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Transitioning from military service is stressful for veterans with service-connected disabilities seeking civilian employment. This descriptive study examined self-assessed mental health, well-being, and substance use of men and women shortly before or after transition from US military service, compared to norms from community and military samples. As part of a prospective study evaluating an innovative employment program, researchers interviewed 229 current and former service members with service-connected disabilities transitioning from U.S. military service. Compared to published norms, respondents reported significantly poorer outcomes on 5 of 6 standardized measures, indicating less life satisfaction, poorer mental health, more symptoms of depression and posttraumatic stress disorder, and greater financial distress. In the previous year, 42% were prescribed opioid medications, over twice the annual opioid prescription rate of 19% in the general US population. Systematic strategies are needed to ensure access for transitioning veterans with serious behavioral health issues to appropriate evidence-based practices.

ObjectiveIn this secondary analysis of data from the Veterans Affairs Augmentation and Switching Treatments for Improving Depression Outcomes (VAST-D) study, the authors sought to determine the effectiveness of early improvement (or lack thereof) for predicting remission from depression with antidepressant therapy.MethodsThis study used data from the VAST-D study, a multisite, randomized, single-blind trial with parallel assignment to one of three medication interventions for 1,522 veterans whose major depressive disorder was unresponsive to at least one course of antidepressant treatment meeting minimal standards for dosage and duration. The authors calculated the positive predictive value (PPV) and negative predictive value (NPV) of early improvement on remission, response, or greater than minimal improvement from depression for various degrees of improvement (10%-50%) on the Quick Inventory of Depressive Symptomatology-Clinician Rated (QIDS-C) at 1, 2, 4, and 6 weeks.ResultsThe end of week 2 of treatment was identified as the best time to evaluate early improvement. The presence of a ≥20% drop from the baseline QIDS-C score by the end of week 2 resulted in a PPV for remission of 38% and an NPV of 93% by week 12. Extending the observational window to week 6 minimally improved NPV (97%). This association did not differ across treatment groups.ConclusionsA lack of early improvement at the end of week 2 of antidepressant therapy can be used to inform clinical decisions on the likelihood of nonremission of depression during the subsequent 10 weeks, even when dosage optimization is incomplete.

ImportanceLess than one-third of patients with major depressive disorder (MDD) achieve remission with their first antidepressant.ObjectiveTo determine the relative effectiveness and safety of 3 common alternate treatments for MDD.Design, setting, and participantsFrom December 2012 to May 2015, 1522 patients at 35 US Veterans Health Administration medical centers who were diagnosed with nonpsychotic MDD, unresponsive to at least 1 antidepressant course meeting minimal standards for treatment dose and duration, participated in the study. Patients were randomly assigned (1:1:1) to 1 of 3 treatments and evaluated for up to 36 weeks.InterventionsSwitch to a different antidepressant, bupropion (switch group, n = 511); augment current treatment with bupropion (augment-bupropion group, n = 506); or augment with an atypical antipsychotic, aripiprazole (augment-aripiprazole group, n = 505) for 12 weeks (acute treatment phase) and up to 36 weeks for longer-term follow-up (continuation phase).Main outcomes and measuresThe primary outcome was remission during the acute treatment phase (16-item Quick Inventory of Depressive Symptomatology-Clinician Rated [QIDS-C16] score ≤5 at 2 consecutive visits). Secondary outcomes included response (≥50% reduction in QIDS-C16 score or improvement on the Clinical Global Impression Improvement scale), relapse, and adverse effects.ResultsAmong 1522 randomized patients (mean age, 54.4 years; men, 1296 [85.2%]), 1137 (74.7%) completed the acute treatment phase. Remission rates at 12 weeks were 22.3% (n = 114) for the switch group, 26.9% (n = 136)for the augment-bupropion group, and 28.9% (n = 146) for the augment-aripiprazole group. The augment-aripiprazole group exceeded the switch group in remission (relative risk [RR], 1.30 [95% CI, 1.05-1.60]; P = .02), but other remission comparisons were not significant. Response was greater for the augment-aripiprazole group (74.3%) than for either the switch group (62.4%; RR, 1.19 [95% CI, 1.09-1.29]) or t

