 PMCID: PMC9529770 DOI: 10.1176/appi.ajp.22010034] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVE In the United States, adult cannabis use has increased over time, but less information is available on time trends in cannabis use disorder. The authors used Veterans Health Administration (VHA) data to examine change over time in cannabis use disorder diagnoses among veterans, an important population subgroup, and whether such trends differ by age group (<35 years, 35-64 years, ≥65 years), sex, or race/ethnicity. METHODS VHA electronic health records from 2005 to 2019 (range of Ns per year, 4,403,027-5,797,240) were used to identify the percentage of VHA patients seen each year with a cannabis use disorder diagnosis (ICD-9-CM, January 1, 2005-September 30, 2015; ICD-10-CM, October 1, 2015-December 31, 2019). Trends in cannabis use disorder diagnoses were examined by age and by race/ethnicity and sex within age groups. Given the transition in ICD coding, differences in trends were tested within two periods: 2005-2014 (ICD-9-CM) and 2016-2019 (ICD-10-CM). RESULTS In 2005, the percentages of VHA patients diagnosed with cannabis use disorder in the <35, 35-64, and ≥65 year age groups were 1.70%, 1.59%, and 0.03%, respectively; by 2019, the percentages had increased to 4.84%, 2.86%, and 0.74%, respectively. Although the prevalence of cannabis use disorder was consistently higher among males than females, between 2016 and 2019, the prevalence increased more among females than males in the <35 year group. Black patients had a consistently higher prevalence of cannabis use disorder than other racial/ethnic groups, and increases were greater among Black than White patients in the <35 year group in both periods. CONCLUSIONS Since 2005, diagnoses of cannabis use disorder have increased substantially among VHA patients, as they have in the general population and other patient populations. Possible explanations warranting investigation include decreasing perception of risk, changing laws, increasing cannabis potency, stressors related to growing socioeconomic inequality, and use of cannabis to self-treat pain. Clinicians and the public should be educated about the increases in cannabis use disorder in general in the United States, including among patients treated at the VHA.
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Affiliation(s)
| | - Andrew J. Saxon
- VA Puget Sound Health Care System and University of Washington
| | | | - Mark Olfson
- Columbia University and New York State Psychiatric Institute
| | | | | | | | | | - Salomeh Keyhani
- San Francisco VA Health System and University of California at San Francisco
| | | | | | | | | | - Melanie M. Wall
- Columbia University and New York State Psychiatric Institute
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Thomas B, Thadani A, Chen PV, Christie IC, Kern LM, Rajan M, Kadiyala H, Helmer DA. Veterans’ ambulatory care experience during COVID-19: veterans’ access to and satisfaction with primary care early in the pandemic. BMC PRIMARY CARE 2022; 23:245. [PMID: 36131246 PMCID: PMC9491256 DOI: 10.1186/s12875-022-01851-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 09/11/2022] [Indexed: 11/10/2022]
Abstract
Background The COVID-19 pandemic caused widespread changes to healthcare, but few studies focus on ambulatory care during the early phase of the pandemic. We characterize veterans’ ambulatory care experience, specifically access and satisfaction, early in the pandemic. Methods We employed a semi-structured telephone interview to capture quantitative and qualitative data from patients scheduled with a primary care provider between March 1 – June 30, 2020. Forty veterans were randomly identified at a single large urban Veterans Health Administration (VHA) medical center. The interview guide utilized 56 closed and open-ended questions to characterize veterans’ perceptions of access to and satisfaction with their primary care experience at VHA and non-VHA primary care sources. We also explored the context of veterans' daily lives during the pandemic. We analyzed quantitative data using descriptive statistics and verbatim quotes using a matrix analysis. Results Veterans reported completing more appointments (mean 2.6 (SD 2.2)) than scheduled (mean 2.3 (SD 2.2)) mostly due to same-day or urgent visits, with a shift to telephone (mean 2.1 (SD 2.2)) and video (mean 1.5 (SD 0.6)). Among those who reported decreased access to care early in the pandemic (n = 27 (67%)), 15 (56%) cited administrative barriers (“The phone would hang up on me”) and 9 (33%) reported a lack of provider availability (“They are not reaching out like they used to”). While most veterans (n = 31 (78%)) were highly satisfied with their VHA care (mean score 8.6 (SD 2.0 on a 0–10 scale), 9 (23%) reported a decrease in satisfaction since the pandemic. The six (15%) veterans who utilized non-VHA providers during the period of interest reported, on average, higher satisfaction ratings (mean 9.5 (SD 1.2)). Many veterans reported psychosocial effects such as the worsening of mental health (n = 6 (15%)), anxiety concerning the virus (n = 12 (30%)), and social isolation (n = 8 (20%), “I stay inside and away from people”). Conclusions While the number of encounters reported suggest adequate access and satisfaction, the comments regarding barriers to care suggest that enhanced approaches may be warranted to improve and sustain veteran perceptions of adequate access to and satisfaction with primary care during times of crisis. Supplementary Information The online version contains supplementary material available at 10.1186/s12875-022-01851-3.
