Search

Veterans with PTSD and SUDs often fail to initiate, or prematurely discontinue, mental health treatment in Veteran Affairs Medical Centers (VAMC). While much is known about clinical characteristics and demographic factors impacting treatment engagement in this population, less is known about the role of social factors. This retrospective study examines primary care-based screening assessment and specialty mental healthcare appointment data in a VAMC, to test whether social factors predict treatment initiation and appointment attendance. Findings reveal veterans were more likely to initiate treatment when (a) those with SUDs (n = 235) reported more frequent negative exchanges with others and (b) those with PTSD (n = 2107) reported more perceived support or being partnered. Those with PTSD who were partnered had higher appointment attendance rates. Findings suggest social factors are relevant to treatment initiation among veterans with PTSD and SUDs and that close others may be helpful in facilitating referrals.

Starting in 2008, the U.S. Veterans Health Administration required the integration of mental health providers (MH providers) in Home-Based Primary Care (HBPC) programs to promote access to and quality of mental health services for veterans enrolled in HBPC. Surveys were administered in both 2010 and 2019 to HBPC program directors and MH providers to evaluate the status of mental health practice in HBPC programs and inform the continued development of program resources. Findings reported here summarize responses to the 2019 survey and highlight changes compared to 2010 in key areas (e.g., mental health staffing and workload, services provided, training needs, and integration with and impact on the HBPC team). In 2019, approximately half of invited HBPC program directors (

Thousands of health systems are now recognized as "Age-Friendly Health Systems," making this model one of the most widely disseminated - and most promising- models to redesign care delivery for older adults. Sustaining these gains will require demonstrating the impact on care delivery and outcomes of older adults. We propose a new measurement model to more tightly link Age-Friendly Health System transformation to outcomes within each "M" (What Matters, Medications, Mobility, and Mentation). We evaluated measures based on the following characteristics: (1) conceptual responsiveness to changes brought about by practicing "4Ms" care; (2) degree to which they represent outcomes that matter to older adults; and (3) how they can be feasibly, reliably, and validly measured. We offer specific examples of how novel measures are currently being used where available. Finally, we present measures that could capture system-level effects across "M"s. We tie these suggestions together into a conceptual measurement model for AFHS transformation, with the intent to spur discussion, debate, and iterative improvement in measures over time.

Introduction: Caregiver distress is prevalent in Parkinson’s disease (PD) and predictive of negative health outcomes for both people with PD and caregivers. To identify future intervention targets, it is important to better elucidate the specific processes, such as criticism, that perpetuate burden. Objective: Evaluate the frequency and impact of criticism and reactivity to criticism in PD caregiving dyads. Methods: Eighty-three people with PD and their caregivers independently completed measures of criticism and physical and emotional health. Results: Criticism in the caregiving relationship was reported by 71.1% (n = 59) of people with PD and 80.7% (n = 67) of caregivers. Both perceived criticism and emotional reactivity to criticism were significant predictors of caregiver distress, adjusting for PD motor and non-motor symptom severity. In contrast, criticism was not related to PD depression. Conclusion: Criticism in the PD caregiving relationship is a clear target for psychotherapeutic intervention and may improve caregiver health and quality of life.

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).

Veterans are at increased risk for dementia and multiple comorbid conditions, often making the family caregiving experience particularly challenging. The objective of this study was to examine the effectiveness of a telephone-based, collaborative dementia care program for improving caregiver (CG) outcomes in CGs of veterans with dementia. All CGs (n=107) received individual care management and were randomized to either individual intervention alone or individual plus group education and social support. CGs were on average 72.5 (+/-11.0) years old, and the majority were female, spouses/partners of the care recipient (CR), and providing care for ≥1 year. Pre-post analyses indicate that CGs experienced a significant reduction in both the frequency of CRs’ dementia-related symptoms (e.g. memory difficulties, disruptive behaviors, depressive affect) and their own distress in response to these symptoms. Our study adds to the literature on the development and evaluation of understudied CG populations, such as CGs of veterans with dementia.

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.

