Treatment Engagement and Outcomes of Mindfulness-Based Cognitive Therapy for Veterans with Psychiatric Disorders

Randomized Controlled Trial of a Brief Mindfulness-Based Intervention for Suicidal Ideation Among Veterans

INTRODUCTION

This study was a preliminary evaluation of a manualized, brief mindfulness-based intervention (MB-SI) for veterans with suicidal ideation (SI), admitted into an inpatient psychiatric unit (IPU).

MATERIALS AND METHODS

A randomized, controlled pilot study of 20 veterans aged 18-70 years with SI, admitted into a psychiatric unit, assigned to treatment as usual (TAU) or MB-SI groups. Outcome data were collected at three time points: preintervention (beginning of first session), postintervention (end of last session), and 1-month postintervention. Primary outcomes were safety and feasibility. Secondary outcome measures were SI and behavior, mindfulness state and trait, cognitive reappraisal, and emotion regulation. Additionally, psychiatric and emergency department admissions were examined. Data analysis included Generalized Linear Models, Wilcoxon Signed-Rank, Mann-Whitney U, and Fisher's exact tests for secondary outcomes.

RESULTS

Mindfulness-based intervention for suicidal ideation was feasible to implement on an IPU, and there were no associated adverse effects. Mindfulness-based intervention for suicidal ideation participants experienced statistically significant increase in Toronto Mindfulness Scale curiosity scores 1-month postintervention compared to preintervention and greater Toronto Mindfulness Scale decentering scores 1-month postintervention compared to TAU. Emotion Regulation Questionnaire Reappraisal scores significantly increased for the MB-SI group and significantly decreased for TAU over time. IPU and emergency department admissions were not statistically different between groups or over time. Both TAU and MB-SI participants experienced a significant reduction in Columbia-Suicide Severity Rating Scale-SI scores after the intervention. MB-SI participants experienced a higher increase in Five-Facet Mindfulness Questionnaire scores postintervention compared to TAU.

CONCLUSIONS

Mindfulness-based intervention for suicidal ideation is feasible and safe to implement among veterans during an inpatient psychiatric admission with SI, as it is not associated with increased SI or adverse effects. Preliminary evidence suggests that MB-SI increases veterans' propensity to view experiences with curiosity while disengaging from experience without emotional overreaction. Further, more rigorous research is warranted to determine efficacy of MB-SI.

TRIAL REGISTRATION

The clinicaltrials.gov registration number is NCT04099173 and dates are July 16, 2019 (initial release) and February 24, 2022 (most recent update).

Evaluation of a mindfulness and self-compassion-based psychotherapy incorporating horses for Veterans who have experienced trauma

OBJECTIVES

The primary aim of this pilot study was to assess the safety, feasibility, acceptability, as well as preliminary outcomes of a mindfulness and self-compassion-based psychotherapy incorporating horses (PIH) intervention, Whispers with Horses, for Veterans who had experienced trauma. Whispers with Horses was developed as a structured intervention that could be easily replicated for additional studies. If shown to be effective by future rigorous research, the aim is to disseminate a manualized version of the intervention to the field.

DESIGN

Prospective open trial.

SETTING

A large Veterans Administration healthcare system and local equine facilities.

INTERVENTION

A six-session PIH intervention that focused on participants developing or enhancing mindfulness and self-compassion skills in the context of an emerging horse-human relationship.

MAIN OUTCOME MEASURES

Safety, feasibility and acceptability were assessed, and psychological instruments were administered. Instruments utilized were the PTSD Checklist for DSM 5 (PCL-V), the Patient Health Questionnaire 9 (PHQ-9), the Positive and Negative Affect Scale (PANAS), the Acceptance and Action Questionnaire II (AAQ-II), and the Physical Activity Enjoyment Scale (PACES).