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Cucciare MA, Abraham TH, Kemp L, White P, Marchant K, Hagedorn HJ, Humphreys K. Adapting the Eliminating Medications Through Patient Ownership of End Results Protocol to Promote Benzodiazepine Cessation Among US Military Veterans: Focus Group Study With US Military Veterans and National Veterans Health Administration Leaders. J Med Internet Res 2022; 24:e35514. [PMID: 36121697 PMCID: PMC9531005 DOI: 10.2196/35514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 07/21/2022] [Accepted: 08/10/2022] [Indexed: 11/13/2022] Open
Abstract
Background Long-term dependence on prescribed benzodiazepines is a public health problem. Eliminating Medications Through Patient Ownership of End Results (EMPOWER) is a promising self-management intervention, delivered directly to patients as a printed booklet, that is effective in promoting benzodiazepine reduction and cessation in older adults. EMPOWER has high potential to benefit large health care systems such as the US Veterans Health Administration (VHA), which cares for many veterans who use benzodiazepines for extended periods. Objective We aimed to adapt the original EMPOWER booklet materials for electronic delivery and for use among US military veterans receiving VHA care who were long-term benzodiazepine users. Methods We used elements of Analysis, Design, Development, Implementation, and Evaluation, a framework commonly used in the field of instructional design, to guide a qualitative approach to iteratively adapting EMPOWER Electronic Delivery (EMPOWER-ED). We conducted 3 waves of focus groups with the same 2 groups of VHA stakeholders. Stakeholders were VHA-enrolled veterans (n=16) with medical chart evidence of long-term benzodiazepine use and national VHA leaders (n=7) with expertise in setting VHA policy for prescription benzodiazepine use and developing electronically delivered educational tools for veterans. Qualitative data collected from each wave of focus groups were analyzed using template analysis. Results Themes that emerged from the initial focus groups included veterans’ anxiety about self-tapering from benzodiazepines and prior negative experiences attempting to self-taper without support. Participants also provided feedback on the protocol’s look and feel, educational content, the tapering protocol, and website functionality; for example, feedback from policy leaders included listing, on the cover page, the most commonly prescribed benzodiazepines to ensure that veterans were aware of medications that qualify for self-taper using the EMPOWER-ED protocol. Both groups of stakeholders identified the importance of having access to supportive resources to help veterans manage sleep and anxiety in the absence of taking benzodiazepines. Both groups also emphasized the importance of ensuring that the self-taper could be personalized and that the taper instructions were clear. The policy leaders emphasized the importance of encouraging veterans to notify their provider of their decision to self-taper to help facilitate provider assistance, if needed, with the taper process and to help prevent medication stockpiling. Conclusions EMPOWER-ED is the first direct-to-patient electronically delivered protocol designed to help US military veterans self-taper from long-term benzodiazepine use. We used the Analysis, Design, Development, Implementation, and Evaluation framework to guide the successful adaption of the original EMPOWER booklet for use with this population and for electronic delivery. The next step in this line of research is to evaluate EMPOWER-ED in a randomized controlled trial.
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Affiliation(s)
- Michael A Cucciare
- Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Affairs Healthcare System, North Little Rock, AR, United States.,Veterans Affairs South Central Mental Illness Research, Education and Clinical Center, Central Arkansas Veterans Healthcare System, North Little Rock, AR, United States.,Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR, United States
| | - Traci H Abraham
- Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Affairs Healthcare System, North Little Rock, AR, United States.,Veterans Affairs South Central Mental Illness Research, Education and Clinical Center, Central Arkansas Veterans Healthcare System, North Little Rock, AR, United States.,Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR, United States
| | - Lakiesha Kemp
- Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Affairs Healthcare System, North Little Rock, AR, United States
| | - Penny White
- Veterans Affairs South Central Mental Illness Research, Education and Clinical Center, Central Arkansas Veterans Healthcare System, North Little Rock, AR, United States
| | - Kathy Marchant
- Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Affairs Healthcare System, North Little Rock, AR, United States
| | - Hildi J Hagedorn
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, United States.,Department of Psychiatry, University of Minnesota Medical School, Minneapolis, MN, United States
| | - Keith Humphreys
- Center for Innovation to Implementation, Veterans Affairs Palo Alto Health Care System, Menlo Park, CA, United States.,Department of Psychiatry, Stanford University, Menlo Park, CA, United States
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Gray KE, Rao M, Gunnink E, Eschenroeder L, Geyer JR, Nelson KM, Reddy A. Home Telehealth in the Veterans Health Administration: Trends and Correlates of Length of Enrollment from 2010 to 2017. J Gen Intern Med 2022; 37:3089-3096. [PMID: 35230624 PMCID: PMC8886698 DOI: 10.1007/s11606-022-07452-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 02/03/2022] [Indexed: 10/26/2022]
Abstract