This study examined associations between three indices of social ties (perceived social support, frequency of negative social exchanges, and degree of social integration) and suicidal ideation among veterans referred by their primary care provider for a behavioral health assessment.The sample included 15,277 veterans who completed a mental health and substance use assessment on referral to a Primary Care-Mental Health Integration (PCMHI) program. Data on sociodemographic factors, mental health and substance use conditions (e.g., depression, anxiety, and substance use), perceived general health, the three indices of social ties, and suicidal ideation were extracted from clinical interviews.The mean±SD age of the sample was 51.3±15.9, most (89%) were men, and about half (48%) were white. Most met criteria for at least one mental health or substance use condition on PCMHI assessment, and 39% reported either low- or high-severity suicidal ideation, as measured by the Paykel Suicide Scale. Logistic regression analyses indicated that after adjustment for sociodemographic factors, perceived health, and comorbid mental health and substance use conditions, each of the three social tie indices was uniquely associated with higher odds of reporting suicidal ideation, compared with no ideation.Findings underscore the value of assessing multiple indices of social ties when examining suicidal ideation among high-risk veterans in primary care experiencing behavioral health issues. Incorporating an assessment of the quality of patients' social interactions and level of social integration into routine PCMHI practice has the potential to enhance screening and intervention efforts aimed at reducing suicidal ideation.

Background Decreased enjoyment from pleasant events is a key component of anhedonia, but evidence has been inconsistent demonstrating its association across levels of depressive symptom severity. We test the hypothesis that depressed participants who engage in greater (rather than lower) concurrent use of experiential avoidance strategies will demonstrate impaired positive (PA) and negative (NA) emotional reactivity when pleasant events take place. Methods 50 Veterans with a range of depression severity completed a 7-day phone-based ecological momentary assessment protocol that assessed the pleasantness of their recent activity, level of PA and NA, and concurrent use of experiential avoidance strategies. Results As events were rated as more pleasant, depressed Veterans using less experiential avoidance were distinguished from depressed Veterans using greater experiential avoidance, such that greater experiential avoidance interfered with PA and NA reactivity. Limitations Small sample of primarily older men, all were Veterans, and assessments relied on self-reports of event pleasantness and depression; we did not include a control group. Conclusions It is critical to understand how depressed individuals experience potentially rewarding aspects of their environments. Our study provides preliminary data that depressed individuals may benefit from positive events in daily life when experiential avoidance is low and may demonstrate impaired reactivity when avoidance is high. This study may help clinicians to identify the contexts that support hedonic responses to potentially rewarding aspects of their depressed patients’ environments.

Capitalization—seeking “support” when good things happen—is linked to healthy couple functioning but has never been studied in distressed couples. We examined whether perceptions of capitalization and traditional social support related to couples' satisfaction prior to, and following, couples' therapy at a Veteran Affairs Medical Center. Perceptions of capitalization and traditional social support were associated yet distinct. Not all distressed couples had poor perceptions of support, and greater perceived support related to greater satisfaction at treatment entry. Relationship satisfaction was higher posttreatment for individuals whose partners reported providing them with greater capitalization support prior to treatment. We focus our discussion on the development of systematic research to investigate how capitalization may promote adaptive processes in vulnerable couples.

This study examined the psychometric properties of the Self-Appraisal of Change Scale, a measure designed to capture domains that are subjectively relevant to caregivers, associated with overall well-being, and amenable to change upon engaging in an intervention. Data from 107 caregivers of veterans with dementia enrolled in a randomized controlled trial of a telephone-delivered caregiver psychoeducation and support group program (the Telehealth Education Program (TEP)) were analyzed. The TEP, which was delivered by master's prepared social workers and a nurse dementia care manager, targeted caregivers' dementia-related knowledge, attitudes, and self-management skills. Analyses were conducted to determine the factor structure, reliability, validity, and measurement invariance of the scale. Factor analyses yielded a single-factor solution for the scale's nine items. The reliability and construct validity of the scale were also supported by the analyses. Multi-group analyses suggested that meaningful comparisons of scale items and total raw scores can be made across usual care (UC) and intervention groups. The findings offer preliminary support that the scale may represent a valid and reliable instrument that captures perceived changes in key domains (e.g. caregiving knowledge, attitudes, and skill) following participation in a psychoeducational and support intervention trial.

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.

