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A greater understanding of factors that are associated with successful outcomes among patients receiving collaborative depression care services is needed. This study sought to examine the unique associations between 3 indices of social ties and changes in depressive symptoms among veterans receiving collaborative depression care management. Data on sociodemographics, behavioral health indices, perceived general health, perceived social support, frequency of negative social exchanges, and degree of social contact were extracted from the electronic health records of 868 veterans meeting criteria for at least moderate depressive symptom severity and enrolled in a Primary Care-Mental Health Integration (PCMHI) program. Veterans were on average 51.3 (SD = 15.9) years old and primarily male. Higher depressive symptoms at baseline were significantly correlated with less perceived social support, less frequent contact with family and friends, and greater frequency of negative social exchanges. Adjusted regression analyses revealed that only social contact was significantly related to changes in depressive symptoms over the course of care management, once controlling for covariates. The results highlight the value of taking multiple indices of social ties into account when providing depression care management services. Routinely assessing patients' level of social contact can potentially help tailor and inform intervention efforts aimed at reducing depressive symptoms. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Introduction Pain is highly comorbid with mental health problems, and can lead to significant disability and loss of function. Pain is common among older adults, with approximately half of older adults nationwide reporting experiencing bothersome pain in the preceding month. The treatment of pain in later life is complicated by a variety of factors, and there are significant safety risks associated with the use of analgesics, especially opioids. Multimodal strategies and collaborative care models that employ both non-pharmacological and pharmacological methods of pain care management may be especially promising in treating pain and improving outcomes. The objective of this project was to explore preliminary results from a pilot study of a telephone-delivered collaborative care service designed for community-dwelling older adults with chronic pain receiving prescriptions for high doses of opioids. Specifically, we were interested in examining program feasibility and acceptability, the extent to which engaged patients and their prescribers achieved opioid dose reduction, and changes in patient-level symptoms (e.g., pain severity and interference, depressive symptoms). Methods Eligible participants included 82 older adults referred by the Pennsylvania Department of Aging's pharmaceutical assistance program for low-income seniors (PACE/PACENET) to the University of Pennsylvania/PACE Behavioral Health Laboratory program. Referred patients were identified as receiving chronic opioid prescriptions for > 120 mg morphine-equivalent dose (MED) per day. Upon enrollment, patients first completed a comprehensive baseline clinical assessment. Clinical data on mental health, cognition, pain and functional status, as well as self-reported daily opioid dose and biopsychosocial needs, were collected over the phone and entered into the program's informatics tool. Patients next engaged in a series of telephone sessions during which care managers offered individualized treatment planning. Program goals included opioid dose reduction to safer levels and improved pain and psychosocial outcomes. Treatment modalities offered included: (1) behavioral pain management, (2) general medication education, (3) reinforcing positive health behaviors, (4) addressing barriers to change, (5) scheduling positive activities, and (6) relaxation techniques. Following each session, summary reports were sent to prescribers with recommendations for pain care management and opioid dose reduction. Results Enrolled patients were on average 73.5 (+/-6.1) years old, and the majority were non-Hispanic white (91%) and female (70%). Seventy-seven percent of the sample met criteria for clinically significant anxiety or depressive symptomatology. Of the 82 patients completing the baseline assessment, 53 (65%) engaged in the program. Patients were considered engaged in the program if they completed the baseline assessment and two or more additional follow-up contacts with a care manager. Those who engaged in the program did not differ on sociodemographic or clinical characteristics or baseline reports of pain when compared to those who did not engage. Pre-post intervention comparisons suggest a significant reduction in medication dose at the last contact relative to baseline. Further, at their last clinical contact, 66% of engaged patients achieved dose reductions of >20%. While there were no significant changes in pain interference or pain-related self-efficacy, engaged patients did report reductions in pain severity (p=0.05) and depressive symptoms (p=0.003) at the last contact relative to baseline. Preliminary findings also suggest that patients who achieved dose reductions of >20%, compared to those who did not, showed greater reductions in depressive symptoms and pain interference at the last contact relative to baseline. Pharmacy record data comparing those who engaged versus those who did not engage in the program were also collected for analysis. Conclusions In conclusion, the findings provide preliminary support for the feasibility of a community-based, collaborative care model for pain management and suggest the potential for positive treatment outcomes. The results also support further development and evaluation of collaborative care models that aim to address opioid use in later life. Funding Pennsylvania Department of Aging, PACE/PACENET program

Objectives To evaluate whether a community-based, telephone-delivered, brief patient/caregiver-centered collaborative dementia care management intervention is associated with improved caregiver and care recipient (CR) outcomes. Design Longitudinal program evaluation of a clinical intervention; assessments at baseline and 3- and 6-month follow-up. Setting General community. Participants Caregivers (N = 440) of older, community-dwelling, low-income CRs prescribed a psychotropic medication by a primary care provider who met criteria for dementia and were enrolled in the SUpporting Seniors Receiving Treatment And INtervention (SUSTAIN) program for older adults. Intervention Dementia care management versus clinical evaluation only. Measurements Perceived caregiving burden and caregiver general health (primary outcomes); CR neuropsychiatric symptoms and caregiver distress in response to CRs' challenging dementia-related behaviors (secondary outcomes). Results Caregivers were, on average, 64.0 (SD: 11.8) years old and 62.6% provided care for the CR for 20 or more hours per week. The majority of the sample was female (73.2%), non-Hispanic White (90.2%), and spousal caregivers (72.5%). Adjusted longitudinal models of baseline and 3- and 6-month data suggest that compared with caregivers receiving clinical evaluation only, caregivers receiving care management reported greater reductions in burden over time. Subgroup analyses also showed statistically significant reductions in caregiver-reported frequency of CR dementia-related behaviors and caregiver distress in response to those symptoms at 3-month follow-up. Conclusions A community-based, telephone-delivered care management program for caregivers of individuals with dementia is associated with favorable caregiver and CR-related outcomes. Findings support replication and further research in the impact of tailored, collaborative dementia care management programs that address barriers to access and engagement.