RESULTS

Subjects were 33 Veterans who were 52% male with a mean age of 46 years-old. There were no adverse outcomes to participants indicating the intervention was safe. Participants completed an average of 3.8 sessions with 24% completing all sessions indicating the intervention is feasible to use, and acceptable to, the population studied. The mean PACES score for all sessions together was 110.4, indicating subjects generally enjoyed participation. Preliminary outcome assessments revealed pre- to post-session significant improvements in affect and psychological flexibility for some sessions (p ranging from.001 -0.015). Pre- to post-intervention outcomes indicated significant improvements in depression (p = .003) and psychological flexibility (p = .005).

CONCLUSIONS

The Whispers with Horses intervention shows promise as a PIH for Veterans who have experienced trauma. More rigorous studies of this intervention are warranted. Also, additional investigations aimed at better understanding mechanisms underlying changes in psychological flexibility are justified.

Utilization and outcomes of a Whole Health model of care by Veterans with psychiatric illness

OBJECTIVES

The Veterans Health Administration (VHA) is implementing a model of healthcare known as Whole Health (WH). The goal of WH is to shift from a disease-oriented system to one that emphasizes health promotion and disease prevention as well as promotes the use of Complementary and Integrative Health. The aim of this project was to investigate utilization and outcomes of WH programming among Veterans with psychiatric disorders.

DESIGN

This was a retrospective study. Subjects were 7138 Veterans who had a mental health diagnosis. Descriptive data, as well as within- and between-subjects analyses were conducted to investigate utilization and outcomes.

SETTING

The study was conducted at a large VHA medical center.

INTERVENTIONS

Whole health interventions considered in this study were mindfulness training, health education, wellbeing, and nutrition classes as well as health coaching. Other whole health interventions, such as acupuncture and message were not evaluated.

MAIN OUTCOME MEASURES

Utilization of mental health treatment services, medication prescriptions, pain scores and suicide-related behaviors were the primary outcome measures.

RESULTS

There were 305 Veterans with at least one WH appointment. The existence of several specific psychiatric disorders was associated with WH utilization. The mean number of appointments completed per individual was 6.9 for all WH programming. Finally, WH participation was associated with decreased risk of suicide as well as reduced use of mental health services. There were no significant changes to other outcome variables.

CONCLUSIONS

WH programming shows promise to reduce suicide risk and the need for mental health services among this population. Additionally, WH services were underutilized and there was a lack of treatment engagement.

Effectiveness of Complementary and Integrative Approaches in Promoting Engagement and Overall Wellness Toward Suicide Prevention in Veterans

Objective: Suicide is a major public health problem, specifically among U.S. veterans, who do not consistently engage in mental health services, often citing stigma as a barrier. Complementary and Integrative Health (CIH) interventions are promising alternatives in promoting patient engagement and further, they may play a critical role in transitioning people into mental health care. Toward this goal, the Resilience and Wellness Center (RWC) was developed to break through the stigma barrier by addressing risk factors of suicide through multimodal CIH interventions via cohort design, promoting social connectedness and accountability among participants. Design: This is a program evaluation study at a large urban VA medical center, where assessments were evaluated from pre- to post-program completion to determine the effectiveness of an intensive multimodal CIH 4-week group outpatient intervention for suicide prevention. Outcome measures: Primary outcomes measured included group connectedness, severity of depression and hopelessness symptoms, suicidal ideation, sleep quality, and diet. Secondary outcomes included measures of post-traumatic stress disorder (PTSD), generalized anxiety severity stress/coping skills, pain, and fatigue. Results: The RWC showed high participant engagement, with an 84%-95% attendance engagement rate depending on suicide risk history. Data from 15 cohorts (N = 126) demonstrate favorable outcomes associated with participation in this comprehensive program, as evidenced by a reduction in suicidal ideation, depression, and hopelessness, but not sleep quality and diet. In addition, in a subset of veterans with a history of suicidal ideation or attempt, significant improvements were noted in pain, PTSD/anxiety symptoms, and stress coping measures. Conclusions: The RWC shows that an intensive complement of CIH interventions is associated with a significant improvement with high veteran engagement. Findings from this program evaluation study can be used to aid health care systems and their providers in determining whether or not to utilize such multimodal CIH integrated interventions as an effective treatment for at-risk populations as a part of suicide prevention efforts.

