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Objective: This study assessed whether increased frequency of clinical monitoring during the high-risk period of 12 weeks after discharge from a psychiatric hospitalization reduced subsequent rehospitalization in a national cohort of Veterans Health Administration patients receiving depression treatment between 1999 and 2004.Methods: A case-control design was used. Patients who had at least two inpatient psychiatric hospitalizations were identified (case group, N=17,852) and then individually matched with up to two patients who also had been discharged from psychiatric inpatient settings but were not rehospitalized for the number of days between the case-group patient's discharge and subsequent rehospitalization (N=35,511).Results: Covariate-adjusted relative risk (RR) did not show an association between increased monitoring and subsequent psychiatric hospitalization, but there was a significant negative interaction between monitoring and a comorbid substance use disorder diagnosis (p<.001). Increased monitoring was positively associated with rehospitalization of patients without a substance use disorder, whereas increased monitoring was not associated with increased risk of rehospitalization of those with a comorbid substance use disorder. The RR of rehospitalization associated with a weekly monitoring visit (12 visits per 84 days) versus no monitoring visit was 1.14 for patients without a substance use disorder, whereas the RR was reduced to .94 for patients with a substance use disorder.Conclusions: Increased outpatient monitoring during the high-risk period after discharge appears to have a modest protective effect on rehospitalization among depressed patients with a comorbid substance use disorder. [ABSTRACT FROM AUTHOR]

Objective: To assess the relationship between closer monitoring of depressed patients during high-risk treatment periods and death from suicide, using two analytic approaches.Data Source: VA patients receiving depression treatment between 1999 and 2004.Study Design: First, a case-control design was used, adjusting for age, gender, and high-risk days (1,032 cases and 2,058 controls). Second, an instrumental variable (IV) approach (N=714,106) was used, with IVs of (1) average monitoring rates in the VA facility of most use and (2) monitoring rates of VA facilities weighted inversely by distance from patients' residences.Principal Findings: The case-control approach indicated a modest increase in suicide risk with each additional visit (odds ratio=1.02; 95 percent confidence interval=1.002, 1.04). The "facility used" IV estimate indicated near zero change in risk (0.0008 percent increase; p=.97) with each additional visit, while the distance-weighted IV estimate indicated a 0.032 percent decrease in risk (p=.29). An alternative analysis assuming a threshold effect of ≥4 visits during high-risk periods also showed a decrease (0.15 percent; p=.08) using the distance IV.Conclusions: The IV approach appeared to address the selection bias more appropriately than the case-control analysis. Neither analysis clearly indicated that closer monitoring during high-risk periods was significantly associated with reduced suicide risks, but the distance-weighted IV estimate suggested a potentially protective effect. [ABSTRACT FROM AUTHOR]

Objectives: This study investigated whether dosing frequency affects antipsychotic medication adherence among patients with schizophrenia.Methods: Databases from the Department of Veterans Affairs were used to assess adherence among patients with a diagnosis of schizophrenia. Adherence was measured by using antipsychotic medication possession ratios (MPRs). Adherence was compared among patients who experienced an increase or decrease in dosing frequency and among patients on stable regimens of once-daily or more than once-daily dosing.Results: Among patients with a dose increase (N=1,639), those with increases in dosing frequency (N=258) had a mean change in MPRs of -.105, compared with -.002 for those without a dosing frequency change (N=1,381) (p<.001). Patients with decreases in dosing frequency (N=1,370) had a small but significant increase in mean MPRs (MPR change=.045) when compared with 2,740 patients without a dosing frequency change (MPR change=-.018) (p<.001). Among patients on stable regimens (N=32,612), there were no significant differences in MPRs between those receiving once-daily dosing (MPR=.80) and those receiving more than once-daily dosing (MPR=.80).Conclusions: Among patients on less stable dosing regimens, increases in dosing frequency may result in modest decreases in adherence. [ABSTRACT FROM AUTHOR]

OBJECTIVE: Nonadherence limits the effectiveness of medications among patients with bipolar disorder. This study examined adherence with lithium and anticonvulsant medication among patients with bipolar disorder receiving treatment in Department of Veterans Affairs (VA) settings. METHODS: Patients receiving treatment in the VA for bipolar disorder during federal fiscal year 2003 (FY03) and receiving lithium or anticonvulsant medication were identified (N=44,637) by using the VA's National Psychosis Registry. Medication adherence was assessed by using the medication possession ratio (MPR) for lithium, valproate or divalproex, carbamazepine, and lamotrigine. Patients were categorized into three groups: fully adherent (MPR greater than .80), partially adherent (MPR from more than .50 to .80), and nonadherent (MPR less than or equal to .50). RESULTS: A slight majority of individuals (54.1%) were fully adherent, 24.5% were partially adherent, and 21.4% were nonadherent. Nonadherent individuals were more likely to be younger, unmarried, nonwhite, or homeless or to have diagnoses of a substance use disorder or fewer outpatient psychiatric visits in FY03. Adherence intensity was somewhat lower for valproate, compared with lithium or other anticonvulsants. Individuals given prescriptions for two agents to stabilize mood had better adherence than individuals given prescriptions for a single agent. Unexpectedly, in multivariate analyses adjusting for prior hospitalization, number of outpatient psychiatric visits, and a diagnosis of substance use disorder, poorer adherence was associated with decreased rates of hospitalization. CONCLUSIONS: Nearly one in two individuals given prescriptions for lithium or anticonvulsant medication to treat bipolar disorder did not take their medications as prescribed. The effectiveness of bipolar medication treatments is reduced by high rates of nonadherence in clinical settings. [ABSTRACT FROM AUTHOR]

OBJECTIVES: Global patient characteristics may affect adherence across all medications in a regimen, making medication-specific risk factors for adherence problems less important. Medication adherence was examined among patients with schizophrenia and comorbid physical conditions for consistency across therapeutic classes. METHODS: A national sample of veterans was selected according to use of medication for schizophrenia, diabetes, and hypertension (N=1,686). Adherence to each medication type was assessed with medication possession ratios (MPRs). Multilevel logistic models were used to study the impact of medication type on adherence, as well as the effect of other medication characteristics (such as the average days of medication supplied per refill), health service use, and patients' sociodemographic characteristics. RESULTS: Adherence was only modestly correlated across types of medication. Information about antipsychotic adherence explained only 13% and 16% of the variance in patients' antihypertensive and hypoglycemic MPRs, respectively. In unadjusted analyses, patients were more likely to have poorer adherence (MPR less than .8) to their antipsychotics (35%) than to their hypoglycemic (29%) or antihypertensive medications (26%) (p<.001). However, when analyses controlled for the average days' supply and other regimen characteristics, hypoglycemic and antihypertensive medications were associated with an increased risk of poor adherence relative to antipsychotics (both adjusted odds ratios=1.5, p<.001). CONCLUSIONS: Patients with schizophrenia and comorbid physical conditions demonstrated important differences in adherence across medications in their regimen, reinforcing the importance of medication-specific factors in determining adherence behavior. The lower levels of adherence observed for antipsychotics may be associated with the shorter refill intervals for these medications. [ABSTRACT FROM AUTHOR]