Treating pain in later life is complex, and there are significant safety risks associated with the use of analgesics, particularly opioids. This study examined preliminary results from a pilot study of a telephone-delivered collaborative care service designed for community-dwelling older adults with chronic pain receiving prescriptions for high doses of opioids (i.e., >120 mg morphine-equivalent dose). Eighty-two older adults referred by the Pennsylvania Department of Aging’s pharmaceutical assistance program for low-income seniors (PACE/PACENET) were eligible and enrolled in the program (i.e., the University of Pennsylvania/PACE Behavioral Health Laboratory). Patients were on average 73.5 (+/-6.1) years old, and the majority were white (91%) and female (70%). Patients completed a comprehensive baseline clinical assessment capturing their mental health, cognition, pain and functional status, as well as self-reported daily opioid dose and biopsychosocial needs. Patients were considered engaged in the program if they completed 2+ additional follow-up contacts with a care manager. During these contacts, care managers offered individualized treatment planning, with the goal of opioid dose reduction to safer levels. Of the 82 patients completing the baseline, 53 (65%) engaged in the program. At their last clinical contact, 91% of engaged patients achieved dose reductions (with 66% achieving dose reductions of >20% and 30% reporting doses

Introduction Depression, anxiety and chronic pain are highly comorbid in the elderly population. These symptoms can interfere with daily activities and adversely affect quality of life. The mechanisms underlying the associations among pain and mental health symptoms are complex and likely bidirectional in nature. This interrelatedness between pain, depression and anxiety symptoms can often lead to diagnostic uncertainty and polypharmacy. Moreover, the literature points to less favorable outcomes among those receiving treatment for depression and anxiety who report comorbid pain. However, less is known about whether pain moderates outcomes among community-dwelling older adults engaged in care for more moderate symptomatology. The primary aim of the study was to examine if baseline pain interference with daily activities had an impact on treatment outcomes in elderly patients with depressive and anxiety symptoms at 3 months and 6 months. The sample consisted of low income, community-dwelling older adults with comorbid pain, depression and anxiety symptoms who were enrolled in a telephone-based collaborative care management program. Methods The sample included 519 older adults newly prescribed an antidepressant or benzodiazepine by a primary care provider and enrolled in the SUpporting Seniors Receiving Treatment And INtervention (SUSTAIN) program. The SUSTAIN program provides behavioral health services by telephone to enrollees in the Pennsylvania Department of Aging's pharmaceutical assistance program (PACE/PACENET). The PACE/PACENET program serves low and moderately low-income seniors. Patients who agree to participate in SUSTAIN complete comprehensive assessments of mental health symptoms, cognition, sleep, pain, and functional status by a health technician. The current study included those patients meeting criteria for clinically significant baseline mental health symptoms who agreed to engage in care management services delivered by a clinician (LSW or RN). Over the course of care management, patients received symptom and medication monitoring, brief behavioral therapy, and psychosocial support, and were connected to needed community resources. Summary reports were also sent to patients’ prescribers with recommendations for treatment planning (where indicated). Baseline clinical program data extracted for the current analyses included self-reported socio-demographics (age, financial status, gender), clinical symptoms (depressive [PHQ-9] and anxiety [GAD-7] symptoms), overall mental functioning (Veterans RAND 12-Item Health Survey [VR12]), and self-reported pain over the past 24?hours and 3 months. Pain interference was rated on a scale of 0 (no interference) to 10 (complete interference). Data on depression, anxiety, and overall mental health outcomes were also collected at 3 and 6-month follow-up. Bivariate analyses were run to examine associations among pain and various clinical and sociodemographic variables at baseline. Longitudinal, mixed effects models were run to examine the extent to which baseline pain moderated changes in depressive symptoms, anxiety symptoms, and overall mental functioning over time. Results Patients were on average 77.7 (SD 6.8) years old. The majority were female (86.7%), non-Hispanic white (92.9%), and reported having enough finances to “get along” (83.4%). Antidepressant or benzodiazepine was reported as the index medication for 59.3% and 40.7% of the patients, respectively. 51.4% reported pain interference with activities. Patients had a mean baseline score of 8.81 (SD 4.6) on the PHQ-9 (range=0-24), 4.74 (SD 4.4) on the GAD-7 (range=0-21), and 47.4 (SD 11.1) on overall mental functioning (range=4.85-72.85). Bivariate results revealed that greater baseline pain was significantly associated with lower financial status (p Conclusions The data suggest that in this sample of community-dwelling older adults enrolled in a state-sponsored pharmacy benefit and treatment support program, baseline pain interference did not impact treatment outcomes of depressive and anxiety symptoms over a period of 6 months. The findings suggest that a collaborative care program for depression and anxiety may be effective in reducing mental health symptoms even in the presence of self-reported pain interference with activities. This research was funded by: Commonwealth of Pennsylvania, Department of Aging, PACE Program, PACE/PACENET.

Introduction Institutionalization of individuals with dementia within the first five years of diagnosis occurs at a rate of 10% per year. However, surveys show that most older adults prefer to age in place in the community. Research in the past two decades indicates numerous variables are associated with increased risk of institutionalization, including both sociodemographic factors (e.g., caregiver employment, financial resources, and older care recipient age), as well as psychosocial and care recipient factors (e.g., care recipient disability level and problem behaviors). Care recipient (CR) characteristics associated with greater risk for institutionalization include increased dependence in activities of daily living, severity of cognitive impairment, and frequency and severity of behavioral symptoms of dementia. Previously investigated caregiver (CG) characteristics, such as physical well-being and self-care behaviors, CG burden and social support, may also contribute to the risk of institutionalization. However, these identified CG factors have not yet been routinely assessed in clinical practice. Additionally, CGs are at a greater risk for poor health, depression, and use of psychotropic drugs and health services. Our aim was to examine the relationship between CG-related factors (e.g., depressive symptomatology, CG burden, perceived health, and social support) and the desire to institutionalize the CR among a real-world community sample of CGs of older adults with dementia. We hypothesized that specific CG domains, including greater perceived health and social support, would decrease the desire to institutionalize the CR. Methods The sample included 334 caregivers (CGs) of older (aged 65+), community-dwelling, low-income care recipients (CRs) prescribed a cholinesterase inhibitor or memantine who met criteria for dementia. CRs were identified from a sample of older adults receiving pharmaceutical assistance from the Pennsylvania Department of Aging's Pharmaceutical Assistance Contract for the Elderly (PACE) program. All eligible CGs who gave verbal consent to participate were enrolled in the Caregiver Resources, Education, and SupporT (CREST) program, a state-sponsored, University-delivered service, with assessment and support provided by behavioral health clinicians (nurses, social worker and psychologist) via telephone. Upon commencing the program, CGs completed a comprehensive assessment that captured sociodemographics and CR's clinical characteristics (including the Revised Memory and Behavior Problems Checklist (RMBPC) for dementia-related symptoms, frequency and severity), the REACH Risk Appraisal Measure (with sub-scales for CG depressive symptoms, social support, and perceived caregiving strain), the Zarit Burden Interview (for caregiving-related burden, perceived general health), and the Desire to Institutionalize Scale (e.g., ever considered placing CR in a nursing home, taken steps to place CR, etc.). Results CGs were on average 65.6?years old (SD=12.1) and primarily female (73.1%) and non-Hispanic White (79.6%). Over half (58.4%) of CGs were adult children of the CRs and providing full-time care (60.5%). Bivariate analyses revealed that greater desire to institutionalize was positively correlated with the following variables: CR's total ADL/IADL difficulty and frequency of dementia-related behavioral symptoms, younger CG age, caregiving burden, caregiving strain, less social support, and being a non-spousal CG. An adjusted regression model revealed that only greater ADL/IADL difficulty (p=0.02), caregiving strain (p=0.003), and social support (p=0.01) were uniquely and significantly associated with CGs’ desire to institutionalize, after controlling for all other variables. Conclusions Findings from this real-world, clinical, community-based sample identified three variables that independently predict increased CG desire to institutionalize the CR. The findings point to the potential value of systematically addressing CG-level factors and incorporating CG assessments into routine clinical care for patients with dementia. Routine CG assessment may increase opportunities for families, health care providers, health systems and community agencies to identify cases in which providing increased ADL/IADL support, reducing caregiver strain, or increasing social supports might lead to reductions in CGs' desire to institutionalize, and increase the chances for care recipients to age in place. This research was funded by: Commonwealth of Pennsylvania, Department of Aging, PACE Program, PACE/PACENET.