Equine-Assisted Activities and Therapies for Veterans With Posttraumatic Stress Disorder: Current State, Challenges and Future Directions

Posttraumatic stress disorder is common among military Veterans. While effective treatments exist, many Veterans either do not engage in treatment or fail to achieve full remission. Thus, there is a need to develop adjunctive complementary interventions to enhance treatment engagement and/or response. Equine-assisted activities and therapies (EAAT) are one category of animal assisted interventions that might serve this function. The aim of this article is to review the current state and challenges regarding the use of EAAT for Veterans with PTSD and provide a roadmap to move the field forward. EAAT hold promise as adjunctive complementary interventions for symptom reduction among Veterans with PTSD. Additionally, there is evidence that these approaches may enhance wellbeing in this population. At this time, many gaps in the literature exist and rigorous randomized controlled trials are needed before definitive conclusions can be drawn. The authors of this work provide recommendations as a roadmap to move the field forward. These include standardizing the EAAT nomenclature, focusing mechanism of action studies on the human-horse bond using biological metrics and using a standardized intervention model across studies.

Mindfulness-based Therapeutic Sailing for Veterans With Psychiatric and Substance Use Disorders

INTRODUCTION

Complementary interventions have the potential to enhance treatment engagement and/or response among veterans with psychiatric disorders and/or substance use disorders (SUDs). Mindfulness-based therapeutic sailing (MBTS) is a novel three-session, complementary intervention, which combines nature exposure via recreational sailing and mindfulness training. It was developed specifically to augment both treatment response and engagement among veterans with psychiatric disorders or SUDs. The study reports a follow-up investigation of a version of MBTS modified based upon a previous initial pilot study.

MATERIALS AND METHODS

This is an institutional review board-approved study of 25 veterans, 23 males and 2 females, who participated in MBTS along with a diagnosis-, gender-, and age-matched control group. All participants had at least one psychiatric disorder or SUD and most (92%) had two or more conditions, with the most common being any SUD (76%) and PTSD (72%). Instruments used to evaluate within-subjects pre- to post-intervention psychological changes were the Acceptance and Action Questionnaire II (AAQII), the Toronto Mindfulness Scale (TMS), and the Five Facet Mindfulness Questionnaire (FFMQ). The Physical Activity Enjoyment Scale (PACES) was administered to evaluate how much the participants enjoyed the intervention. Outcome measures were collected for 1-year pre-intervention and 1-year post-intervention for between-subject analyses. These were numbers of medical and psychiatric hospitalizations, emergency department visits, mental health (MH) and substance abuse treatment visits, and MH and substance abuse treatment failed appointments. Data analysis consisted of using paired, two-tailed t-tests on psychological instrument results, Poisson regression on discrete outcome measures, and chi-square test of independence on demographic factors.

RESULTS

Within-subjects comparisons revealed significant mean pre- to post-intervention increases in AAQII (P = .04) and TMS scores (P = .009). The FFMQ scores increased but the change was nonsignificant (P = .12). The PACES scores were high for all sessions, indicating enjoyment of the intervention by participants. Although the coefficient was nonsignificant, Poisson regression uncovered reduction in substance abuse treatment visits post-intervention. There were no significant differences for the other variables. For demographic factors, the differences between intervention and control groups were not statistically significant.

CONCLUSIONS

The MBTS is associated with increases in psychological flexibility (AAQII) and state mindfulness (TMS). The intervention was perceived as pleasurable by participants (PACES) and is potentially associated with decreased utilization of substance use treatment services. These results must be considered as preliminary; however, these finding corroborate results from a previous pilot study and indicate that MBTS holds promise as a complementary intervention that could result in enhanced treatment engagement and/or outcomes for the population studied. A randomized controlled trial of MBTS is warranted. Further, the model of a three-session intervention combining mindfulness training with nature exposure could be adapted for other types of nature exposure, such as hiking or snowshoeing or other complementary interventions including equine-assisted activities and therapies.