This paper describes the development and testing of a new self-report measure, the Dyspepsia Symptom Severity Index (DSSI), for assessing the severity of symptoms commonly associated with dyspepsia. The instrument was based on the literature, focus groups, and feedback from gastroenterologists; 48 patients and 24 controls participated in testing. Patients completed the DSSI and a symptom diary to test concurrent validity; one-week reproducibility was evaluated in 21 stable patients. Three subscales comprise the 20-item DSSI, representing reflux-, ulcer-, and dysmotility-like symptoms. Subscale internal consistency levels (alpha) were high (0.84-0.89), total score alpha levels were very good (0.76, 0.80), and scores were reproducible (ICC = 0.90-0.92). Correlations between the DSSI and diary were moderate to strong (r = 0.33-0.77; P < 0.05). Patients reported significantly more severe symptoms than controls (P < 0.001). Results indicate the DSSI is a reliable and valid tool for evaluating symptom severity in patients with functional dyspepsia. [ABSTRACT FROM AUTHOR]

The aim of this study was to determine the prevalence of upper gastrointestinal symptoms (UGIS) in a general population and quantify the relationship of those symptoms to healthcare utilization and quality of life. In-person interviews were conducted with 2056 United States and Canadian residents selected at random. Subjects reported frequency and severity for 11 symptoms, prescription and over-the-counter medication use, primary care and specialty physician visits in prior three months, and completed the Psychological General Well-Being Scale. For analyses, subjects were classified into four mutually exclusive symptom groups: gastroesophageal reflux disease (GERD) -like, GERD plus motility-like (GERD+), ulcerlike, and motility-like. Of the total sample, 51.4% reported the occurrence of at least one UGIS in the prior three months. Subjects in the GERD+ and ulcer groups used more prescription medications and were more likely to see a physician about the symptoms (P<0.001). Subjects with symptoms demonstrated poorer quality of life compared to subjects with no symptoms. The prevalence of UGIS in the general population is high and symptoms are associated with significant health-care utilization and poorer quality of life. [ABSTRACT FROM AUTHOR]

A study examining records from U.S. veterans receiving opioids for pain management between 2004 and 2009 has found an increased risk of death from opioid overdose in patients who took opioids and benzodiazepines concurrently. Risk of death increased at higher daily benzodiazepine doses, study authors reported. Results were published online June 10 in the BMJ. INSET: précis. [ABSTRACT FROM AUTHOR]

Background: Little information is available on the impact of the atypical antipsychotic olanzapine on quality of life (QOL). A 6-week, double-blind randomized multicenter trial, with a long-term extension, was conducted to evaluate the clinical efficacy and QOL of olanzapine and haloperidol in treating schizophrenia and other psychotic disorders.Methods: A total of 828 outpatients provided QOL data. Study patients were aged greater than 18 years with a DSM-III-R diagnosis of schizophrenia, schizophreniform disorder, or schizoaffective disorder and baseline BPRS (items scored on 0-6 scale) total scores, > or = 18 were randomized to 6 weeks of treatment with olanzapine 5 to 20 mg/day or haloperidol 5 to 20 mg/day. Patients entered a 46-week double-blind extension if they demonstrated minimal clinical response and were tolerant to study medication. The Quality of Life Scale (QLS) and SF-36 Health Survey were used to evaluate QOL.Results: During the 6-week acute phase, olanzapine treatment significantly improved BPRS total (p = 0.004), PANSS total scores (p = 0.043), QLS total (p = 0.005), intrapsychic foundations (p < 0.001) and interpersonal relations scores (p = 0.036), and SF-36 mental component summary scores (p < 0.001) compared with haloperidol. During the extension phase, olanzapine treatment significantly improved PANSS negative scores (p = 0.035) and improved QLS total (p = 0.001), intrapsychic foundations (p < 0.001), and instrumental role category scores (p = 0.015) versus haloperidol treatment. Significantly more haloperidol patients discontinued treatment due to adverse events during the acute and extension phases (p = 0.041 and p = 0.014, respectively). Changes in QLS total and MCS scores were associated with changes in clinical symptoms, depression scores and extrapyramidal symptoms.Conclusions: Olanzapine was more effective than haloperidol in reducing severity of psychopathology and in improving QOL in patients with schizophrenia and other psychotic disorders. The QOL benefits of olanzapine, although modest, may be important for long-term treatment. [ABSTRACT FROM AUTHOR]

Introduction Methods Results Conclusion Aspects of social relationships have variably been associated with suicidal ideation (SI) and suicide attempts (SAs). This study assessed whether social support and social distress measures have general factors versus measure‐specific factors that are associated with suicide risk.Adults (N = 455, 60.0% female), admitted to psychiatric inpatient units following a recent suicide attempt or active SI, completed assessments of social support (emotional support, instrumental support, friendship, perceived support from significant others, friends, family) and social distress (loneliness, perceived rejection, perceived burdensomeness, thwarted belongingness). Bifactor modeling examined general and specific factors of social support and distress in relation to SI (week prior to hospitalization, via the Beck Scale for SI) and SAs (past 30 days, via the Columbia Suicide Severity Rating Scale).SI was significantly associated with the general social support (B = −1.51), the general social distress (B = 1.67), and the specific perceived burdensomeness (B = 1.57) factors. SAs were significantly associated with the specific Perceived Rejection (OR = 1.05) and Thwarted Belongingness (OR = 0.91) factors.General social support and social distress were associated with SI but not recent SAs. Specific social distress factors were also related to SI and SAs controlling for general social distress, suggesting areas for future interventions. [ABSTRACT FROM AUTHOR]

Abstract Background Observational research frequently uses administrative codes for mental health or substance use diagnoses and for important behaviours such as suicide attempts. We sought to validate codes (International Classification of Diseases, 9th edition, clinical modification diagnostic and E-codes) entered in Veterans Health Administration administrative data for patients with depression versus a gold standard of electronic medical record text ("chart notation"). Methods Three random samples of patients were selected, each stratified by geographic region, gender, and year of cohort entry, from a VHA depression treatment cohort from April 1, 1999 to September 30, 2004. The first sample was selected from patients who died by suicide, the second from patients who remained alive on the date of death of suicide cases, and the third from patients with a new start of a commonly used antidepressant medication. Four variables were assessed using administrative codes in the year prior to the index date: suicide attempt, alcohol abuse/dependence, drug abuse/dependence and tobacco use. Results Specificity was high (≥ 90%) for all four administrative codes, regardless of the sample. Sensitivity was ≤75% and was particularly low for suicide attempt (≤ 17%). Positive predictive values for alcohol dependence/abuse and tobacco use were high, but barely better than flipping a coin for illicit drug abuse/dependence. Sensitivity differed across the three samples, but was highest in the suicide death sample. Conclusions Administrative data-based diagnoses among VHA records have high specificity, but low sensitivity. The accuracy level varies by different diagnosis and by different patient subgroup.