The New York/New Jersey VA Health Care Network maintains an evidence-based approach to improving dementia recognition and supporting family caregivers of primary care veterans with dementia. This telephone-based program is administered through a telehealth call center and currently provides services to primary care clinics and family caregivers across the upstate New York region. The program includes brief cognitive and health behavior assessment for veterans with identified risk for undiagnosed dementia, linkage between primary care providers and dementia specialists, and, care management services. Caregiver education and support emphasizes training in management of behavioral symptoms of dementia. Program evaluation by the VA Center for Integrated Healthcare has demonstrated positive outcomes including: more rapid recognition of dementia in primary care; improved caregiver attitude, self-efficacy, and, understanding of veteran behaviors; and, the decreased costs of care for these veterans.

This cohort study evaluates factors associated with the transition to long-term benzodiazepine use among older adults newly prescribed this drug by a nonpsychiatric clinician.

Engagement rates in specialty mental health (MH) care for depression are suboptimal across the lifespan, prompting various efforts to promote treatment engagement. This study examined the extent to which age moderates the impact of message framing on appointment attendance among patients referred to specialty MH care. The study employed a randomized, prospective, experimental design. Patients meeting criteria for major depression and referred to specialty MH care at a Veterans Affairs Medical Center (n=360) were randomized to receive either a routine, neutrally worded patient reminder letter prior to their scheduled specialty MH care appointment or a letter that included one of two messages (gain-framed or loss-framed) that were added to the routine letter. Appointment/attendance data were extracted from the computerized patient record system. Logistic regression was used to determine the potential moderating effect of age on the association between message frame and appointment attendance. The sample (mean age = 51.5 (SD=13.5)) was primarily male (85%), non-white (62%), and reported an average depressive symptom score of 19.3 (SD=3.8, range=9-27). Age moderated the impact of message frame on the odds of attending the MH appointment: while younger adults were more likely to attend after receiving a gain-framed message, older adults’ engagement rates did not differ significantly across conditions. Findings suggest that overtly highlighting the benefits of attending an initial specialty MH care appointment, even if in writing, can impact engagement rates among younger adults. Potential alternative, targeted approaches utilizing message framing that may be more effective among older adults should be explored.

Introduction In 2008, the Pennsylvania Department of Aging (PA DoA) and its pharmacy benefits programs for low- to low-middle income older Pennsylvanians—the Pharmaceutical Assistance Contract for the Elderly (PACE) and PACE Needs Enhancement Tier (PACENET)—partnered with the University of Pennsylvania (Penn) to establish a telephone-delivered clinical service that supported geriatric patients and their primary care providers in delivering mental health care integrated within the primary care setting. This evidence-based collaborative care service improved outcomes for elderly Pennsylvanians with disorders of mood or cognition. In the context of the current opioid epidemic, PACE/PACENET and Penn agreed to pilot a new telephone-delivered collaborative care service to help geriatric patients with chronic pain who receive continuing prescriptions for very high doses of opioids. Objectives: To report preliminary findings from a pilot project that adapted an existing collaborative care service to facilitate reduction of high doses of prescription opioids in community dwelling elders. The principle aims were to measure levels of patient participation and engagement, and to determine the extent to which engaged patients and their prescribers achieve opioid dose reduction. Methods Patient Sample: From May through October 2018, a convenience sample of elderly patients receiving chronic opioid prescriptions for > 120 mg morphine-equivalent dose (MED) was referred by PACE/PACENET to the Penn collaborative care service. Clinical Intervention: Patients who agree to participate undergo comprehensive assessments of mental health, cognition, sleep, pain, and functional status by a Behavioral Health Lab (BHL) technician. Measures include the Patient Health Questionnaire-9 (PHQ-9); Generalized Anxiety Disorder -7 (GAD-7); Blessed Orientation-Memory-Concentration test (BOMC); Insomnia Severity Index (ISI); Pain intensity, interference with Enjoyment of life, and interference with General activity (PEG); pain self-efficacy questionnaire (PSEQ); and Veterans RAND 12-item Health Survey (VR-12) for mental and physical function. A follow up baseline interview with a BHL clinician (LSW or RN) includes self-reported daily opioid dose, assessment of medical-psychiatric co-morbidity, other medications and pain treatment modalities, and identification of unmet biopsychosocial needs. The BHL clinician engages the patient in individualized treatment planning, with emphasis on goals of opioid dose reduction to safer levels. Modalities of treatment offered include but are not limited to (1) behavioral pain management, (2) general medication education, (3) reinforcing positive health behaviors, (4) addressing barriers to change, (5) scheduling positive activities, and (6) relaxation techniques. Summary reports are sent to prescribers with recommendations for pain care management and opioid dose reduction. Program Evaluation: “Participation” was defined as patient agreement to participate in the initial health assessment with a BHL technician. “Engagement” was defined as completion of the baseline health assessment and at least two follow-up contacts with a BHL clinician. “Substantial dose reduction” was defined as at least 20% reduction from the self-reported baseline MED within the first 12 weeks of program engagement. Results 71 patients were referred over the first 5 months, 3 of whom were unable to participate due to communication barriers. Of the remaining 68 eligible patients, 49 (72%) participated in the initial health assessment. Of these participants, 25 (36.8% of eligibles) had at least 2 follow-up contacts with a BHL clinician and were considered “engaged” in the program. Participants’ mean age was 73.9 years (range, 65-87); 61.5% were male; 94.2% were White, 1.9% were Black; 96.2% were non-Hispanic, 1.9% were Hispanic. Participants’ mean PHQ-9 score was 8.3; mean GAD-7 score 4.3; mean BOMC score 4.1; and mean ISI score was 6.3. Mean baseline PEG and PSEQ scores were 7.1 and 6.0, respectively. Mean VR 12 mental health score was 47.4 indicating average overall functioning, and VR-12 physical score was 20.4 indicating low overall functioning. Of the 25 engaged patients, 21 (84%) achieved dose reductions, with a mean MED of 420 mg on initial assessment and 276 mg at the last contact. 36% of engaged individuals achieved dose reductions of >20%. Conclusions In this pilot program for elderly patients taking very high doses of prescription opioids, we found a high rate of participation in the initial assessment, and a moderate rate of engagement in follow-up. Although 36% of the engaged patients achieved substantial opioid dose reductions, these patients were still receiving unsafe doses. Nevertheless, these findings suggest that it is possible to adapt a collaborative care model to help some older adults achieve substantial reductions from high doses of prescription opioids. This research was funded by Pennsylvania Department of Aging