BACKGROUND Home telehealth (HT) programs enable communication and remote monitoring of patient health data between clinician visits, with the goal of improving chronic disease self-management and outcomes. The Veterans Health Administration (VHA) established one of the earliest HT programs in the country in 2003; however, little is known about how these services have been utilized and expanded over the last decade. OBJECTIVE To describe trends in use of VHA's HT program from 2010 through 2017 and correlates of length of enrollment in HT services. DESIGN Retrospective observational cohort study. PARTICIPANTS Patients enrolled in HT between January 1, 2010 and December 31, 2017. MAIN MEASURES We described the number and characteristics of patients enrolled in HT, including the chronic conditions managed. We also identified length of HT enrollment and examined patient and facility characteristics associated with longer enrollment. KEY RESULTS The total number of patients enrolled in HT was 402,263. At time of enrollment, half were >65 years old, 91% were male, and 59.3% lived in urban residences. The most common conditions addressed by HT were hypertension (28.8%), obesity (23.9%), and diabetes (17.0%). The median time to disenrollment in HT was 261 days (8.6 months) but varied by chronic condition. In a multivariable Cox proportional hazards model, covariates associated with higher likelihood of staying enrolled were older age, male gender, non-Hispanic Black race/ethnicity, lower neighborhood socioeconomic status, living in a more rural setting, and a greater burden of comorbidities per the Gagne index. CONCLUSIONS Across 8 years, over 400,000 veterans engaged in HT services for chronic disease management and over half remained in the program for longer than 8 months. Our work provides a real-world evaluation of HT service expansion in the VHA. Additional studies are necessary to identify optimal enrollment duration and patients most likely to benefit from HT services.
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Affiliation(s)
- Kristen E Gray
- Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, USA.,Department of Health Systems and Population Health, School of Public Health, University of Washington, Seattle, WA, USA
| | - Mayuree Rao
- Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, USA. .,General Medicine Service, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA, USA. .,Department of Medicine, School of Medicine, University of Washington, Seattle, WA, USA.
| | - Eric Gunnink
- Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, USA
| | - Lee Eschenroeder
- Department of Medicine, School of Medicine, University of Washington, Seattle, WA, USA
| | - John R Geyer
- General Medicine Service, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA, USA.,Department of Medicine, School of Medicine, University of Washington, Seattle, WA, USA
| | - Karin M Nelson
- Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, USA.,Department of Health Systems and Population Health, School of Public Health, University of Washington, Seattle, WA, USA.,General Medicine Service, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA, USA.,Department of Medicine, School of Medicine, University of Washington, Seattle, WA, USA
| | - Ashok Reddy
- Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, USA.,Department of Health Systems and Population Health, School of Public Health, University of Washington, Seattle, WA, USA.,General Medicine Service, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA, USA.,Department of Medicine, School of Medicine, University of Washington, Seattle, WA, USA
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Feeney M, Duda J, Hiller A, Phillips J, Evers C, Yarab N, Todaro V, Rader L, Rosenfeld S. Understanding health care needs among Veterans with Parkinson's disease: A survey study. Front Neurol 2022; 13:924999. [PMID: 36034294 PMCID: PMC9405651 DOI: 10.3389/fneur.2022.924999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 07/15/2022] [Indexed: 12/03/2022] Open
Abstract
Among Veterans, it is estimated that 110,000 are living with Parkinson's disease (PD) in the United States. Whether or not Veterans living with PD are enrolled in the Veterans Health Administration (VHA), they may require special considerations when it comes to their care. We administered a survey to Parkinson's Foundation constituents with PD who had previously reported their Veteran status. Our goal was to identify areas where intervention can lead to improved health outcomes for Veterans living with Parkinson's disease. We specifically wanted to examine 1) the proportion of our Veteran constituents receiving services through the VHA, 2) the comprehensive care services that were utilized by Veterans living with PD, and 3) self-reported mental health and mobility status. We also wanted to compare those receiving care within and outside the VHA to see where there may be areas for improvement. With a response rate of 29.8% we received surveys from 409 United States Veterans with PD. As expected, mental health (MH) concerns in the previous 12 months were common with 36.0% of Veterans reporting concerns. Only 22.1% of respondents received care through VHA. Respondents with more falls and mental health concerns as well as those with higher levels of education and younger age were more likely to be seen at a VHA facility. In this sample, education level, household income, marital status, and VHA status were positively associated with increased health care utilization among Veterans. Those seen within the VHA were more likely to utilize MH and speech and language pathology consultation. This study highlights the importance of targeting educational outreach about care best practices for Veterans living with PD beyond VHA's current reach as well as the importance of access to good MH resources.