Crisis line responders initiate emergency dispatches by activating 911 or other local emergency services when individuals are determined to be at imminent risk for undesired outcomes. This study examined the association of characteristics, psychiatric diagnoses, and somatic symptoms with emergency dispatches in a national sample. Veterans Crisis Line data were used to identify contacts (i.e., calls, texts, chats, emails) that were linked with medical records and had a medical encounter in the year prior to contact. Hierarchical logistic regression clustered by responders was used to identify the association among demographics, psychiatric diagnoses, and somatic disorders, and emergency dispatches. Analyses examined 247,340 contacts from 2017 to 2020, with 27,005 (10.9%) emergency dispatches. Odds of an emergency dispatch increased with each diagnosis (three diagnoses Adjusted Odds Ratio [AOR] (95% CI) = 1.88 [1.81,1.95]). Odds were highest among individuals with substance use disorders (SUD) (alcohol AOR (95% CI) = 1.85 [1.80,1.91]; drugs AOR (95% CI) = 1.63 [1.58, 1.68]), which may be a result of intoxication or overdose during contact, requiring further research. Having more psychiatric and somatic conditions was associated with greater odds of an emergency dispatch, indicating that comorbidity contributed to the need for acute care., Competing Interests: Declaration of competing interest PCB, KMB, LMD, DG, and MAI have no conflicts of interest., (Published by Elsevier Ltd.)

Objective: To better understand processes of mental health crisis line utilization by examining associations between reasons for contacting a crisis line with the initiation of emergency dispatches (i.e., activation of 911 or local emergency services) in a national sample., Methods: Contacts (i.e., calls, texts, email, and chats) to the Veterans Crisis Line (VCL) across 2017-2020 were used to examine associations among stated reasons for the contact and the use of an emergency dispatch. Hierarchical logistic regression models were used to determine the odds of an emergency dispatch by reason for the contact., Results: Suicidal thoughts/crisis were present in 61.5% of contacts that ended in emergency dispatches and were associated with the largest adjusted odds of a dispatch, (Adjusted Odds Ratio [AOR] [95% CI] = 9.34 [9.21, 9.48]), followed by homicidal thoughts/crisis (AOR [95% CI] = 3.84 [3.73, 3.95]), and third-party concerns (AOR [95% CI] = 2.42 [2.37, 2.47]). Substance use/ addiction (AOR [95% CI] = 2.14 [2.10, 2.18]), abuse and violence (AOR [95% CI] = 1.89 [1.82, 1.96]), and physical health (AOR [95% CI] = 1.87 [1.84, 1.91]) were also associated with increased odds of a dispatch., Conclusions: Emergency dispatches are primarily used in response to imminent suicide risk but are also used in other potentially violent or lethal circumstances such as homicides, violence or abuse, and other crises. These findings highlight the role that crisis lines play in emergency service delivery, and the need to better understand how they are utilized under real world circumstances., Competing Interests: Declaration of competing interest PCB, KMB, LMD, DG, and MAI have no conflicts of interest., (Copyright © 2024. Published by Elsevier Inc.)

Abstract: Residential posttraumatic stress disorder (PTSD) treatment in the Department of Veterans Affairs is helpful for many Veterans, yet the majority experience symptom rebound after discharge. This study examined a national cohort of Veterans (n = 1872) who completed VA residential PTSD treatment and identified factors associated with maintenance of gains from discharge to 4-month follow-up. We generated three logistic regression models based on response profiles during residential treatment. In the "marginal responders" group, 1-3 "booster" sessions of PTSD treatment were associated with decreased odds of maintenance of gains (odds ratio [OR], 0.42), whereas in the "clinically significant responders" group, these sessions were associated with increased odds of maintenance of gains (OR, 2.89). Greater pain severity was associated with decreased odds of maintenance of gains in the "clinically significant responder" group (OR, 0.90). Results demonstrate several avenues for intervention including targeting pain severity and matching aftercare psychotherapy to Veteran residential treatment response., (Copyright © 2024 Written work prepared by employees of the Federal Government as part of their official duties is, under the U.S. Copyright Act, a “work of the United States Government” for which copyright protection under Title 17 of the United States Code is not available. As such, copyright does not extend to the contributions of employees of the Federal Government.)

Objective/Background: Intravenous (IV) ketamine is effective for reducing symptoms of major depressive disorder in short-term clinical trials; this study characterized clinical outcomes of repeated infusions in routine clinical practice and the frequency and number of infusions used to sustain symptom improvement., Methods: Records of IV ketamine infusions for depression and associated Patient Health Questionnaire-9 (PHQ-9) scores were identified from Veterans Health Administration (VA) electronic medical records for patients treated in Fiscal Year 2020 and up to 12 months following the date of their first infusion., Results: Sample patients (n = 215) had a mean baseline PHQ-9 score of 18.6 and a mean of 2.1 antidepressant medication trials in the past year and 6.1 antidepressant trials in the 20 years prior to their first ketamine infusion. Frequency of infusions decreased from every 5 days to every 3-4 weeks over the first 5 months of infusions, with a mean of 18 total infusions over 12 months. After 6 weeks of treatment, 26% had a 50% improvement in PHQ-9 score (response) and 15% had PHQ-9 score ≤ 5 (remission). These improvements were similar at 12 and 26 weeks. No demographic characteristics or comorbid diagnoses were associated with 6-week PHQ-9 scores., Conclusions: While only a minority of patients treated with IV ketamine for depression experienced response or remission, symptom improvements achieved within the first 6 weeks were sustained over at least 6 months with decreasing infusion frequency. Further study is needed to determine optimal infusion frequency and potential for adverse effects with repeated ketamine infusions for depression., (© Copyright 2024 Physicians Postgraduate Press, Inc.)

Objective: To characterize guideline-concordant use of cognitive behavioral therapy for insomnia vs. sleep medications among Veterans Health Administration patients., Methods: Cognitive behavioral therapy for insomnia was identified from the text of psychotherapy notes within the Veterans Health Administration's electronic medical record. Patients that received first-line cognitive behavioral therapy for insomnia (ie, no prior insomnia treatment) were compared to those who first received a sleep medication in fiscal year 2021., Results: Among 5,519,016 patients, first-line cognitive behavioral therapy for insomnia was received by 9313 (0.2%) whereas 225,618 (4.1%) were newly prescribed a sleep medication without prior cognitive behavioral therapy for insomnia. Patients over 60 years old and those with substance use disorders were less likely to receive first-line cognitive behavioral therapy for insomnia compared to other patients., Conclusions: Adherence to practice guidelines to provide cognitive behavioral therapy for insomnia as first-line treatment for insomnia disorder remains a challenge, highlighting the need to better integrate effective implementation strategies within therapist training programs. Targeted strategies may be needed for older patients or those with substance use disorders., Competing Interests: Declaration of conflicts of interest The authors have no conflicts of interest to report., (Copyright © 2023. Published by Elsevier Inc.)