Background Posttraumatic Stress Disorder (PTSD) is a disabling illness suffered by many Veterans returning from war. Some Veterans believe that cannabis may be therapeutic for PTSD. The purpose of this study was to better understand the association between cannabis use and PTSD symptoms. Methods The study was a matched case-control cross-sectional evaluation of the psychiatric and sociocultural associations of cannabis use in Veterans with probable PTSD. Patient self-report measures were examined comparing cannabis users (cases) to non-users (controls) who were case-matched on age and gender. Results Results indicated that there were no significant differences between cases and controls in mean PTSD Checklist-Civilian version (PCL-C) scores (59.2 and 59.1, respectively). There was also no association between PTSD scores and frequency of cannabis use. It was also observed that cases were more likely to be non-Caucasian, financially challenged, and unmarried. Limitations The sample is a convenience sample of Veterans being referred for a clinical assessment and therefore, sampling biases may limit the generalizability of the results to other populations including Veterans not seeking health care in the Veterans Affairs (VA) system. Conclusions The results do not support the theory that cannabis use would be associated with less severe PTSD symptoms. Results do suggest important sociocultural differences in cannabis users compared to controls.

This study examined the extent to which perceived social support is related to longitudinal treatment outcomes among heavy drinkers randomized to a brief, telephone-based care management intervention versus standard care.This is a secondary analysis of data from a randomized trial comparing an enhanced, brief alcohol intervention to standard care. Participants comprised 136 male, heavy drinkers (mean age = 57.3 years) receiving primary care at Corporal Michael J. Crescenz Veterans Affairs Medical Center clinics. Participants in the intervention arm received a telephone-based care management intervention focused on helping patients reduce their alcohol use. Primary measures included the Timeline Followback method for number of heavy drinking days and the Multidimensional Scale of Perceived Social Support for self-reported baseline social support.Although there was no significant main effect for baseline perceived social support on number of heavy drinking days over time, there was a significant three-way interaction (Perceived Social Support × Randomization Group × Time). Specifically, among patients reporting high support, those randomized to the intervention arm experienced significantly greater declines in number of heavy drinking days over time. Conversely, among patients reporting low support, those randomized to standard care experienced more improvement over the course of followup.Perceived social support may be related to differential outcomes depending on whether patients are in care management or standard care. For those receiving brief intervention, certain therapy techniques may mobilize pre-existing social resources and/or enhance the ability for patients to use their social supports, suggesting the need for replication and further research in understanding this interaction.

Mental disorders have been linked to unemployment among veterans. Improving mental health conditions, such as depression, can improve veteran employment outcomes. This study compared mental health treatment among unemployed Operation Enduring Freedom (OEF; in Afghanistan) and Operation Iraqi Freedom (OIF; in Iraq) veterans and veterans from other service eras. The study included 3165 unemployed veterans from six Veterans Affairs medical centers with a positive screen that indicates a possible mental disorder. Chi-squared tests and logistic regression analyses assessed whether veteran era was associated with mental health treatment. Unemployed OEF/OIF veterans were less likely to receive psychotropic medication and four or more psychotherapy sessions compared to veterans from other eras. Multivariable analyses controlling for age found associations based on younger age rather than era. Younger unemployed veterans received fewer mental health services, which is concerning because reducing mental health symptoms may increase employment and employment may reduce symptoms, which are key factors in reintegration into civilian life.

Engagement rates in specialty mental health care for depression are suboptimal. This study examined the extent to which framing-by gain, by loss, or neutral- of health messages promotes appointment attendance among patients referred to specialty mental health care.The study employed a randomized, prospective, experimental design. Patients meeting criteria for major depression and referred to specialty mental health care at the Corporal Michael J. Crescenz Department of Veterans Affairs Medical Center were randomly assigned (N=360) to receive a patient reminder letter routinely mailed prior to scheduled specialty care appointments (neutral) or one of two messages (gain framed versus loss framed) that were added to the routine letter. Appointment and attendance data were extracted from the computerized system. Logistic regression was used to determine the association between message frame condition and initial appointment attendance.The sample (mean±SD age=51.5±13.5) was primarily male (85%) and nonwhite (62%), and the mean depressive symptom score indicated moderately severe depression. Participants who received the gain-framed message after being referred to specialty mental health care were significantly more likely to attend their appointment than those who received a neutral letter (p=.04). No statistically significant differences were noted among those receiving a loss-framed message compared with the other two arms.Findings suggest that highlighting the benefits of attending an initial specialty mental health care appointment, even if in writing, can affect engagement rates. If replicated, results have the potential to improve mental health treatment initiation rates in a timely, efficient, and cost-effective manner.

This study examined whether a telephone-delivered collaborative care intervention (SUpporting Seniors Receiving Treatment And INtervention [SUSTAIN]) improved access to mental health services similarly among older adults in rural areas and those in urban-suburban areas.This cohort study of 8,621 older adults participating in the SUSTAIN program, a clinical service provided to older adults in Pennsylvania newly prescribed a psychotropic medication by a primary care or non-mental health provider, examined rural versus urban-suburban differences in rates of initial clinical interview completion, patient clinical characteristics, and program penetration.Participants in rural counties were more likely than those in urban-suburban counties to complete the initial clinical interview (27.0% versus 24.0%, p=.001). Program penetration was significantly higher in rural than in urban-suburban counties (p=.02).Telephone-based care management programs such as SUSTAIN may be an effective strategy to facilitate access to collaborative mental health care regardless of patients' geographic location.

Parkinson's disease (PD) significantly impacts both patients' and spouses' emotional and physical health. However, despite the importance of social relationships for wellbeing, few studies have examined relationship quality and their correlates in individuals with PD and their partners. Specifically, no known studies have examined the association between benefit finding, or the experience of personal growth and other positive changes in the face of a stressor, and perceived marital quality. To address these gaps in the field, 25 married couples participated in a cross-sectional, pilot study. Patients were veterans diagnosed with idiopathic PD receiving care at the Philadelphia VA Medical Center. Each patient and spouse independently completed self-reported measures of sociodemographics, physical and mental wellbeing, caregiver burden, marital quality, and perceived benefits associated with having PD. Actor-partner interdependence models revealed that, after adjusting for covariates, greater perceived benefits from either having PD or living with a spouse with PD was associated with greater marital quality, both for that individual and their partner. Thus, perceiving positive consequences, such as personal growth, as a result of personally having PD or living with a spouse with PD is related to greater marital quality for both members of the marital dyad. Findings may inform individual and couples-based interventions that address the value of benefit finding and incorporate other techniques of positive reappraisal.