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Affiliation(s)
- Megan Feeney
- Parkinson's Foundation, New York, NY, United States
| | - John Duda
- Parkinson's Disease Research, Education and Clinical Center of the Michael J. Crescenz VA Medical Center, Department of Neurology of the University of Pennsylvania, Philadelphia, PA, United States
| | - Amie Hiller
- Department of Neurology, School of Medicine, Oregon Health and Science University, Portland, OR, United States
- Department of Neurology, VA Portland Health Care System, Portland, OR, United States
| | - Jay Phillips
- Parkinson's Foundation, New York, NY, United States
| | | | - Nicole Yarab
- Parkinson's Foundation, New York, NY, United States
| | | | - Lydia Rader
- Parkinson's Foundation, New York, NY, United States
| | - Sheera Rosenfeld
- Parkinson's Foundation, New York, NY, United States
- *Correspondence: Sheera Rosenfeld
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45
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Hill ML, Loflin M, Nichter B, Na PJ, Herzog S, Norman SB, Pietrzak RH. Cannabis use among U.S. military veterans with subthreshold or threshold posttraumatic stress disorder: Psychiatric comorbidities, functioning, and strategies for coping with posttraumatic stress symptoms. J Trauma Stress 2022; 35:1154-1166. [PMID: 35275431 DOI: 10.1002/jts.22823] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 12/27/2021] [Accepted: 01/19/2022] [Indexed: 11/07/2022]
Abstract
Cannabis use is common among individuals with posttraumatic stress disorder (PTSD) symptoms, but its impact on psychiatric symptoms and functioning in this population is unclear. To clarify the clinical and functional correlates of cannabis use in individuals with PTSD symptoms, we analyzed data from the 2019-2020 National Health and Resilience in Veterans Study, a nationally representative survey of U.S. military veterans. Participants with current subthreshold or full PTSD (N = 608) reported on their past-6-month cannabis use and current psychiatric symptoms, functioning, treatment utilization, and PTSD symptom management strategies. Veterans with subthreshold/full PTSD who used cannabis more than weekly were more likely to screen positive for co-occurring depression, anxiety, and suicidal ideation than those who did not use cannabis, ORs = 3.4-3.8, or used cannabis less than weekly, ORs = 2.7-3.7. Veterans who used cannabis more than weekly also scored lower in cognitive functioning than veterans with no use, d = 0.25, or infrequent use, d = 0.71, and were substantially more likely to endorse avoidance coping strategies, ORs = 8.2-12.2, including substance use, OR = 4.4, and behavioral disengagement, ORs = 2.7-9.1, to manage PTSD symptoms. Despite more psychiatric and functional problems, veterans with frequent cannabis use were not more likely to engage in mental health treatment, ORs = 0.87-0.99. The results suggest enhanced cannabis use screening, interventions targeting risky use, and strategies promoting treatment engagement may help ameliorate more severe clinical presentations associated with frequent cannabis use among veterans with subthreshold/full PTSD.
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Affiliation(s)
- Melanie L Hill
- Department of Psychiatry, University of California, San Diego, California, USA.,VA San Diego Healthcare System, San Diego, California, USA
| | - Mallory Loflin
- Department of Psychiatry, University of California, San Diego, California, USA
| | - Brandon Nichter
- Department of Psychiatry, University of California, San Diego, California, USA
| | - Peter J Na
- Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut, USA.,VA Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Sarah Herzog
- Department of Psychiatry, Columbia University Irving Medical Center, Columbia University, New York, New York, USA.,Division of Molecular Imaging and Neuropathology, New York State Psychiatric Institute, New York, New York, USA
| | - Sonya B Norman
- Department of Psychiatry, University of California, San Diego, California, USA.,VA San Diego Healthcare System, San Diego, California, USA.,National Center for PTSD, White River Junction, Vermont, USA.,VA Center of Excellence for Stress and Mental Health, San Diego, California, USA
| | - Robert H Pietrzak
- Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut, USA.,National Center for PTSD, VA Connecticut Healthcare System, West Haven, Connecticut, USA.,Department of Social and Behavioral Sciences, Yale School of Public Health, New Haven, Connecticut, USA
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46
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Nichter B, Holliday R, Monteith LL, Na PJ, Hill ML, Kline AC, Norman SB, Pietrzak RH. Military sexual trauma in the United States: Results from a population-based study. J Affect Disord 2022; 306:19-27. [PMID: 35301038 DOI: 10.1016/j.jad.2022.03.016] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 03/08/2022] [Accepted: 03/10/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND The reported prevalence of military sexual trauma (MST) has increased over the past decades in the United States, yet scarce population-based studies have examined the prevalence, correlates, and health burden of MST in the general veteran population. METHODS Data were from the 2019-2020 National Health and Resilience in Veterans Study, a population-based survey of veterans (n = 4069). ANALYSES (1) estimated the prevalence of MST; (2) identified sex-stratified sociodemographic, military, and trauma characteristics associated with MST; and (3) examined sex-stratified associations between MST and psychiatric comorbidities, functioning, disability, and treatment utilization. RESULTS Female veterans reported substantially higher rates of MST (44.2%) than male veterans (3.5%). Relative to male veterans without MST histories, male veterans with MST histories had nearly 3-fold increased odds of reporting future suicidal intent, 2-to-3-fold greater odds of screening positive for current posttraumatic stress disorder (PTSD), depression, and generalized anxiety disorder; and nearly 2-fold increased odds of being disabled. Male veterans with MST histories also scored lower on mental, physical, cognitive, and psychosocial functioning (d's = 0.16-0.29). Relative to female veterans without MST histories, female veterans with MST histories had 5-fold greater odds of current PTSD, 2-fold greater odds of engaging in mental health treatment, and scored lower on psychosocial functioning and higher on somatic symptoms (both d's = 0.25). LIMITATIONS Cross-sectional design precludes causal inference. CONCLUSIONS A substantial proportion of veterans in the U.S. experience sexual trauma during their military service, and these experiences are associated with an elevated health burden.