Purpose: To identify temporal patterns of emergency dispatches as initiated by Veteran Crisis Line (VCL) responders and among moderate- and high-risk contacts., Methods: Incidence rate ratios (IRRs) were used to examine the incidence of emergency dispatches among all 1,437,543 VCL contacts across 2019-2020., Results: Emergency dispatches were initiated in 57,077 (4.0%) contacts. IRRs were elevated during Labor Day, IRR (95% CI) = 1.33 (1.15-1.54), and Independence Day, IRR (95% CI) = 1.22 (1.05-1.43), weekends, Saturdays, IRR (95% CI) = 1.04 (1.01-1.08), Sunday (reference), and 6 pm to 11:59 pm, IRR (95% CI) = 1.06 (1.04-1.09). IRRs for moderate- and high-risk contacts were higher on Memorial Day, IRR (95% CI) = 1.16 (1.00-1.33), Sunday (reference), and 6 pm to 11:59 pm (reference)., Conclusions: The initiation of emergency dispatches fluctuates over time and were highest during Labor Day and Independence Day, weekends, and evenings. Moderate- and high-risk contact also fluctuate over time and were highest on Memorial Day, Sundays, and midnight to 5:59 am. VCL policy makers can use knowledge of temporal fluctuations to allocate public health resources for increased efficiency and greatest impact; however, additional research on temporal stability and generalizability is needed., (Published 2023. This article is a U.S. Government work and is in the public domain in the USA.)

Background: Posttraumatic stress disorder (PTSD) disproportionately affects low-income individuals and is untreated in 70% of those affected. One third of low-income Americans are treated in Federally Qualified Health Centers (FQHCs), which do not have the capacity to provide all patients with first-line treatments such as Prolonged Exposure (PE). To address this problem, FQHCs could use low-intensity interventions (e.g., Clinician-Supported PTSD Coach: CS PTSD Coach) and medium-intensity interventions (e.g., PE for Primary Care: PE-PC) to treat PTSD with fewer resources. However, some patients will still require high-intensity treatments (e.g., full-length PE) for sustained clinical benefit. Thus, there is a critical need to develop stepped-care models for PTSD in FQHCs., Method: We are conducting a Sequential, Multiple Assignment, Randomized Trial (SMART) with 430 adults with PTSD in FQHCs. Participants are initially randomized to CS PTSD Coach or PE-PC. After four sessions, early responders step down to lower frequency interaction within their assigned initial treatment strategy. Slow responders are re-randomized to either continue their initial treatment strategy or step up to Full PE for an additional eight weeks. The specific aims are to test the effectiveness of initiating treatment with PE-PC versus CS PTSD Coach in reducing PTSD symptoms and to test the effectiveness of second-stage strategies (continue versus step-up to Full PE) for slow responders., Conclusions: This project will provide critical evidence to inform the development of an effective stepped-care model for PTSD. Testing scalable, sustainable sequences of PTSD treatments delivered in low-resource community health centers will improve clinical practice for PTSD., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Published by Elsevier Inc.)

Background: Few studies examine the utility of the Cannabis Use Disorder Identification Test - Revised (CUDIT-R) in relation to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (DSM-5) criteria for cannabis use disorder (CUD). This study assesses the performance of the CUDIT-R among a sample of Veterans with and without medical cannabis use., Methods: We approached and consented primary care patients presenting to one of three Department of Veterans Affairs (VA) Medical Centers. Veterans with at least monthly cannabis use and complete CUD data at baseline were included in this analysis (n=234). CUDIT-R scores were compared against Alcohol Use Disorder and Associated Disabilities Interview Schedule-5 (DSM-5) CUD as the standard to calculate measures of validity (sensitivity, specificity), identify optimal CUDIT-R cutoff values, and assess the diagnostic proficiency of the CUDIT-R using receiver operating characteristic (ROC) curves. We further stratified analyses by active medical cannabis card holder status and DSM-5 CUD severity (any, moderate, and severe)., Results: Among the entire sample, 38.9% qualified for any DSM-5 CUD, with 10.7% and 3.0% meeting criteria for moderate and severe CUD, respectively. We identified optimal CUDIT-R scores at 10 for any DSM-5 CUD (sensitivity=0.58; specificity=0.80), at 12 for moderate CUD (sensitivity=0.72; specificity=0.82), and at 14 for severe CUD (sensitivity=0.71; specificity=0.87). ROC curves showed higher CUDIT-R validity among non-card holders compared with medical cannabis card holders., Conclusion: The present study identified optimal CUDIT-R cutoff scores for Veterans who use cannabis. Varying DSM-5 validity measures inform the need for population-specific CUDIT-R cutoff values., (Published by Elsevier B.V.)

Background: Acceptance and Commitment Therapy for depression (ACT-D) is a promising depression treatment which has not been evaluated on a large scale within VA. This study aimed to evaluate ACT-D's effectiveness in a national, treatment-seeking sample of Veterans., Methods: The sample comprised 831 Veterans who received a primary depression diagnosis and received at least two sessions of ACT-D during fiscal years 2015-2020. We used GLM to measure predictors of symptom change, treatment response (50 % reduction in PHQ-9 and AAQ-II scores), subthreshold depression symptoms (PHQ-9 < 10; AAQ-II < 27), and treatment completion., Results: Veterans experienced an average reduction of 3.39 points on the PHQ-9 (Cohen's d = 0.56) and 3.76 points on the AAQ-II (Cohen's d = 0.43). On the PHQ-9, 40 % achieved subthreshold depression symptoms. On the AAQ-II, 36 % of Veterans achieved subthreshold psychological inflexibility scores. Service-connected disability rating for depression and higher levels of medical comorbidity were both related to lower levels of overall depression symptom change and treatment response. Substance use disorder and bipolar/psychosis diagnoses were associated with greater reductions in psychological inflexibility., Limitations: This is an observational study without a control group, so we were unable to compare the effectiveness of ACT-D to other usual care for depression. We were also unable to assess variables that can influence treatment success, such as therapist fidelity and patient engagement., Conclusions: ACT-D achieved similar improvements in depression as reported in controlled trials. Adaptations to ACT-D may be needed to improve outcomes for Veterans with depression and comorbid PTSD., Competing Interests: Conflict of interest The authors declare no relevant competing interests., (Published by Elsevier B.V.)