Objective The objective of this study is to understand the characteristics of older adults on newly prescribed psychotropic medication with minimal psychiatric symptoms. Methods Naturalistic cohort study of non-institutionalized older adults in Pennsylvania participating in the Pharmaceutical Assistance Contract for the Elderly. Persons newly prescribed antidepressant or anxiolytic monotherapy or combination therapy were contacted for clinical assessment by a telephone-based behavioral health service. The initial assessment included standardized mental health screening instruments and scales including the Blessed Orientation-Memory-Concentration test, Patient Health Questionnaire-9, Generalized Anxiety Disorder-7, and Medical Outcomes Survey (SF-12). In addition, patients were asked for their understanding of the prescription indication. Results Of the 254 participants who met minimal symptom criteria (Patient Health Questionnaire-9

Objective The aim of this investigation was to assess the relationships between suicidal ideation and insomnia symptoms in Veterans misusing alcohol. Method Data were extracted in this retrospective chart review of Veterans referred from primary care for a behavioral health evaluation (N = 161) based on evidence of heavy drinking, drug use or another behavioral problem. Suicidal ideation (SI) was assessed using the Paykel questionnaire. Insomnia symptoms were assessed with standard diary questions in an interview format and pertained to sleep latency (SL), wake after sleep onset time (WASO), sleep quality (SQ), and habitual sleep duration (HSD). The relations between suicidal ideation and insomnia symptoms were assessed using ordinal regression analyses adjusted for socio-demographic, psychiatric and addiction-related variables. Results Suicidal ideation was reported in 62 (39%) of the Veterans interviewed. In a multivariable model, only inadequate SQ was associated with suicidal ideation. Short sleepers were more likely to endorse suicidal ideation and have attempted suicide in the past year. In addition, older age, inadequate financial status, and the presence of a psychiatric disorder were also significantly associated with suicidal ideation in most of the adjusted models. Conclusion Given their association with suicidal ideation, insomnia symptoms in Veterans misusing alcohol should prompt an assessment of underlying psychiatric and social factors.

Dementia care is largely provided in primary care settings. This article describes a pilot project aimed at evaluating the effectiveness of an accessible, telephone-based, patient- and caregiver (CG)-centered, collaborative care management program that involves CG education and psychosocial support in improving CG and patient outcomes. CGs (n = 75) of older veterans with dementia receiving care from Veterans Affairs (VA) Medical Center primary care practices were randomized to receive either dementia care management or usual care (UC). Of interest in this study were the frequency and severity of patients' dementia-related symptom, CG distress related to patients' behavioral and neuropsychiatric symptoms (primary outcomes), and CG coping and mastery (secondary outcomes). Adjusted, intention-to-treat longitudinal models suggest that CGs receiving care management reported significantly greater reductions in distress due to patients' dementia-related (p = .05) and neuropsychiatric (p = .01) symptoms compared with CGs in UC. Additionally, CGs in the intervention reported significantly larger improvements in their ability to cope (p = .03) and caregiving mastery (p = .03). No significant group differences were found in CG burden or patients' dementia-related symptom frequency or severity over time. Findings suggest that CGs of veterans with dementia may benefit from a telephone-delivered, care management program in improving CG-related outcomes. Further research of care management programs for CG of veterans with dementia in addressing barriers to care and reducing CG burden is warranted. These findings highlight the potential for such programs as adjuncts to dementia care offered in primary care practices. (PsycINFO Database Record

The current study examined the independent association between positive (e.g., emotional and instrumental support) and negative (e.g., insensitive behavior, unwanted advice from others) social exchanges and suicidal ideation among veterans referred for a behavioral health assessment. The sample included 606 veterans [mean age = 54.96 (SD = 14.96)] referred by primary care for a clinical mental health/substance abuse (MH/SA) assessment following a positive MH/SA screen. Data on sociodemographics, MH/SA conditions (e.g., depression, PTSD, anxiety, and alcohol abuse), the self-reported frequency of positive and negative social exchanges, and suicidal ideation were extracted from clinical interviews and evaluated. Veterans were primarily male, non-married, and had adequate financial resources, and approximately half were White. 74.4 and 20.3 % met criteria for a MH/SA condition and suicidal ideation, respectively. Multiple logistic regression analyses revealed that, adjusting for sociodemographics, physical functioning, and comorbid MH/SA conditions, veterans reporting more frequent negative exchanges with network members were significantly more likely to report suicidal ideation. Positive exchanges, in contrast, were not significantly related to the outcome. Inadequate finances and MH/SA conditions also were significantly related to suicidal ideation. Findings highlight the value of exploring the quality of social exchanges among veterans in primary care who screen positive for behavioral health issues, as such information has the potential to inform screening and intervention efforts aimed at reducing suicidal ideation.

Objective This study aimed to explore the longitudinal, 6-month symptom course of older adults newly started on an antidepressant or anxiolytic by non-psychiatrist physicians and enrolled in a care management program. Method This is a naturalistic cohort study of older adults (age ≥65 years) receiving pharmacotherapy and telephone-based care management. Participants are non-institutionalized adults participating in Pennsylvania's Pharmaceutical Assistance Contract for the Elderly who completed telephone-based clinical assessments including demographic data, self-report on history of psychiatric treatment and adherence, and standardized symptom scales. Results A total of 162 participants with an average age of 77.2 years (SD 6.8) were followed and, for analysis, split into two groups by PHQ-9 score: 75 (46.3%) scoring 0–4 (minimally symptomatic group, MSG) and 87 (53.7%) scoring ≥5 (symptomatic group, SG). Over 6 months, the SG improved with PHQ-9 scores beginning on average at 10.0 (SD 4.6) and falling to 5.4 (SD 4.2) (F(1, 86) = 29.53, p

Objectives To examine overall cognitive screening results and the relationship between cognitive screen score and sociodemographic characteristics, reason for referral, and clinical outcomes of older veterans referred by primary care for a behavioral health assessment. Design Cross-sectional, naturalistic study. Setting Primary care clinics affiliated with two VA Medical Centers. Participants The sample included 4,325 older veterans referred to the Behavioral Health Laboratory who completed an initial mental health/substance abuse assessment. Veterans were categorized into the following three groups on the basis of cognitive status: within normal limits, possible cognitive impairment, and possible dementia. Measurements Sociodemographic and clinical data on reason for referral, cognitive functioning (i.e., Blessed Orientation-Memory-Concentration test), and behavioral health assessment outcomes were extracted from patients' medical records. Data were analyzed using multiple linear and logistic regressions. Results Results of cognitive screenings indicated that the majority of the sample was within normal limits (62.5%), with 25.8%, 8.1%, and 3.6% of patients evidencing possible cognitive impairment, possible dementia, and Blessed Orientation-Memory-Concentration scores of 17 or more, respectively. With regard to reason for referral, patients with greater cognitive impairment were more likely to be identified by the antidepressant case finder than patients with less impairment. Increased age, non-white ethnicity, self-perceived inadequate finances, major depressive disorder, and symptoms of psychosis were associated with greater cognitive impairment. Conclusions Findings highlight the importance of evaluating cognitive status in older adults who are referred for a behavioral health assessment and/or receive a new mental health/substance abuse diagnosis. Doing so has the potential to improve recognition and treatment of cognitive impairment and dementia, thereby improving quality of care for many older adults.