The Veterans Health Administration Whole Health Model of Care: Early Implementation and Utilization at a Large Healthcare System

INTRODUCTION

The U.S. Veterans Health Administration (VHA) is changing the way it provides healthcare to a model known as Whole Health (WH). The aim is to shift from a primarily medical/disease-oriented system to a model that focuses on health promotion and disease prevention; utilizes personalized, proactive, and patient-driven care; and emphasizes the use of complementary and integrative health. This investigation aimed to examine referral and utilization patterns in early implementation at tertiary care VHA medical care system. Specific aims were to evaluate (1) referral patterns, (2) initial treatment engagement, and (3) continuity of treatment engagement.

MATERIALS AND METHODS

This is an institutional review board-approved, retrospective study of the first 561 veterans referred to WH programming in the first 20 months of implementation. Data analyses included a chi-square goodness of fit to compare demographics of veterans who were referred to WH Services with those of local patient population. At this facility, WH offers services in three tracks (General WH, Mindfulness Center [MC], and WH Nutrition), which offer unique services to veterans. A chi-square test for independence was conducted to analyze differences in initial engagement among the WH components, in referrals and retention among WH components by time period, and in demographics or diagnoses among self-referred or veterans referred by a consult. Finally, a regression model was used to assess for predictive factors that might influence continuity of treatment engagement across all the WH tracks.

RESULTS

Key findings indicated potential implementation challenges including disproportionate numbers of referrals from clinical services; poor initial and ongoing treatment engagement; and older, male, and non-service-connected Veterans being less likely to be referred.

CONCLUSION

Implementation of the WH model of care has the potential to transform the way VHA delivers healthcare and improve the health and lives of veterans. However, a shift of this magnitude is likely to face challenges during implementation. This article reports on initial barriers to implementation, which can guide implementation at other sites as well as future investigations. Further research is needed to replicate these results as well as to determine underlying causal factors. However, if replicated, these results indicate that successful implementation of WH, or similar models of care, will require extensive efforts focused on outreach to, and education of, facility providers and certain patient demographic groups. Finally, efforts will be required to enhance treatment engagement.

Mindfulness-based interventions for military veterans: A systematic review and analysis of the literature

BACKGROUND

In recent years, mindfulness-based interventions (MBIs) have experienced exponential growth in terms of development, application, and research. However, few studies have examined implementation and efficacy of these interventions in particular populations, such as military Veterans. Such studies are needed as one cannot assume that the literature on MBIs implemented with the general population or other specific populations apply equally well to Veterans. This population is unique regarding professional competencies, military ethos, high degrees of medical comorbidities and barriers to treatment. The aim of this work was to review and summarize the literature over the previous five years (2014-2020) assessing the use of MBIs among military Veterans to guide clinical care and future research.

METHODS

Systematic literature review.

RESULTS

A total of 88 articles were found. Screening titles and abstracts resulted in 49 articles being excluded. The remaining 39 articles were read in full, and of these, 12 were excluded due to not fully meeting the inclusion criteria. Thus, the present review included a total of 27 articles, 3 of which used qualitative methods and 24 of which used quantitative methods.

CONCLUSIONS

MBIs hold promise as complementary adjunctive interventions for Veterans with PTSD and possibly other psychiatric disorders. Currently there are significant gaps in the literature that must be addressed to move the field forward. The main deficiency is, with a few exceptions, the lack of rigorous RCTs. Another major concern is the lack of generalizability to female and non-white Veterans given that the subject samples across all studies reviewed were 85% male and 76% white. At this time, MBSR, PCBMT and MBCT can be recommended as adjunctive complementary interventions for the reduction of PTSD symptoms. Research recommendations to move the field forward are provided.

A Brief Report on an 8-Week Course of Mindfulness-based Care for Chronic Pain in the Treatment of Veterans With Back Pain: Barriers Encountered to Treatment Engagement and Lessons Learned

BACKGROUND

Chronic pain and associated symptoms are debilitating for veterans. Medical costs of treatments are high and current treatment options, most notably with opioid medications, have been associated with significant risk. Mindfulness-based interventions appear promising for chronic pain, but require additional testing in veteran care settings.