To inform the potential use of patient-reported depression symptom outcomes as measures of care quality, this study collected and analyzed longitudinal Patient Health Questionnaire (PHQ9) scores among 1,638 patients who screened positive for major depression according to a PHQ9 ≥ 10 across 29 Department of Veterans Affairs facilities. The study found baseline PHQ9, prior mental health visits, physical functioning, and treatment expectancy were consistently associated with subsequent PHQ9 outcomes. No facilities outperformed any others on PHQ9 scores at the 6-month primary endpoint, and the corresponding intra-class coefficient was ≤ .01 for the entire sample (n = 1,214) and 0.03 for the subgroup of patients with new depression episodes (n = 629). Measures of antidepressant receipt, psychotherapy, or treatment intensification were not associated with 6-month PHQ9 scores. PHQ9 outcomes are therefore unlikely to be useful as quality indicators for VA healthcare facilities due to low inter-facility variation, and new care process measures are needed to inform care for patients with chronic depression prevalent in this sample., (© 2022. This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply.)

Background: Although most veterans with posttraumatic stress disorder (PTSD) benefit from evidence-based treatments, questions persist concerning the profiles of those at risk for poor outcomes. To help address these gaps, this study analyzed a large clinical cohort of veterans receiving prolonged exposure (PE) or cognitive processing therapy (CPT)., Methods: Cluster analysis using Ward's method with Euclidian distances identified clinically meaningful subgroups of veterans in a national cohort (n = 20,848) using variables maintained in the electronic medical record. The clusters were then compared via one-way analysis of variance and Tukey's HSD on indicators of treatment progress including PTSD symptom change, clinical recovery, clinically significant change, remission, and treatment completion., Results: Effect size differences on clinical outcome measures for PE and CPT were negligible. Less than half of veterans achieved at least a 15-point reduction in PCL-5 score and half completed treatment. We identified 10 distinct clusters. Higher rates of PTSD service-connected disability were linked to poorer outcomes across multiple clusters, especially when combined with Post-Vietnam service era. Non-White race was also linked with poorer clinical outcomes. Factors associated with better outcomes included a greater proportion of female veterans, especially when combined with recent service era, and longer PTSD diagnosis duration., Conclusions: This study suggests the need to improve PTSD treatment outcomes for non-White and male veterans, examine treatment response in Post-Vietnam era veterans, and consider ways in which the service connection process could hinder treatment response. The results from this study also indicate the benefits of integrating elements of clinical complexity into an analytic approach., Competing Interests: Conflict of Interest The authors declare no relevant competing interests., (Published by Elsevier B.V.)

Although improving residential PTSD care is a priority for the Department of Veterans Affairs, previous evaluations have been limited by a lack of systematic data collection across more than two timepoints. This study used recently available data to assess symptom trajectories in a large, national sample of veterans who engaged in residential PTSD treatment. Group-based trajectory analysis PROC TRAJ was used to identify PTSD residential treatment response in a national cohort of veterans (n = 10,832) and the subset of veterans (n = 6515) receiving evidence-based psychotherapy (EBP). PTSD symptoms were assessed at intake, discharge, and 4-month follow-up. Predictors of trajectory membership were estimated using multinomial models. For the full cohort, a three-group trajectory model provided the best fit with the following identified groups: "Severe/Stable" (51.8%), "Moderate/Rebound" (40.1%), and "Mild/Rebound" (8.1%). For the EBP sub-cohort, a three-group trajectory model was selected with the following groups: "Severe/Stable" (58.5%), "Moderate/Rebound" (34.1%), and "Mild/Rebound" (7.4%). Across all trajectories, psychological distress, pain severity, substance use, Iraq/Afghanistan combat era, non-White race, and treatment dropout were associated with poorer treatment response. In the EBP sub-cohort, homelessness and unemployment at the time of admission were also associated with poorer treatment outcomes to varying degrees. This study demonstrates that residential treatment for PTSD is associated with heterogeneous treatment trajectories which highlight the need to continue to explore and improve residential PTSD treatment outcomes. Our results underscore the importance of obtaining follow-up data and identifying ways to maintain therapeutic gains following discharge., Competing Interests: Declarations of Competing Interest The authors declare no relevant competing interests., (Published by Elsevier Ltd.)

Posttraumatic stress disorder (PTSD) is a debilitating psychiatric disorder that affects 6% of U.S. adults, yet is treated in only 30% of affected individuals and even fewer low-income individuals. One third of the nation's low-income individuals are treated in Federally Qualified Health Centers (FQHCs). Most of these facilities lack capacity to provide their patients with first-line, evidence-based treatments for PTSD such as Prolonged Exposure (PE). To address this problem, PE has been adapted for use in a primary care setting and demonstrated efficacy in a brief model for military service members (PE in Primary Care: PE-PC). The effectiveness of this treatment in civilian, low-resource settings such as FQHCs is unknown. This pilot study tested the feasibility and acceptability of PE-PC in 30 Michigan FQHC patients. High rates of therapy participation suggest that the intervention was feasible and acceptable. Semi-structured interview data from 10 patients and 5 FQHC providers indicated that the intervention was helpful and filled a critical need for effective PTSD treatment in the FQHC setting. Interviews also elucidated barriers such as transportation, provider training, and time commitment for patients and providers. These findings set the stage for a full-scale randomized controlled trial to test the effectiveness of PE-PC on PTSD symptoms in this low-resource, high-need setting.Trial registry ClinicalTrials.gov Identifier: NCT03711266. October 18, 2018., (© 2022. This is a U.S. government work and not under copyright protection in the U.S.; foreign copyright protection may apply.)

Prolonged Exposure therapy (PE) is a first-line treatment for posttraumatic stress disorder (PTSD); however, few VA patients receive this treatment. One of the barriers to PE receipt is that it is only available in an individual (one-on-one) format, whereas many VA mental health clinics provide the majority of their psychotherapy services in group format. In particular, PTSD residential rehabilitation treatment programs (RRTPs) offer most programming in group format. Consequently, strategies are needed to improve the scalability of PE by adapting it to fit the delivery setting. The current study was designed to pilot test a group-facilitated format of PE in RRTPs. Thirty-nine Veterans who were engaged in care in the PTSD RRTP at a Midwestern VA were recruited to participate in a Group-facilitated PE protocol. Participants engaged in twelve 90-minute sessions of Group PE over the course of 6 weeks, plus six 60-minute individual sessions for imaginal exposure. Group treatment followed the PE model and consisted of psychoeducation, treatment rationale, and in vivo exposure to reduce trauma-related avoidance and thereby improve PTSD symptoms. PTSD symptoms were measured via the PTSD Checklist for DSM-5 (PCL-5) and depression symptoms were measured via the Patient Health Questionnaire (PHQ-9) at baseline, endpoint (6 weeks), and at 2-month follow-up. Thirty-nine individuals initiated Group-facilitated PE and 34 completed treatment. The average number of group sessions attended was 11 out of 12. Acceptability ratings were high. Mean change (improvement) in the intent-to-treat sample at 2-month follow-up was 20.0 points on the PCL-5 (CI 18.1, 21.9; Cohen's d = 1.1) and 4.8 points on the PHQ-9 (CI 4.1, 5.5, d = .8). These results suggest that adapted evidence-based interventions for PTSD can improve treatment access and efficiency for the RRTP setting. A group-based approach has the potential to improve the scalability of PTSD treatment by reducing required resources. A fully powered trial is now needed to test the effectiveness of Group-facilitated PE in the RRTP setting., (Copyright © 2022. Published by Elsevier Ltd.)