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Affiliation(s)
- Brandon Nichter
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA.
| | - Ryan Holliday
- VA Rocky Mountain Mental Illness Research, Education and Clinical Center for Veteran Suicide Prevention, Aurora, CO, USA; Department of Psychiatry, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Lindsey L Monteith
- VA Rocky Mountain Mental Illness Research, Education and Clinical Center for Veteran Suicide Prevention, Aurora, CO, USA; Department of Psychiatry, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Peter J Na
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA; VA Connecticut Healthcare System, West Haven, CT, USA
| | - Melanie L Hill
- Department of Psychiatry, University of California San Diego, La Jolla, CA, USA; VA San Diego Healthcare System, San Diego, CA, USA
| | - Alexander C Kline
- Department of Psychiatry, University of California San Diego, La Jolla, CA, USA; VA San Diego Healthcare System, San Diego, CA, USA
| | - Sonya B Norman
- Department of Psychiatry, University of California San Diego, La Jolla, CA, USA; National Center for PTSD, White River Junction, VT, USA; VA Center of Excellence for Stress and Mental Health, San Diego, CA, USA
| | - Robert H Pietrzak
- National Center for PTSD, VA Connecticut Healthcare System, West Haven, CT, USA; Social and Behavioral Sciences, Yale School of Public Health, New Haven, CT, USA
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47
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Kline AC, Panza KE, Nichter B, Tsai J, Harpaz-Rotem I, Norman SB, Pietrzak RH. Mental Health Care Use Among U.S. Military Veterans: Results From the 2019-2020 National Health and Resilience in Veterans Study. Psychiatr Serv 2022; 73:628-635. [PMID: 34775790 DOI: 10.1176/appi.ps.202100112] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Psychiatric and substance use disorders are prevalent among U.S. military veterans, yet many veterans do not engage in treatment. The authors examined characteristics associated with use of mental health care in a nationally representative veteran sample. METHODS Using 2019-2020 data from the National Health and Resilience in Veterans Study (N=4,069), the authors examined predisposing, enabling, and need factors and perceived barriers to care as correlates of mental health care utilization (psychotherapy, counseling, or pharmacotherapy). Hierarchical logistic regression and relative importance analyses were used. RESULTS Among all veterans, 433 (weighted prevalence, 12%) reported current use of mental health care. Among 924 (26%) veterans with a probable mental or substance use disorder, less than a third (weighted prevalence, 27%) reported care utilization. Mental dysfunction (24%), posttraumatic stress disorder symptom severity (18%), using the U.S. Department of Veterans Affairs as primary health care provider (14%), sleep disorder (12%), and grit (i.e., trait perseverance including decision and commitment to address one's needs on one's own; 7%) explained most of the variance in mental health care utilization in this subsample. Grit moderated the relationship between mental dysfunction and use of care; among veterans with high mental dysfunction, those with high grit (23%) were less likely to use services than were those with low grit (53%). CONCLUSIONS A minority of U.S. veterans engaged in mental health care. Less stigmatized need factors (e.g., functioning and sleep difficulties) may facilitate engagement. The relationship between protective and need factors may help inform understanding of veterans' decision making regarding treatment seeking and outreach efforts.