Objectives To examine age group differences in the identification, engagement, clinical outcomes, and monitoring of older, relative to middle aged and younger, veterans with behavioral health needs enrolled in an integrated care management program Design Cross-sectional and longitudinal Setting Primary care clinics affiliated with two Veterans Affairs Medical Centers Participants A total of9,087 veterans were referred to the Behavioral Health Laboratory (BHL) for a behavioral health assessment and 7,251 completed an initial assessment Measurements Data on consult source and reason for the referral, clinical assessment outcomes, and engagement were collected during a 3-year period. Variations in process and patient-level factors were examined as a function of age group. Results Although all age groups evidenced high rates of engagement in clinical assessment calls, older adults were slightly more likely to complete the assessments than young/middle-aged veterans. Clinical assessment outcomes revealed that although older adults were less likely to meet criteria for more complex, severe conditions, rates of disorder remained clinically significant, and comorbidity was common. Finally, older veterans receiving treatment monitoring for a newly prescribed antide- pressant consistently reported high rates of antidepressant adherence during the course of the monitoring calls and showed significant reductions in depressive symptomatology during the course of monitoring. Conclusions Results indicate age-related variability in processes and outcomes among veterans referred to the BHL and suggest that older veterans are just as likely to benefit from a program designed to facilitate the identification, engagement, monitoring, and care management of primary care patients experiencing behavioral health issues.

This investigation assessed the extent to which various health factors are associated with difficulties initiating and maintaining sleep (DIMS) and nightmares among Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) veterans reporting a trauma (combat, noncombat, or a trauma before service). Veterans (N = 201, 88.1% male, mean age = 34.2, SD = 10.1) were referred by primary care for a behavioral health assessment upon evidence of psychiatric symptoms. Sleep problems were assessed using items from the PTSD checklist. After controlling for demographics and nonsleep PTSD symptoms, head injury with a loss of consciousness increased the likelihood of severe nightmares (OR = 3.77, p = 0.019), alcohol abuse or dependence increased the likelihood of moderate nightmares (OR = 4.80, p = 0.007), and greater nonsleep depression increased the likelihood of severe DIMS (OR = 1.20, p = 0.008). Thus, factors aside from PTSD severity are related to sleep disturbance in OIF/OEF veterans reporting a trauma.

Introduction: Experts speculate about the mechanisms through which depression interventions operate. However, little is known about what patients think are the "active ingredients" in depression treatment. Given the importance of patient-centered care, understanding this dimension of the provider-intervention-patient interaction provides a missing piece to designing interventions that are congruent with patients' beliefs and preferences about treatment initiation, treatment adherence, and treatment maintenance. Methods: The authors used a parallel mixed methods design to identify a purposive sample of 24 older adults with depression who participated in either an integrated care or an enhanced referral model of depression treatment. Open-ended semistructured interviews were used to identify patient perceptions about the benefits of depression treatment during the study. Quantitative assessments of depression status were made at the completion of participation in the treatment study and 6 months postparticipation. Results: Twelve of 24 participants achieved remission of their depression symptoms, with the remainder showing no improvement or a partial response to treatment. Participants who achieved and sustained a remission of their depression symptoms (N = 7) attributed their improvement to clear psychoeducational support with their depression care providers and described an ability to affect the outcome of their treatment. Participants who improved but then relapsed described their treatment in vague terms, referring to social aspects of participation. Participants who did not achieve remission ascribed recognition and treatment of their depression to forces outside themselves and described few details about their treatment. Conclusion: Clinicians should consider patient perceptions of the benefits of depression treatment as they discuss and implement therapeutic interventions with depressed older adults.

OBJECTIVES: To investigate whether pain severity and interference with normal work activities moderate the effects of depression treatment on changes in depressive symptoms over time in older adults in primary care. DESIGN: Patient-randomized, clinical trial. SETTING: Multisite: three clinics located in Veterans Affairs Medical Centers. PARTICIPANTS: Adults aged 60 and older (n=524) who screened positive for depression and participated in the Primary Care Research in Substance Abuse and Mental Health for the Elderly Study. INTERVENTION: Integrated care versus enhanced specialty referral care. MEASUREMENTS: Pain severity, the degree to which pain interferes with work inside and outside of the home, and depressive symptoms were examined at baseline and 3, 6, and 12 months. RESULTS: Intention-to-treat analyses revealed that both treatment groups showed reduced depressive symptoms over time, although self-reported pain moderated reductions in depressive symptoms. At higher levels of pain severity and interference with work activities, improvements in depressive symptoms were blunted. Furthermore, pain interference appeared to have a greater effect on depressive symptoms than did pain severity; in individuals with major depression, pain interference fully accounted for the moderating effects of pain severity on changes in depressive symptoms over time. CONCLUSION: Pain and its interference with functioning interfere with recovery from depression. Findings highlight the importance of addressing multiple domains of functioning (e.g., physical and social disability) and the degree to which pain and other forms of physical comorbidity may hinder or minimize treatment-related improvements in depressive symptoms.

Importance Mental health (MH) conditions are undertreated in late life. It is important to identify treatment strategies that address variability in treatment content and delivery and take individual-specific symptoms into account, particularly among low-income, community-dwelling older adults. Objective To evaluate program feasibility and MH outcomes among community-dwelling older adults randomized to 1 of 2 treatment arms of varying intensity of evidence-based, collaborative MH care management services (ie, the Supporting Seniors Receiving Treatment and Intervention [SUSTAIN] program) that provide standardized, measurement-based, software-aided MH assessment and symptom monitoring and connection to community resources via telephone. Design, Setting, and Participants Trial participants were 1018 older, community-dwelling, low-income adults prescribed an antidepressant or anxiolytic by a primary care or non-MH professional and experiencing clinically significant MH symptoms at intake. The participant subsample was drawn from a larger parent sample of older adults enrolled in the SUSTAIN program. Individuals were randomized to receive MH symptom monitoring alone (hereafter monitoring alone) or MH symptom monitoring plus care management (hereafter care management) provided by an MH professional. Baseline characteristics were examined, and changes in clinical MH outcomes were evaluated at 3-month and 6-month follow-up. The study dates were August 5, 2010, to May 5, 2014. Interventions Monitoring alone or care management delivered by an MH professional. Main Outcomes and Measures Overall MH functioning (primary) and depressive and anxiety symptoms. Results A total of 509 participants were randomized to the monitoring alone group and 509 to the care management group; 377 and 401 completed ≥2 research assessments in the monitoring alone and case management groups, respectively. Compared with those randomized to monitoring alone, individuals randomized to care management showed greater improvements in the 3 domains of MH functioning (β [SE], 0.36 [0.12]; 95% CI, 0.12 to 0.60; P = .004), depressive symptoms (β [SE], −0.20 [0.06]; 95% CI, −0.32 to −0.09; P P Conclusions and Relevance The SUSTAIN program, which provides assessment, monitoring, care management, and brief therapies for MH symptoms and needs in primary care settings, is feasible and scalable. A more intense level of care (ie, symptom monitoring plus care management) is associated with more favorable individual outcomes for low-income, community-dwelling older adults experiencing clinically significant MH symptoms. Trial Registration clinicaltrials.gov Identifier:NCT02440594