Objective To assess mental health symptoms, suicidal ideation/behaviors, and treatment among a nationally representative probability sample of student veterans. Participants : Student veterans enrolled in post-secondary educational institutions and matched comparison students. Methods: Sampled participants completed an online survey (n = 1,838). Analyses accounted for the complex sample design and non-response. Results : Substantial percentages of student veterans screened positive for: depression (36.9%, 95% CI: 31.1-42.7), PTSD (35.7%, 95% CI 29.9-41.5), anxiety (29.5%, 95% CI 26.8-32.2), and suicidal ideation (14.6%, 95% CI 12.1-17.1), with student veterans having odds ratios between 1.7 to 2.4 for positive screens compared to non-veteran students. Only 41.5% (95% CI 33.0-50.0) of student veterans with positive screens received treatment, although they had 50% higher odds of receiving treatment than non-veteran students. Conclusions: Student veterans have high rates of mental health symptoms and low rates of treatment. However, they are more likely to receive treatment than comparison students.

Introduction: Veterans with comorbid posttraumatic stress disorder (PTSD) and substance use disorder (SUD) have complex needs and often do not receive adequate mental health treatment. The purpose of this study was to examine rates and predictors of PTSD-only, SUD-only, or PTSD and SUD psychotherapy receipt among newly diagnosed Veterans with PTSD and SUD., Design and Setting: An administrative dataset including Veterans Health Administration (VHA) users., Participants: The sample comprised 32,779 United States Veterans with a new PTSD and a new SUD diagnosis in fiscal year 2015., Measurement: Multinomial logistic regression was used to identify predictors of receipt of any and adequate psychotherapy for PTSD, SUD, or PTSD and SUD across settings. Binomial logistic regression was used to identify predictors of PTSD psychotherapy among those who received any psychotherapy., Findings: A total of 13,824 (42.17%) Veterans in this sample received any PTSD- or SUD-related therapy in the year following diagnosis. Low rates of veterans received an adequate dose of PTSD-related psychotherapy (6.58%), SUD-related psychotherapy (7.72%), or both PTSD and SUD-related psychotherapy (<1%) In adjusted models, older age, service-connected disability, and psychiatric comorbidities were associated with decreased odds of treatment. Specific types of SUDs, including alcohol, cocaine, and opioid use disorders, along with receipt of diagnosis in a PTSD or SUD clinic, were associated with increased odds of treatment., Conclusions: Low rates of PTSD and SUD related psychotherapy highlight a need to better engage and retain Veterans with these disorders in care. Predictors of decreased treatment utilization, such as older age, service connection, and bipolar and major depressive disorders, may inform efforts by the VHA to further target and engage Veterans with indicated treatments., Competing Interests: The authors declare no relevant competing interests., (Published by Elsevier B.V.)

Objective: Clinical practice guidelines recommend concurrent treatment of co-occurring depression and substance use disorders; however, the degree to which patients with substance use disorders receive guideline-concordant treatment for depression is unknown. The authors investigated the provision of guideline-concordant depression treatment to patients with and without substance use disorders in a large integrated health care system., Methods: In a retrospective cohort study of 53,034 patients diagnosed with a depressive disorder in fiscal year 2017 in the U.S. Veterans Health Administration, the authors assessed the association of comorbid substance use disorders with guideline-concordant depression treatment, including both medication and psychotherapy, while adjusting for patient demographic and clinical characteristics., Results: Guideline-concordant depression treatment was lower across metrics for patients with co-occurring depression and substance use disorders compared to those without substance use disorders. Consistent findings emerged in covariate-adjusted models of antidepressant treatment, such that patients with substance use disorders had 21% lower odds of guideline-concordant acute treatment (adjusted odds ratio=0.79, 95% CI=0.73, 0.84) and 26% lower odds of continuation of treatment (adjusted odds ratio=0.74, 95% CI=0.69, 0.79). With regard to psychotherapy, patients with co-occurring depression and substance use disorders had 13% lower odds (adjusted odds ratio=0.87, 95% CI=0.82, 0.91) of adequate acute-phase treatment and 19% lower odds (adjusted odds ratio=0.81; 95% CI=0.73, 0.89) of psychotherapy continuation., Conclusions: Despite the availability of effective treatments for depression, patients with co-occurring substance use disorders are less likely to receive guideline-concordant depression treatment. Efforts to improve the provision of care to those with co-occurring substance use disorders should focus on clinician-based interventions and use of integrated care models to improve the quality of depression treatment.

Objective: Psychotherapy for depression is effective for many veterans, but the relationship between number of treatment sessions and symptom outcomes is not well established. The Dose-Effect model predicts that greater psychotherapeutic dose (total sessions) yields greater symptom improvement with each additional session resulting in smaller session-to-session improvement. In contrast, the Good-Enough Level (GEL) model predicts that rate of symptom improvement varies by total psychotherapeutic dose with faster improvement associated with earlier termination. This study compared the dose-effect and GEL model among veterans receiving psychotherapy for depression within the Veterans Health Administration. Method: The sample included 13,647 veterans with ≥2 sessions of psychotherapy for depression with associated Patient Health Questionnaire-9 (PHQ-9) scores in primary care ( n = 7,502) and specialty mental health clinics ( n = 6,145) between October 2014 and September 2018. Multilevel longitudinal modeling was used to compare the Dose-Effect and GEL models within each clinic type. Results: The GEL model demonstrated greater fit for both clinic types relative to dose-effect models. In both treatment settings, veterans with fewer sessions improved faster than those with more sessions. In primary care clinics, veterans who received 4-8 total sessions achieved similar levels of symptom response. In specialty mental health clinics, increased psychotherapeutic dose was associated with greater treatment response up to 16 sessions. Veterans receiving 20 sessions demonstrated minimal treatment response. Conclusions: These findings support the GEL model and suggest a flexible approach to determining length of psychotherapy for depression may be useful for optimizing treatment response and allocation of clinical resources. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Background: The prevalence and incidence of attention-deficit/hyperactivity disorder (ADHD) have increased substantially among children and adolescents over the past decade; however, little is known regarding trends in adult populations., Objective: The objective of this study was to explore trends in the prevalence, incidence, and correlates of adult ADHD in a national sample of veterans receiving care at Veteran Affairs (VA) hospitals and clinics., Research Design: A retrospective design was used to examine ADHD diagnosed in all VA primary care (PC) and mental health clinics (MHCs) from fiscal years (FYs) 2009 to 2016. Age-adjusted prevalence and incidence were calculated using direct standardization, and Poisson regressions modeled differences in trends between demographic groups., Subjects: All veterans with VA PC or MHC visits during the observation period., Measures: ADHD incidence and prevalence, psychiatric comorbidity, neuropsychological evaluation., Results: An annual average of 5.09 million (range: 4.63-5.42 million) VA patients attended a PC or MHC appointment between FY09 and FY16. During this period, age-adjusted annual prevalence increased 258% from 0.23% to 0.84% and incidence increased 240% from 0.14% to 0.48%. Black veterans and older veterans had the lowest prevalence and incidence across all years. Increases in prevalence and incidence occurred across all demographic subgroups. The proportion of patients who had a neuropsychological evaluation within 6 months before or after a new ADHD diagnosis decreased from 12.6% to 10.8% [χ(1)=16.59, P<0.001]., Conclusion: Overall increases and demographic differences in adult veterans diagnosed with ADHD suggest a growing need to establish the reliability of diagnostic practices to ensure appropriate and equitable care.