This concurrent embedded mixed methods study explored important aspects of communication occurring between military service members and their intimate partners during a combat deployment to Iraq or Afghanistan. Fifty-eight participants (32 military veterans and 26 non-veteran partners) participated in an interview using standardized self-report measures assessing the current level of relationship satisfaction, trauma symptoms of the veteran, and the veterans' trauma exposure. Participants also participated in a semistructured interview focused on combat deployment and reintegration experiences. The findings suggested that communication between service members and their intimate partners during deployment is important to maintaining an emotional connection, preventing distancing to ease the transition back, obtaining assurance regarding the safety of the deployed partner, and meeting current needs to be emotionally engaged with their partner. Access to the methods of deployment communication, however, was reported to be highly variable within and across deployments. Planned withholding of unpleasant or distressing information from one's partner appeared to be common and may represent a choice by participants to improve their well-being and outcomes. Recommendations for clinical interventions include preventive programs to help couples discuss their expectations for communication during the deployment. Future research might focus on the development of measures of preferences in deployment communication, as well as the degree of impact of communication on service member duty performance, individual psychological outcomes, and couple-based outcomes. (PsycINFO Database Record

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

This study explored gender differences in social relationships and associated symptoms of depression and post-traumatic stress disorder (PTSD) among 6,449 Veterans Affairs (VA) primary care patients referred for a behavioral health assessment. Patients provided demographic information, information on social relationships, and mental health symptoms. Multiple regression analyses were conducted to examine associations between gender, social relationships, and symptoms, and to test moderation by gender. Women reported more social interaction and negative social exchanges than men. No gender differences were obtained in perceived social support. Social functioning difficulties were associated with greater symptom severity. Gender did not moderate the strength of these associations. Findings highlight gender differences in experiences of social relationships.

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

The association between the quality and nature of social relationships and suicidal outcomes across the lifespan is well established. However, social ties are rarely assessed in primary care and other clinical settings where older adults at high risk for suicide-related outcomes are seen. This study examined the unique associations between three indices of social ties (i.e., perceived social support, frequency of negative social exchanges, and degree of social integration) and death/suicidal ideation among 3,261 older veterans (aged 65+) who completed a clinical mental health/substance use (MH/SU) assessment upon referral to a Primary Care-Mental Health Integration (PCMHI) program. Data on sociodemographics, MH/SU conditions (e.g., depression, anxiety, and substance use), perceived health, the three indices of social ties, and death/suicidal ideation were extracted from clinical interviews. Veterans were on average 70.8 years old (+6.5 years) and primarily male. Approximately half were married and 60.3% were non-Hispanic white. Forty percent reported death ideation or suicidal ideation, as measured by the Paykel Suicide Scale. Logistic regression analyses revealed that, adjusting for covariates, while perceived social support was associated with a greater risk of reporting death ideation relative to no ideation, both social support and frequency of negative exchanges were uniquely associated with greater risk of reporting suicidal ideation relative to no ideation. Social integration was unrelated to odds of death or suicidal ideation. Findings underscore the value of integrating assessments of multiple aspects of social ties into routine PCMHI practice, as doing so has the potential to enhance suicide screening and intervention efforts.

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.

Objective: Patients with alcohol dependence presenting for treatment may have multiple associated co‐morbid conditions and limited social supports, which complicate treatment. Each of these factors has been independently associated with complaints of insomnia. In this preliminary study, we investigated the relations between insomnia complaints and socio‐demographic factors and psychiatric co‐ morbidity in treatment‐seeking patients with alcohol dependence. Method: We conducted a retrospective chart review on 84 consecutive patients referred to the Behavioral Health Laboratory of the Philadelphia Veterans Affairs Medical Center for evaluation of psychiatric and substance use disorders. Patients met DSM‐IV diagnostic criteria for alcohol dependence and completed a series of self‐assessments of sleep. Univariate and multivariable analyses were used to examine the relations amongst the variables of interest. Results: In multivariable models, Sleep Latency was significantly greater in individuals without partners (p ¼ .01), those with psychiatric disorders (p ¼ .03) and smokers (p ¼ .01), with a non‐ significant trend for those with past‐year suicidal ideation. No significant predictor of Wake Time After Sleep Onset was seen. Poor Sleep Quality was predicted by younger age (OR ¼ .93 [.88, .98], p ¼ .004) and the presence of a psychiatric disorder (OR ¼ 20.80 [4, 102], p ¼ .0002), with a non‐significant trend for suicidal ideation. Conclusions: Insomnia symptoms in treatment‐seeking alcohol dependent patients should prompt consideration of the individuals’ psychiatric and psychosocial features. (Am J Addict 2013;22:266– 270)

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.