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Affiliation(s)
- Alexander C Kline
- U.S. Department of Veterans Affairs (VA) San Diego Healthcare System, San Diego (Kline, Panza); Department of Psychiatry, University of California, San Diego (Kline, Panza, Nichter, Norman); National Center on Homelessness Among Veterans, VA Central Office, Washington, D.C. (Tsai); School of Public Health, University of Texas Health Science Center at Houston, Houston (Tsai); VA National Center for Posttraumatic Stress Disorder, West Haven, Connecticut (Harpaz-Rotem, Pietrzak), and White River Junction, Vermont (Norman); Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut (Harpaz-Rotem, Pietrzak)
| | - Kaitlyn E Panza
- U.S. Department of Veterans Affairs (VA) San Diego Healthcare System, San Diego (Kline, Panza); Department of Psychiatry, University of California, San Diego (Kline, Panza, Nichter, Norman); National Center on Homelessness Among Veterans, VA Central Office, Washington, D.C. (Tsai); School of Public Health, University of Texas Health Science Center at Houston, Houston (Tsai); VA National Center for Posttraumatic Stress Disorder, West Haven, Connecticut (Harpaz-Rotem, Pietrzak), and White River Junction, Vermont (Norman); Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut (Harpaz-Rotem, Pietrzak)
| | - Brandon Nichter
- U.S. Department of Veterans Affairs (VA) San Diego Healthcare System, San Diego (Kline, Panza); Department of Psychiatry, University of California, San Diego (Kline, Panza, Nichter, Norman); National Center on Homelessness Among Veterans, VA Central Office, Washington, D.C. (Tsai); School of Public Health, University of Texas Health Science Center at Houston, Houston (Tsai); VA National Center for Posttraumatic Stress Disorder, West Haven, Connecticut (Harpaz-Rotem, Pietrzak), and White River Junction, Vermont (Norman); Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut (Harpaz-Rotem, Pietrzak)
| | - Jack Tsai
- U.S. Department of Veterans Affairs (VA) San Diego Healthcare System, San Diego (Kline, Panza); Department of Psychiatry, University of California, San Diego (Kline, Panza, Nichter, Norman); National Center on Homelessness Among Veterans, VA Central Office, Washington, D.C. (Tsai); School of Public Health, University of Texas Health Science Center at Houston, Houston (Tsai); VA National Center for Posttraumatic Stress Disorder, West Haven, Connecticut (Harpaz-Rotem, Pietrzak), and White River Junction, Vermont (Norman); Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut (Harpaz-Rotem, Pietrzak)
| | - Ilan Harpaz-Rotem
- U.S. Department of Veterans Affairs (VA) San Diego Healthcare System, San Diego (Kline, Panza); Department of Psychiatry, University of California, San Diego (Kline, Panza, Nichter, Norman); National Center on Homelessness Among Veterans, VA Central Office, Washington, D.C. (Tsai); School of Public Health, University of Texas Health Science Center at Houston, Houston (Tsai); VA National Center for Posttraumatic Stress Disorder, West Haven, Connecticut (Harpaz-Rotem, Pietrzak), and White River Junction, Vermont (Norman); Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut (Harpaz-Rotem, Pietrzak)
| | - Sonya B Norman
- U.S. Department of Veterans Affairs (VA) San Diego Healthcare System, San Diego (Kline, Panza); Department of Psychiatry, University of California, San Diego (Kline, Panza, Nichter, Norman); National Center on Homelessness Among Veterans, VA Central Office, Washington, D.C. (Tsai); School of Public Health, University of Texas Health Science Center at Houston, Houston (Tsai); VA National Center for Posttraumatic Stress Disorder, West Haven, Connecticut (Harpaz-Rotem, Pietrzak), and White River Junction, Vermont (Norman); Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut (Harpaz-Rotem, Pietrzak)
| | - Robert H Pietrzak
- U.S. Department of Veterans Affairs (VA) San Diego Healthcare System, San Diego (Kline, Panza); Department of Psychiatry, University of California, San Diego (Kline, Panza, Nichter, Norman); National Center on Homelessness Among Veterans, VA Central Office, Washington, D.C. (Tsai); School of Public Health, University of Texas Health Science Center at Houston, Houston (Tsai); VA National Center for Posttraumatic Stress Disorder, West Haven, Connecticut (Harpaz-Rotem, Pietrzak), and White River Junction, Vermont (Norman); Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut (Harpaz-Rotem, Pietrzak)
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48
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Edwards ER, Tran H, Wrobleski J, Rabhan Y, Yin J, Chiodi C, Goodman M, Geraci J. Prevalence of Personality Disorders Across Veteran Samples: A Meta-Analysis. J Pers Disord 2022; 36:339-358. [PMID: 35647770 DOI: 10.1521/pedi.2022.36.3.339] [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: 11/20/2022]
Abstract
Despite priorities around mental health, Veteran health care organizations have historically considered personality disorders to be preexisting conditions ineligible for disability benefits. However, growing evidence suggests potentially elevated prevalence of these disorders among military and Veteran samples and attests to implications of risk. The current study provides a meta-analytic review of literature on the prevalence of personality disorders in Veteran samples. Analysis of 27 unique samples, comprising 7,161 Veterans, suggests alarmingly high rates of Veteran personality disorders. Prevalence was highest for paranoid (23%) and borderline (21%) personality disorders and lowest for histrionic (0.8%) personality disorder. Rates were generally highest among Veterans experiencing substance use or elevated suicide risk and among studies establishing diagnoses through clinical interview (versus official medical record review). Results attest to the need for Veteran health care organizations to acknowledge personality disorders in this population, through both research and treatment, and to consider reclassifying personality disorders as potential "service-connected conditions."