Objective: This study tested whether computerized cognitive-behavioral therapy for depression supported by a peer specialist with lived experience of depression (PS-cCBT) improves mental health-related outcomes for primary care patients., Methods: In the U.S. Department of Veterans Affairs, primary care patients with a new diagnosis of depression (N=330) were randomly assigned to 3 months of PS-cCBT or a usual-care control condition. Linear mixed-effects models were used to assess differences in depression symptoms, general mental health status, quality of life, and mental health recovery measured at baseline and 3 and 6 months., Results: In adjusted analyses, participants who received PS-cCBT experienced 1.4 points' (95% confidence interval [CI]=0.3-2.5, p=0.01) greater improvement in depression symptoms on the Quick Inventory of Depression Symptomatology-Self Report at 3 months, compared with the control group, but no significant difference was noted at 6 months. PS-cCBT recipients also had 2.6 points' (95% CI=0.5-4.8, p=0.02) greater improvement in quality of life at 3 months on the Quality of Life Enjoyment and Satisfaction Questionnaire Short Form and greater improvement in recovery on the Recovery Assessment Scale at 3 months (3.6 points; 95% CI=0.9-6.2, p=0.01) and 6 months (4.5 points; 95% CI=1.2-7.7, p=0.01)., Conclusions: PS-cCBT is an effective option for improving short-term depression symptoms and longer-term recovery among primary care patients newly diagnosed as having depression.

Although most veterans in the Department of Veterans Affairs (VA) health system are treated for posttraumatic stress disorder (PTSD) in the outpatient setting, the VA has approximately 40 residential PTSD treatment facilities across the country for those requiring more intensive care. The symptom profiles of these veterans are poorly understood. Thus, the current study was designed to characterize classes of PTSD symptoms in a national sample of veterans undergoing residential treatment. We analyzed latent classes of PTSD symptoms among 2,452 veterans entering VA PTSD residential treatment in fiscal year 2013. The model with the best fit was a 4-class model comprising a low symptom class, moderate symptom class with high reexperiencing symptoms, a moderate symptom class with high emotional numbing, and a high symptom class. Compared to classes identified in outpatient samples, these classes were similar in type but greater in severity. Classes differed by age, race/ethnicity, trauma type, co-occurring medical conditions, co-occurring psychiatric conditions, and social functioning. Compared to the moderate class with high emotional numbing, those in the moderate class with high reexperiencing symptoms were more likely to be non-White, have greater pain severity, greater sleep problems, and were less likely to be depressed. Our findings suggest that veterans in residential treatment who have more severe PTSD symptoms also experience other medical and psychosocial stressors. A better understanding of symptom profiles may help to create more individualized treatment planning and thus potentially improve care for these veterans. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Evidence-based treatments for posttraumatic stress disorder (PTSD) often produce significant symptom reduction within eight sessions. However, some patients take longer to respond and a better understanding of predictors of later response can help guide treatment. In the current study, the cohort consisted of all VA patients with a PTSD diagnosis who received at least eight sessions of documented evidence-based treatment within a 6-month period in FY16-FY17 and had at least two PTSD symptom assessments. We examined the proportion of patients who achieved meaningful change (defined as at least 50% reduction in self-reported PTSD symptoms), both within the first eight sessions and subsequently. Fourteen percent of patients achieved meaningful change within eight sessions and 10% subsequently. Symptom change within the first eight sessions was highly predictive of subsequent change. Those who experienced at least 20% symptom reduction by session eight were twice as likely to subsequently achieve meaningful change as compared with all patients who continued treatment. Patients receiving service-connected disability compensation were less likely and White patients more likely to achieve meaningful change. Without some degree of symptom reduction by session eight, patients are unlikely to achieve meaningful change if treatment is not enhanced or changed., (Copyright © 2019. Published by Elsevier Ltd.)

Various measures of social support have been associated with suicidal ideation (SI). However, a brief, consistent, multidimensional approach to social support assessment has not been established. We assessed the NIH Toolbox Adult Social Relationship (ASR) scales and their associations with the Beck Scale for Suicidal Ideation (BSI). Five ASR scales (emotional support, instrumental support, friendship, loneliness, perceived rejection) were used to predict BSI scores among psychiatric inpatients at baseline (N = 79) and at 3-months follow-up (N = 63). Mean BSI scores were 22.2 (SD 8.6) at baseline and 5.7 (SD 6.7) at follow-up. The ASR scales had high internal consistency (Cronbach's α = 0.93-0.96). Emotional support was associated with SI at baseline and 3-month follow-up. Instrumental support, loneliness and perceived rejection were associated with SI at baseline. Friendship was not associated with SI at either time-point. The ASR scales appear promising in differentiating aspects of social support most relevant to SI.

Objectives: To assess possession of household firearms among veterans receiving mental health care and the frequency of their discussions with clinicians about firearms. Methods: We surveyed random samples of veterans receiving mental health care in each of five purposively chosen, geographically diverse VA facilities; 677 (50% of recipients) responded. Results: 45.3% (95% CI 41.2, 49.3) of veteran respondents reported household firearms; 46.9% of those with suicidal thoughts and 55.6% with a suicide plan had household firearms. Only 27.5% of all veteran respondents and 44% of those with recent suicidal ideation and household firearms had had a firearm-related discussion with a clinician. Discussion: Many veterans receiving mental health care can readily access firearms, a highly lethal means for suicide. Increasing clinician-patient discussions and health system efforts to reduce firearm access might reduce suicide in this clinical population.