Author(s): Sorkin, Dara H; Mavandadi, Shahrzad; Rook, Karen S; Biegler, Kelly A; Kilgore, David; Dow, Emily; Ngo-Metzger, Quyen | Abstract: ObjectiveThis study sought to evaluate the feasibility of a pilot, dyad-based lifestyle intervention, the Unidas por la Vida program, for improving weight loss and dietary intake among high-risk Mexican American mothers who have Type 2 diabetes and their overweight/obese adult daughters.MethodMother-daughter dyads (N = 89) were recruited from two federally qualified health centers and randomly assigned to either the Unidas intervention or to the control condition. The 16-week Unidas intervention consisted of the following: (a) four group meetings, (b) eight home visits, and (c) booster telephone calls by a lifestyle community coach. The control condition consisted of educational materials mailed to participants' homes. Participants completed surveys at T1 (baseline) and T2 (16 weeks) that assessed various demographic, social network involvement, and dietary variables.ResultsUnidas participants lost significantly more weight at T2 (p l .003) compared with the control participants. Furthermore, intervention participants also were more likely to be eating foods with lower glycemic load (p l .001) and less saturated fat (p = .004) at T2. Unidas participants also reported a significant increase in health-related social support and social control (persuasion control only) and a decrease in undermining.ConclusionsThe Unidas program promoted weight loss and improved dietary intake, as well as changes in diet-related involvement of participants' social networks. The results from this study demonstrate that interventions that draw upon multiple people who share a health-risk have the potential to foster significant changes in lifestyle behaviors and in social network members' health-related involvement. Future research that builds on these findings is needed to elucidate the specific dyadic and social network processes that may drive health behavior change.

Purpose of the Study The evidence base for dementia care management interventions for informal caregivers (CGs) is strong, yet enrollment and sustained engagement in academic and community-based research trials is low. This study sought to examine rates and correlates of participation in a community-based, telephone-delivered dementia care management program designed to address logistic and practical barriers to participation in CG trials and services. Design and Methods Participants included 290 CGs of older, community-dwelling, low-income care recipients (CRs) who met criteria for enrollment in a collaborative dementia care management program that provides assessment, psychosocial support and education, and connection to community resources via telephone. Cross-sectional analyses examined the association between CG-related (e.g., financial status, relationship to CR, caregiving burden) and CR-related (e.g., functional limitations, symptom severity) factors and CG enrollment and engagement. Results The majority of CGs were non-Hispanic White, female, financially stable, and adult children of the CRs. Over half of CGs lived with the CR and provided 20 or more hours of care per week. Roughly half of CGs refused care management services. Adjusted logistic regression models revealed that perceived caregiving burden and financial status were related to initial enrollment and engagement in services once enrolled, respectively. Implications A significant proportion of CGs refuse free, convenient, evidence-based dementia care management services, underscoring the need for further examination of correlates of program acceptance. Nonetheless, community-based programs that address barriers may improve enrollment and engagement rates among CGs, including those who are especially vulnerable to negative CG and CR outcomes.

How to best use urine drug test (UDT) results in the management of opioid pharmacotherapy has not been elucidated. The purpose of this study was to describe how the results of UDTs gathered from a group of chronic pain patients in a high-risk monitored opioid pharmacotherapy program apply to treatment outcome.: Retrospective review of the medical records of 335 primary care patients on chronic opioids more than 22 months.: Patients with a UDT containing unprescribed opioids were more likely to demonstrate resolution of aberrant behavior (P = 0.02) and less likely to be discharged from treatment (P = 0.04). Patients with cocaine, alone or in combination, in the UDT were less likely to resolve aberrant behavior (P = 0.007 and 0.001), and were more likely to be electively or administratively discharged from treatment (P = 0.012 and 0.001).: In this group of high-risk pain patients on chronic opioids, information gained from UDT results can be used to predict treatment outcomes and inform appropriate interventions. Patients on chronic opioids who have a UDT positive for an illicit opioid or unprescribed opioids alone are more likely to respond to monitored opioid pharmacotherapy. Patients with a UDT positive for cocaine, alone or in combination, are less likely to resolve aberrant behavior within the structure of a monitored opioid pharmacotherapy program and are more likely to be discharged electively or administratively from the program without significant transition to addiction treatment. Further studies are needed to investigate which patient responded best to structured opioid pharmacotherapy programs and how to appropriately handle abnormal UDT results to improve the management and engagement in appropriate treatment for this population.

Objective:The primary purpose of this study was to compare referral to additional clinical services after primary care clinicians screened for and found a positive screen for alcohol misuse, depression, or posttraumatic stress disorder (PTSD). Methods:Results from the Alcohol Use Disorders Identification Test, Patient Health Questionnaire 2, and Primary Care PTSD screens performed over two years at the Philadelphia Veterans Affairs (VA) Medical Center and affiliated VA community sites were analyzed by mixed-effects logistic regression. A total of 9,052 veterans with positive screens were eligible for additional clinical services. Results:Odds of referral to additional clinical services for positive depression or PTSD screens were significantly higher than for positive screens for alcohol misuse (odds ratio=10.60 and 19.49, respectively). Conclusion:Primary care-based screening for alcohol misuse is managed differently than for depression or PTSD. (Psychiatric Services 62:310–312, 2011)

Utilizing a heterogenous sample of adults diagnosed with HIV infection, the current study sought to explore associations among age, various dimensions of social support, and psychological and functional well-being.Cross-sectional data capturing subjective and instrumental support, social interaction, behavioral health service utilization, and psychological well-being (ie, positive affect and depressive symptomatology), and physical functioning, were collected from 109 men and women living with HIV. To explore age group differences, participants were stratified by age (54 vs. 55+ years).Despite endorsing greater medical comorbidity, older adults reported significantly lower depressive symptomatology and greater positive affect and were less likely to report seeing a behavioral health specialist than their younger counterparts. No age group differences emerged for instrumental support or amount of social interaction. However, older adults reported higher subjective support, which in turn was associated with lower depressive symptomatology, greater positive affect, and nonutilization of behavioral health services.More attention should be paid to the social environment of individuals diagnosed with HIV as the quality of social relationships may be particularly important for successful psychological adaptation to HIV.