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Affiliation(s)
- Emily R Edwards
- VISN 2 MIRECC, James J. Peters VA Medical Center, Bronx, New York
| | - Hannah Tran
- Teachers College, Columbia University, New York, New York
| | - Joseph Wrobleski
- VISN 2 MIRECC, James J. Peters VA Medical Center, Bronx, New York.,Teachers College, Columbia University, New York, New York
| | | | - Justin Yin
- Teachers College, Columbia University, New York, New York
| | | | - Marianne Goodman
- VISN 2 MIRECC, James J. Peters VA Medical Center, Bronx, New York
| | - Joseph Geraci
- VISN 2 MIRECC, James J. Peters VA Medical Center, Bronx, New York.,Teachers College, Columbia University, New York, New York
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Mavragani A, Chhatre S, Prigge JM, Meline J, Kaminstein D, Rodriguez KL, Fraenkel L, Kravetz JD, Whittle J, Bastian LA, Vachani A, Akers S, Schrand S, Ibarra JV, Asan O. A Veteran-Centric Web-Based Decision Aid for Lung Cancer Screening: Usability Analysis. JMIR Form Res 2022; 6:e29039. [PMID: 35394433 PMCID: PMC9034418 DOI: 10.2196/29039] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 11/12/2021] [Accepted: 12/17/2021] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Web-based tools developed to facilitate a shared decision-making (SDM) process may facilitate the implementation of lung cancer screening (LCS), an evidence-based intervention to improve cancer outcomes. Veterans have specific risk factors and shared experiences that affect the benefits and potential harms of LCS and thus may value a veteran-centric LCS decision tool (LCSDecTool). OBJECTIVE This study aims to conduct usability testing of an LCSDecTool designed for veterans receiving care at a Veteran Affairs medical center. METHODS Usability testing of the LCSDecTool was conducted in a prototype version (phase 1) and a high-fidelity version (phase 2). A total of 18 veterans and 8 clinicians participated in phase 1, and 43 veterans participated in phase 2. Quantitative outcomes from the users included the System Usability Scale (SUS) and the End User Computing Satisfaction (EUCS) in phase 1 and the SUS, EUCS, and Patient Engagement scale in phase 2. Qualitative data were obtained from observations of user sessions and brief interviews. The results of phase 1 informed the modifications of the prototype for the high-fidelity version. Phase 2 usability testing took place in the context of a pilot hybrid type 1 effectiveness-implementation trial. RESULTS In the phase 1 prototype usability testing, the mean SUS score (potential range: 0-100) was 81.90 (SD 9.80), corresponding to an excellent level of usability. The mean EUCS score (potential range: 1-5) was 4.30 (SD 0.71). In the phase 2 high-fidelity usability testing, the mean SUS score was 65.76 (SD 15.23), corresponding to a good level of usability. The mean EUCS score was 3.91 (SD 0.95); and the mean Patient Engagement scale score (potential range 1 [low] to 5 [high]) was 4.62 (SD 0.67). The median time to completion in minutes was 13 (IQR 10-16). A thematic analysis of user statements documented during phase 2 high-fidelity usability testing identified the following themes: a low baseline level of awareness and knowledge about LCS increased after use of the LCSDecTool; users sought more detailed descriptions about the LCS process; the LCSDecTool was generally easy to use, but specific navigation challenges remained; some users noted difficulty understanding medical terms used in the LCSDecTool; and use of the tool evoked veterans' struggles with prior attempts at smoking cessation. CONCLUSIONS Our findings support the development and use of this eHealth technology in the primary care clinical setting as a way to engage veterans, inform them about a new cancer control screening test, and prepare them to participate in an SDM discussion with their provider.
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Affiliation(s)
| | - Sumedha Chhatre
- Center for Health Equity Research and Promotion, Michael J Crescenz VA Medical Center, Philadelphia, PA, United States.,Department of Psychiatry, University of Pennsylvania School of Medicine, Philadelphia, PA, United States
| | - Jason M Prigge
- Center for Health Equity Research and Promotion, Michael J Crescenz VA Medical Center, Philadelphia, PA, United States
| | - Jessica Meline
- Center for Health Equity Research and Promotion, Michael J Crescenz VA Medical Center, Philadelphia, PA, United States
| | - Dana Kaminstein
- Center for Health Equity Research and Promotion, Michael J Crescenz VA Medical Center, Philadelphia, PA, United States.,Department of Organizational Dynamics, School of Arts & Sciences, University of Pennsylvania, Phlladelphia, PA, United States
| | - Keri L Rodriguez
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, United States
| | - Liana Fraenkel
- Department of Rheumatology, Berkshire Health Systems, Pittsfield, MA, United States.,Department of Medicine, Yale University, New Haven, CT, United States
| | - Jeffrey D Kravetz
- Department of Medicine, Yale University, New Haven, CT, United States.,VA Connecticut Healthcare System, West Haven, CT, United States
| | - Jeff Whittle
- Clement J Zablocki VA Medical Center, Milwaukee, WI, United States
| | - Lori A Bastian
- Department of Medicine, Yale University, New Haven, CT, United States.,VA Connecticut Healthcare System, West Haven, CT, United States
| | - Anil Vachani
- Department of Medicine, Michael J Crescenz VA Medical Center, Philadelphia, PA, United States.,Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA, United States