Unemployed Veterans with posttraumatic stress disorder (PTSD) were prospectively randomized into a multi-site study comparing Individual Placement and Support (IPS), an evidenced-based model of supported employment, to VA vocational rehabilitation treatment-as-usual (VRP-TAU). Over the course of the 52-week follow-up, 25 of the 48 IPS participants (52%) gained competitive employment, compared with 15 of the 46 VRP-TAU participants (33%) ( 2= 3.64, df=1, p=.056). That is, Veterans with PTSD who participated in IPS were 1.7 times more likely to gain competitive employment than those who received VRP-TAU. The number-needed-to-treat (NNT) was 5.26. The IPS and VRP-TAU participants worked in a competitive job an average of 23% and 13% of the eligible weeks, respectively (Mann-Whitney z test, p=0.10). There were no statistically significant between-group differences in terms of number of weeks, days, or hours worked, or the amount of income earned. The IPS group achieved competitive employment significantly more quickly than VRP-TAU (log-rank 2= 4.25, p=0.04). Most job acquisition in IPS group occurred within the first 25 weeks. There were no significant differences between groups in terms of PTSD, depression, or quality of life rating scales. A large-scale randomized controlled study of IPS has been launched by the VA Cooperative Studies Program to further evaluate the effectiveness of IPS in Veterans with PTSD., The original document contains color images.

ObjectivesWe compared homeless patients' experiences of care in health care organizations that differed in their degree of primary care design service tailoring.MethodsWe surveyed homeless-experienced patients (either recently or currently homeless) at 3 Veterans Affairs (VA) mainstream primary care settings in Pennsylvania and Alabama, a homeless-tailored VA clinic in California, and a highly tailored non-VA Health Care for the Homeless Program in Massachusetts (January 2011-March 2012). We developed a survey, the "Primary Care Quality-Homeless Survey," to reflect the concerns and aspirations of homeless patients.ResultsMean scores at the tailored non-VA site were superior to those from the 3 mainstream VA sites (P < .001). Adjusting for patient characteristics, these differences remained significant for subscales assessing the patient-clinician relationship (P < .001) and perceptions of cooperation among providers (P = .004). There were 1.5- to 3-fold increased odds of an unfavorable experience in the domains of the patient-clinician relationship, cooperation, and access or coordination for the mainstream VA sites compared with the tailored non-VA site; the tailored VA site attained intermediate results.ConclusionsTailored primary care service design was associated with a superior service experience for patients who experienced homelessness.

ObjectivesWe compared homeless patients' experiences of care in health care organizations that differed in their degree of primary care design service tailoring.MethodsWe surveyed homeless-experienced patients (either recently or currently homeless) at 3 Veterans Affairs (VA) mainstream primary care settings in Pennsylvania and Alabama, a homeless-tailored VA clinic in California, and a highly tailored non-VA Health Care for the Homeless Program in Massachusetts (January 2011-March 2012). We developed a survey, the "Primary Care Quality-Homeless Survey," to reflect the concerns and aspirations of homeless patients.ResultsMean scores at the tailored non-VA site were superior to those from the 3 mainstream VA sites (P < .001). Adjusting for patient characteristics, these differences remained significant for subscales assessing the patient-clinician relationship (P < .001) and perceptions of cooperation among providers (P = .004). There were 1.5- to 3-fold increased odds of an unfavorable experience in the domains of the patient-clinician relationship, cooperation, and access or coordination for the mainstream VA sites compared with the tailored non-VA site; the tailored VA site attained intermediate results.ConclusionsTailored primary care service design was associated with a superior service experience for patients who experienced homelessness.

Researchers have shown that certain demographic variables and parenting strategies can predict the degree of potential for child abuse that a mother may experience with her children. The major objective of this study was to determine the specific characteristics and traits that identify mothers who have the greatest potential to abuse or neglect their children by determining whether parenting strategies, age of the mother, educational attainment, and isolation indicated by place of residence and marital status are predictive of the potential for child abuse. T-tests were performed to see if there significant differences in scale means for the subscales of parenting strategies in urban and rural groups of the sample. All subscale’s scores were significantly different when the urban and rural groups were compared. T-test and Chi square tests were computed on the relationship between demographic variables including educational attainment, age and marital status and urban and rural groups. Significant differences were found on all three demographic variables. Four variables were found to be predictive of the potential for child abuse. Four parenting strategies (i.e., spank, reason, allow, and praise) were tested for their power in predicting the potential for child abuse. Only allow was found to be a significant predictor for the potential for child abuse. Educational attainment, support group (which is a combined variable representing marital status and living arrangements) and urban vs. rural residence were found among the demographic variables to be predictors of the potential for child abuse. These results suggest that although a demographic like educational attainment may be important, the context of parenting (urban vs. rural and support group) and parenting style (allow) are the best predictors of the potential for child abuse.

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