Recent studies have shown that a significant number of veterans returning from conflicts in Iraq (Operation Iraqi Freedom [OIF]) and Afghanistan (Operation Enduring Freedom [OEF]) are struggling with recovery from trauma.1,2,3 While posttraumatic stress disorder (PTSD) has traditionally been diagnosed using Axis I criteria, understanding the impact of trauma in OEF/OIF veterans may also require an analysis of subdromal or partial PTSD, which is characterized by a constellation of PTSD symptoms without meeting full criteria for the disorder. In light of the fact that reactions to extreme stress may exist on a dimensional scale,4 it is possible that individuals on the border of meeting criteria for a formal diagnosis of PTSD (ie, partial PTSD) may be in need of mental health treatment. Community-based studies and investigations from clinical populations have documented rates of partial PTSD ranging from 50% to approximately 3 times that of full PTSD.5–8 Thus, focusing only on individuals with the full diagnosis of PTSD may significantly underestimate the number of newly returning veterans who may be in need of care. In order to assess whether those with partial PTSD indeed exhibit meaningful symptoms that may require or warrant clinical care, a number of studies have compared functioning differences between those with partial and full PTSD. These investigations have generally revealed greater disability in individuals with full PTSD as compared to those with partial PTSD, who in turn, report greater disability than trauma-only groups who experienced a trauma with few or no symptoms.6–9 The extent of the disparities between groups, however, has been mixed, suggesting that the disability associated with partial PTSD requires greater clarification. Further, only 1 other study has assessed for functional problems in partial PTSD among veterans. In this study, Grubaugh et al9 compared older veterans (mean age = 61.4 years) with various symptom levels of PTSD on the Medical Outcomes Study 36-item Short-Form Health Survey,10 which can be used to compare disability to a healthy national sample. Although scores for partial PTSD were significantly worse than those of a trauma-only comparison group after controlling for depression, these scores were in fact better than the national average.9 This suggests that the partial PTSD among veterans did not necessarily show significant impairment. However, this Clinical Points ♦ Newly returning veterans reporting a trauma who do not meet full criteria for posttraumatic stress disorder (PTSD) may still be experiencing meaningful symptoms warranting care. ♦ Careful assessment of functioning and other psychopathology in those below the cutoff for full PTSD may help identify individuals in need of clinical attention. study included older veterans who experienced trauma many years prior to their participation in the study. Consequently, these findings may not be representative of current OEF/OIF veterans.9 Also, because depression shares multiple symptoms with PTSD and may be subject to the same effects of trauma,11 it is possible that controlling for depression minimized the observed association between trauma/PTSD and functioning.9 In order to build upon prior work and address the relationship between functioning and partial/full PTSD diagnoses specifically among newly returning veterans, the current study compared mental and physical functioning among OEF/OIF veterans who were referred by primary care for a behavioral health assessment and reported an emotional trauma. We used a standardized measure of functioning that can be compared to national norms and assessed functioning both with and without accounting for other psychiatric factors. PTSD is consistently associated with increased disability,12–15 and it is expected that OEF/OIF veterans with PTSD will also report greater functional problems as compared to a trauma-only group who experience no or few symptoms of PTSD. If individuals with partial PTSD show functioning complaints similar to that of full PTSD, it will provide evidence that their clinical symptoms may warrant greater attention and may indicate that these individuals should be offered psychosocial and psychiatric treatment similar to those with the full disorder.

BACKGROUND: This investigation aims to determine the 12-month drinking trajectory of older at-risk drinkers in treatment. Furthermore, the drinking trajectory between at-risk drinkers who had met the threshold suggestive of alcohol dependence (problem at-risk drinkers) and those who did not meet this threshold (nonproblematic at-risk drinkers) were compared. METHODS: This investigation is a component of the PRISM-E (Primary Care Research in Substance Abuse and Mental Health for the Elderly) Study, a multisite randomized trial comparing service use, outcomes, and cost between Integrated (IC) versus Enhanced Specialty Referral (ESR) care models for older (65+ years) adults with depression, anxiety, and/or at-risk alcohol consumption. This investigation focuses only on at-risk drinkers, generally defined as exceeding recommended drinking limits, which in the case of older adults has been classified as consuming more than one drink per day. Two hundred fifty-eight randomized older at-risk drinkers were examined, of whom 56% were problem drinkers identified through the Short Michigan Alcohol Screening Test-Geriatric version. RESULTS: Over time, all at-risk drinkers showed a significant reduction in drinking. Problem drinkers showed reductions in average weekly consumption and number of occurrences of binge drinking at 3, 6, and 12 months, whereas nonproblematic drinkers showed significant reductions in average weekly consumption at 3, 6, and 12 months and number of occurrences of binge drinking at only 6 months. IC treatment assignment led to higher engagement in treatment, which led to better binge drinking outcomes for problem drinkers. Despite significant reductions in drinking, approximately 29% of participants displayed at-risk drinking at the end of the study. CONCLUSIONS: Results suggest that older at-risk drinkers, both problem and nonproblematic, show a considerable decrease in drinking, with slightly greater improvement evidenced in problem drinkers and higher engagement in treatment seen in those assigned to IC. Language: en

The growing demand for laparoscopic bariatric surgery has led to an increase in the development of new bariatric surgical practices. Proper hospital facilities and an experienced bariatric surgical team are necessary to ensure optimal patient results. We surveyed academic centers participating in the University HealthSystem Consortium to examine the current practice of bariatric surgery. The survey questioned (1) availability of resources and equipment designed for the morbidly obese, (2) accidents, equipment problems, and workers' compensation relating to the care of bariatric surgical patients, (3) credentialing of bariatric surgeons, and (4) suggestions for improvements in the bariatric surgery program. Twenty-five institutions that perform bariatric surgery responded. Although the majority of institutions noted that they had basic bariatric equipment, some organizations did not have facility resources such as high-weight operating room tables and computed tomography scanners or transfer devices. Twenty-eight percent of institutions reported having accidents or equipment problems and 40% of institutions had workers' compensation claims relating to the care of bariatric patients. With regard to credentialing, 60% of institutions required the surgeons to have performed a minimum number of procedures prior to granting privileges. Suggested improvements included the need for more specialized bariatric equipment, enhancement of the education of all members of the bariatric surgical team, and designation of a bariatric physician who would coordinate care. This survey of bariatric surgery practices at academic medical centers demonstrates that the practice of bariatric surgery could be improved with regard to availability of bariatric equipment and resources and credentialing of surgeons.

Hypothesis An increase in national utilization of bariatric surgery correlates with the dissemination of laparoscopic bariatric surgery. Design Evaluation of Nationwide Inpatient Sample data from 1998 through 2002. Setting National database. Patients A total of 188 599 patients underwent bariatric surgery for the treatment of morbid obesity. Main Outcome Measures Annual total number of bariatric operations, the proportion of Roux-en-Y gastric bypass vs gastroplasty, the proportion of laparoscopic cases, postoperative length of stay, crude in-hospital mortality, and the number of institutions that perform bariatric surgery. Results Between 1998 and 2002, the number of bariatric operations increased from 12 775 cases to 70 256 cases. The rate of bariatric surgery increased from 6.3 to 32.7 procedures per 100 000 adults. Laparoscopic bariatric surgery increased from 2.1% to 17.9%. The number of bariatric surgeons with membership in the American Society for Bariatric Surgery increased from 258 to 631, and the number of institutions that perform bariatric surgery increased from 131 to 323. During this 5-year period, the annual rate of laparoscopic bariatric surgery increased exponentially (by 44-fold) compared with a linear growth in open bariatric surgery (by 3-fold). Conclusions Between 1998 and 2002, there was a 450% increase in the number of bariatric operations performed in the United States, a 144% increase in the number of American Society for Bariatric Surgery bariatric surgeons, and a 146% increase in the number of bariatric centers. The growth of laparoscopic bariatric surgery during this 5-year period greatly exceeds that of open bariatric surgery.