| | - Scott Akers
- Department of Radiology, Michael J Crescenz VA Medical Center, Philadelphia, PA, United States.,Department of Radiology, University of Pennsylvania School of Medicine, Philadelphia, PA, United States
| | - Susan Schrand
- Department of Medicine, Michael J Crescenz VA Medical Center, Philadelphia, PA, United States
| | | | - Onur Asan
- The Stevens Institute of Technology, School of Systems and Enterprise, Hoboken, NJ, United States
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50
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Jaworski BK, Taylor K, Ramsey KM, Heinz AJ, Steinmetz S, Owen JE, Tsai J, Pietrzak RH. Predicting Uptake of the COVID Coach App Among US Military Veterans: Funnel Analysis Using a Probability-Based Panel. JMIR Ment Health 2022; 9:e36217. [PMID: 35245204 PMCID: PMC8985691 DOI: 10.2196/36217] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 02/15/2022] [Accepted: 03/01/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Although the COVID-19 pandemic has not led to a uniform increase of mental health concerns among older adults, there is evidence to suggest that some older veterans did experience an exacerbation of preexisting mental health conditions, and that mental health difficulties were associated with a lack of social support and increasing numbers of pandemic-related stressors. Mobile mental health apps are scalable, may be a helpful resource for managing stress during the pandemic and beyond, and could potentially provide services that are not accessible due to the pandemic. However, overall comfort with mobile devices and factors influencing the uptake and usage of mobile apps during the pandemic among older veterans are not well known. COVID Coach is a free, evidence-informed mobile app designed for pandemic-related stress. Public usage data have been evaluated; however, the uptake and usage of the app among older veterans have not been explored. OBJECTIVE The purpose of this study was to characterize smartphone ownership rates among US veterans, identify veteran characteristics associated with downloading and use of COVID Coach, and characterize key content usage within the app. METHODS Data were analyzed from the 2019-2020 National Health and Resilience in Veterans Study (NHRVS), which surveyed a nationally representative, prospective cohort of 3078 US military veterans before and 1 year into the pandemic. The NHRVS sample was drawn from KnowledgePanel, a research panel of more than 50,000 households maintained by Ipsos, Inc. The median time to complete the survey was nearly 32 minutes. The research version of COVID Coach was offered to all veterans who completed the peripandemic follow-up assessment on a mobile device (n=814; weighted 34.2% of total sample). App usage data from all respondents who downloaded the app (n=34; weighted 3.3% of the mobile completers sample) were collected between November 14, 2020, and November 7, 2021. RESULTS We found that most US veterans (81.5%) own smartphones, and that veterans with higher education, greater number of adverse childhood experiences, higher extraversion, and greater severity of pandemic-related posttraumatic stress disorder symptoms were more likely to download COVID Coach. Although uptake and usage of COVID Coach were relatively low (3.3% of eligible participants, n=34), 50% of the participants returned to the app for more than 1 day of use. The interactive tools for managing stress were used most frequently. CONCLUSIONS The COVID-19 pandemic has increased the need for and creation of digital mental health tools. However, these resources may require tailoring for older veteran populations. Future research is needed to better understand how to optimize digital mental health tools such as apps to ensure uptake and usage among older adults, particularly those who have experienced traumas across the lifespan.
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Affiliation(s)
- Beth K Jaworski
- National Center for Posttraumatic Stress Disorder, Dissemination & Training Division, US Department of Veterans Affairs, Menlo Park, CA, United States
| | - Katherine Taylor
- National Center for Posttraumatic Stress Disorder, Dissemination & Training Division, US Department of Veterans Affairs, Menlo Park, CA, United States
| | - Kelly M Ramsey
- National Center for Posttraumatic Stress Disorder, Dissemination & Training Division, US Department of Veterans Affairs, Menlo Park, CA, United States
| | - Adrienne J Heinz
- National Center for Posttraumatic Stress Disorder, Dissemination & Training Division, US Department of Veterans Affairs, Menlo Park, CA, United States
| | - Sarah Steinmetz
- National Center for Posttraumatic Stress Disorder, Dissemination & Training Division, US Department of Veterans Affairs, Menlo Park, CA, United States
| | - Jason E Owen
- National Center for Posttraumatic Stress Disorder, Dissemination & Training Division, US Department of Veterans Affairs, Menlo Park, CA, United States
| | - Jack Tsai
- National Center on Homelessness Among Veterans, US Department of Veterans Affairs, Tampa, FL, United States.,School of Public Health, San Antonio Campus, University of Texas Health Science Center at Houston, San Antonio, TX, United States
| | - Robert H Pietrzak
- National Center for Posttraumatic Stress Disorder, VA Connecticut Healthcare System, US Department of Veterans Affairs, New Haven, CT, United States.,Department of Psychiatry, Yale School of Medicine, New Haven, CT, United States
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