Objective: Members of the U.S. military are at a high suicide risk. While studies have examined predictors of suicide in the U.S. military, more studies are needed which examine protective factors for suicide. Informed by the interpersonal theory of suicide, this study examined the strength of the intimate relationship and its role as a buffer of suicidality in National Guard service members., Method: A total of 712 National Guard residing in a Midwestern state, who had all recently returned home from a deployment, took part in this study and completed surveys at 6 and 12 months postdeployment. They were assessed on suicide risk, mental health (depression, post-traumatic stress disorder, anxiety), and relationship satisfaction., Results: Lower relationship satisfaction and more depressive symptoms at the 6-month assessment were significantly related to greater suicide risk at 12 months. Each interaction between couple satisfaction and three mental health variables (PTSD, depression, and anxiety) at the 6-month assessment was significantly associated with suicide risk at 12 months., Conclusions: The strength of the intimate relationship serves as a buffer for suicide in National Guard service members who have PTSD, anxiety, or depression. Interventions that strengthen these intimate relationships could reduce suicide in service members., (© 2018 The American Association of Suicidology.)

Background: Any opioid-related hospitalization is an indicator of opioid-related harm and should ideally trigger carefully monitored decreases in opioid prescribing after inpatient stays in many, if not most, cases. However, past studies on opioid prescribing after hospitalizations have largely been limited to overdose related visits. It is unclear whether prescribing is different for other opioid-related indications such as opioid dependence and abuse and how that may compare with hospitalizations for overdose., Objective: To examine opioid-prescribing patterns before and after opioid-related hospitalizations for all opioid-related indications, not limited to overdose., Research Design: Retrospective cohort analysis of Veterans Health Administration (VHA) administrative claims from 2011 to 2014., Subjects: VHA patients who were hospitalized between fiscal years 2011 and 2014 and had at least 1 prescription opioid medication filled through the VHA pharmacy before their hospitalization., Measures: Opioid dispensing trajectories after hospitalization by opioid-related indication (ie, opioid dependence and/or abuse vs. overdose) compared with prescribing patterns for non-opioid-related hospitalizations., Results: Overall, opioid dosage dropped significantly (66% for dependence/abuse, 42% for overdose, and 3% for nonopioid diagnoses; P<0.001) across all 3 categories when comparing dose 57-63 days after admission to 57-63 days before hospitalization. However, 47% of the patients remained on the same dose or increased their opioid dose at 60 days after an opioid-related hospitalization. After adjusting for covariates, patients with a primary diagnosis of dependence/abuse had higher odds of having their dose discontinued compared with those with overdose: odds ratio (OR) 2.17 (1.19-3.96). Patients with admissions for opioid dependence and/or abuse had a statistically significant higher prevalence of depression, posttraumatic stress disorder, anxiety, and substance use disorders compared with those with an opioid overdose hospitalization., Conclusions: Opioid prescribing and patient risk factors before and after opioid-related hospitalizations vary by indication for hospitalization. To reduce costs and morbidity associated with opioid-related hospitalizations, opioid deintensification efforts need to be tailored to indication for hospitalization.

Suicide rates in the United States have been increasing in recent years, and the period after an inpatient psychiatric hospitalization is one of especially high risk for death by suicide. Peer support specialists may play an important role in addressing recommendations that suicide prevention activities focus on protective factors by improving hope and connectedness. The present study developed a peer specialist intervention titled Peers for Valued Living (PREVAIL) to reduce suicide risk, incorporating components of motivational interviewing and psychotherapies targeting suicide risk into recovery-based peer support. A randomized controlled pilot study was conducted to assess the acceptability, feasibility, and fidelity of the intervention. A total of 70 adult psychiatric inpatients at high risk for suicide were enrolled into the study. Participants were randomized to usual care (n = 36) or to the 12-week PREVAIL peer support intervention (n = 34). Those in the PREVAIL arm completed an average of 6.1 (SD = 5.0) peer sessions over the course of 12 weeks. Fidelity was rated for 20 peer support sessions, and 85% of the peer specialist sessions demonstrated adequate fidelity to administering a conversation tool regarding hope, belongingness, or safety, and 72.5% of general support skills (e.g., validation) were performed with adequate fidelity. Participants' qualitative responses (n = 23) were highly positive regarding peer specialists' ability to relate, listen, and advise and to provide support specifically during discussions about suicide. Findings demonstrate that a peer support specialist suicide prevention intervention is feasible and acceptable for patients at high risk for suicide. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Objective: Assess whether neighborhood characteristics predict patient-reported outcomes for depression., Data Sources: VA electronic medical record data and U.S. census data., Study Design: Retrospective longitudinal cohort., Data Extraction Methods: Neighborhood and individual characteristics of patients (N = 4,269) with a unipolar depressive disorder diagnosis and an initial Patient Health Questionnaire (PHQ-9) score ≥10 were used to predict 50 percent improvement in 4-8-month PHQ-9 scores., Principal Findings: The proportion of a patient's neighborhood living in poverty (OR = 0.98; 95% CI: 0.97-.1.00; P = 0.03) was associated with lower likelihood of depression symptom improvement in addition to whether the patient was black (OR = 0.76; 95% CI:0.61-0.96; P = 0.02) had PTSD (OR = 0.59; 95% CI:0.50-0.69; P < 0.001) or had any service-connected disability (OR = 0.73; 95% CI:0.61-0.87; P < 0.001)., Conclusions: Neighborhood poverty should be considered along with patient characteristics when determining likelihood of depression improvement., (© Health Research and Educational Trust.)

Objective: The U.S. Department of Veterans Affairs (VA) has placed increased emphasis on the availability and use of evidence-based psychotherapies (EBPs) for posttraumatic stress disorder (PTSD). However, many individuals do not complete a full course of EBP. The current study aimed to quantify the percentage of veterans receiving adequate EBP in VA hospitals and identify factors related to treatment completion., Methods: A national sample of 16,559 VA patients who began cognitive processing therapy (CPT) or prolonged exposure (PE) during fiscal year 2015 was obtained via administrative data. Generalized estimating equations were used to evaluate individual-level predictors of treatment adequacy, defined as eight sessions within 14 weeks. Generalized linear models were used to examine facility-level factors., Results: A total of 5,142 (31.1%) veterans completed eight or more sessions of psychotherapy. Older age was associated with greater odds of completing eight or more sessions (odds ratio OR=1.02, 95% confidence interval [CI]=1.01, 1.02, p<0.001), and comorbid bipolar or psychotic disorders were associated with reduced odds of completion (OR=0.89, 95% CI=0.80, 0.99, p=0.03). The percentage of patients who completed eight or more sessions was higher at facilities with higher percentages of EBP use among all patients with PTSD (β=6.55, SE=1.97, p=0.001) and greater numbers of EBP-certified providers (β=0.004, SE=0.002, p=0.038) and lower at facilities with a higher percentage of patients receiving a PTSD Checklist (β=-1.16, SE=0.46, p=0.011)., Conclusions: A minority of VA patients with PTSD complete an adequate dose of EBPs for PTSD. Individual and facility-level factors related to treatment adequacy may point to opportunities for intervention.