Objectives The purpose of this study is to explore behavioral health symptoms and characteristics of noninstitutionalized older adults newly started on an antidepressant, anxiolytic, or antipsychotic agent by nonpsychiatrist physicians. Design Naturalistic cohort study of older adults participating in the Pharmaceutical Assistance Contract for the Elderly (PACE) of the state of Pennsylvania. Setting/Participants Noninstitutionalized adults in Pennsylvania. Measurements Standardized scales including the Blessed Orientation-Memory-Concentration (BOMC) test, Mini International Neuropsychiatric Interview (including Psychosis, Mania, Generalized Anxiety Disorder [GAD], Panic Disorder, and Alcohol Abuse/Dependence modules), Patient Health Questionnaire-9 (PHQ-9), Paykel Scale for suicide ideation, and Medical Outcomes Survey (SF-12). Results Participants were mostly women (83.7%) with a mean age of 79.2 years (SD 7.1). The average PHQ-9 score for those on antidepressants was 5.8 (5.2), with no statistically significant difference between medication groups (F [2, 409] = 1.48, p=0.23); just seven (4.9%) of those receiving anxiolytics met criteria for an anxiety disorder, which was not significantly different than other medication classes (χ 2 (2) = 0.83, p=0.66). Overall, 197 (47.8%) of the sample did not meet criteria for a mental health disorder. Just 69 (28.8%) of those on antidepressants reported depression as the self-reported reason for taking the medication, while 91 (22.8%) of the total reported poor sleep or stressful life events as the reason. Conclusions In this sample, many older persons received psychotropic medications despite low symptomatology, increasing the costs of care and possible exposure to unnecessary side effects. It is important to understand perceived benefit to both patient and provider of such prescribing patterns and work towards minimizing unnecessary use.

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: A range of psychiatric symptoms and cognitive deficits occur in Parkinson disease (PD), and symptom overlap and comorbidity complicate the classification of nonmotor symptoms. The objective of this study was to use analytic-based approaches to classify psychiatric and cognitive symptoms in PD. Design: Cross-sectional evaluation of a convenience sample of patients in specialty care. Setting: Two outpatient movement disorders centers at the University of Pennsylvania and Philadelphia Veterans Affairs Medical Center. Participants: One hundred seventy-seven patients with mild-moderate idiopathic PD and without significant global cognitive impairment. Measurements: Subjects were assessed with an extensive psychiatric, neuropsychological, and neurological battery. Latent class analysis (LCA) was used to statistically delineate group-level symptom profiles across measures of psychiatric and cognitive functioning. Predictors of class membership were also examined. Results: Results from the LCA indicated that a four-class solution best fit the data. The 32.3% of the sample had good psychiatric and normal cognitive functioning, 17.5% had significant psychiatric comorbidity but normal cognition, 26.0% had few psychiatric symptoms but had poorer cognitive functioning across a range of cognitive domains, and 24.3% had both significant psychiatric comorbidity and poorer cognitive functioning. Age, disease severity, and medication use predicted class membership. Conclusions: LCA delineates four classes of patients in mild-moderate PD, three of which experience significant nonmotor impairments and comprise over two thirds of patients. Neuropsychiatric symptoms and cognitive deficits follow distinct patterns in PD, and further study is needed to determine whether these classes are generalizable, stable, predict function, quality of life, and long-term outcomes and are amenable to treatment at a class level.

Objectives: Pain in older adulthood is correlated with both depressive symptomatology and positive and negative social exchanges, but the direction of these relationships remains unclear. This study investigated whether (a) pain is associated with increases in negative exchanges and decreases in positive exchanges and (b) negative exchanges play a greater role than positive exchanges in accounting for the association between pain and depressive symptomatology. Methods: Data were derived from the Later Life Study of Social Exchanges, a longitudinal survey of noninstitutionalized older adults. Interviews assessed participants' sociodemographic and biopsychosocial characteristics, as well as their interactions with network members. Results: Pain was significantly associated with negative exchanges, and both pain and negative exchanges predicted greater depressive symptomatology over time. Positive social exchanges, however, were not related to either pain or depression. Discussion: The findings underscore the value of examining older adults' social exchanges in efforts to understand pain-induced depressive symptomatology.

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.