OBJECTIVE

This project was designed to test the feasibility of engaging and retaining veterans with chronic lower back pain in a new mindfulness protocol tailored for veterans, mindfulness-based care for chronic pain (MBCP). Clinical outcomes were also assessed.

DESIGN

An open pilot trial of an 8-week MBCP course that included meditation, gentle yoga, and psychoeducation.

SUBJECTS

Twenty-two veterans (mean age=49.77; 18% women) were recruited from a VA Medical Center in the Northeastern US. After screening for inclusion/exclusion criteria, 20 were eligible at baseline.

MEASURES

Veterans were assessed at baseline and postintervention for functional impairment, pain intensity and bothersomeness, depression, and mindfulness.

RESULTS

The average number of sessions completed was 5; only 4 (20%) attended all sessions. Eleven of the 20 participants (55%) attended 5 or more sessions and had complete preintervention and postintervention visits. Five of the 11 had a clinically meaningful decrease in pain intensity and in depressive symptoms, while 6 of 11 had a meaningful decrease in pain bothersomeness and functional impairment.

CONCLUSIONS

It was challenging to enroll and retain participants in this study, even with our intervention designed for veterans. We discuss possible adaptations and refinements in MBCP for veterans with chronic pain to enhance feasibility and improve upon these interventions.

Veterans' interests, perceptions, and use of mindfulness

Objective:

Mindfulness-based interventions are an evidence-based approach utilized in health care. There is developing evidence for effective use with military Veterans. However, little is known about Veterans’ view of mindfulness. This study aims to understand their interests, perceptions, and use of mindfulness to enhance educational outreach and treatment engagement.

Methods:

A cross-sectional study was conducted across the Veterans Health Administration in Salt Lake City, UT by administering a questionnaire to military Veterans. The questionnaire included the following themes: (1) demographics and respondents’ mindfulness practice; (2) respondents’ perceptions and beliefs about mindfulness; and (3) respondents’ knowledge and interest in learning about mindfulness.

Results:

In all, 185 military Veterans were surveyed; 30% practiced mindfulness in the past year, mainly for stress, posttraumatic stress disorder, sleep, and depression. Over 75% who practiced reported perceived benefit. Veterans rarely reported negative beliefs about mindfulness; 56% perceived an understanding of mindfulness and 46% were aware of Veterans Health Administration mindfulness offerings. In all, 55% were interested in learning about mindfulness, 58% were interested in learning how it could help, and 43% were interested in combining mindfulness with a pleasurable activity.

Conclusion:

Educational engagement approaches should be directed toward the benefits of mindfulness practice with minimal need to address negative beliefs. Outreach including education, with an experiential component, about mindfulness classes, availability of evening and weekend classes, individual sessions, and virtual offerings into Veteran’s homes, may enhance engagement in mindfulness-based interventions. Mindfulness-based interventions that combine mindfulness training with an experiential pleasurable activity may be one mechanism to enhance treatment engagement.

Mindfulness Training plus Nature Exposure for Veterans with Psychiatric and Substance Use Disorders: A Model Intervention

There is a need to develop novel complementary interventions aimed at enhancing treatment engagement and/or response for veterans with psychiatric and substance use disorders. There is evidence that both mindfulness training and nature exposure (MT/NE) may be beneficial for this population and that combining the two approaches into one intervention might result in synergistic benefit. However, to date, the MT/NE concept has not been tested. This article reports a pilot feasibility and acceptability study of MT/NE which was, in this case, provided via recreational sailing. The primary aim of this project was to develop a model intervention and evaluation process that could be used for future studies of MT/NE interventions using a variety of methods of nature exposure (e.g., hiking, skiing, mountain biking). Results indicate preliminary evidence that it is feasible to utilize MT/NE interventions for the population studied and that the MT/NE model described can serve as a template for future investigations. Further, there were significant pre- to post-intervention decreases in state anxiety, as well as increases in trait mindfulness. Three psychological instruments were identified that might be used in future studies to evaluate MT/NE outcomes. Results from this project provide a model MT/NE intervention template along with evaluation metrics for use in future studies.