Association of Veterans Affairs Primary Care Mental Health Integration With Care Access Among Men and Women Veterans

Primary care mental health integration to improve early treatment engagement for veterans who screen positive for depression

OBJECTIVE

To examine the relationship between the penetration (or reach) of a national program aiming to integrate mental health clinicians into all primary care clinics (PC-MHI) and rates of guideline-concordant follow-up and treatment among clinic patients newly identified with depression in the Veterans Health Administration (VA).

DATA SOURCES/STUDY SETTING

15,155 screen-positive patients 607,730 patients with 2-item Patient Health Questionnaire scores in 82 primary care clinics, 2015-2019.

STUDY DESIGN

In this retrospective cohort study, we used established depression care quality measures to assess primary care patients who (a) newly screened positive (score ≥3) and (b) were identified with depression by clinicians via diagnosis and/or medication (n = 15,155; 15,650 patient-years). Timely follow-up included ≥3 mental health, ≥3 psychotherapy, or ≥3 primary care visits for depression. Minimally appropriate treatment included ≥4 mental health visits, ≥3 psychotherapy, or ≥60 days of medication. In multivariate regressions, we examined whether higher rates of PC-MHI penetration in clinic (proportion of total primary care patients in a clinic who saw any PC-MHI clinician) were associated with greater depression care quality among cohort patients, adjusting for year, healthcare system, and patient and clinic characteristics.

DATA COLLECTION/EXTRACTION METHODS

Electronic health record data from 82 VA clinics across three states.

PRINCIPAL FINDINGS

A median of 9% of all primary care patients were seen by any PC-MHI clinician annually. In fully adjusted models, greater PC-MHI penetration was associated with timely depression follow-up within 84 days (∆P = 0.5; SE = 0.1; p < 0.001) and 180 days (∆P = 0.3; SE = 0.1; p = 0.01) of a positive depression screen. Completion of at least minimal treatment within 12 months was high (77%), on average, and not associated with PC-MHI penetration.

CONCLUSIONS

Greater PC-MHI program penetration was associated with early depression treatment engagement at 84-/180-days among clinic patients newly identified with depression, with no effect on already high rates of completion of minimally sufficient treatment within the year.

Preliminary Investigation Into the Effectiveness of Group webSTAIR for Trauma-exposed Veterans in Primary Care

INTRODUCTION

A substantial number of trauma-exposed veterans seen in primary care report significant symptoms of PTSD and depression. While primary care mental health integration (PCMHI) providers have been successful in delivering brief mental health treatments in primary care, few studies have evaluated interventions that combine mobile health resources with PCMHI groups. This pilot study assessed the potential benefits of webSTAIR, a 10-module transdiagnostic treatment for trauma-exposed individuals, supported by 5 biweekly group sessions delivered via telehealth. The transdiagnostic and mobile health nature of the treatment, as well as the therapist and peer support provided through group sessions, may offer an innovative approach to increasing access to patient-centered and trauma-informed treatment in primary care settings.

MATERIALS AND METHODS

Thirty-nine male and female veterans with trauma-related symptoms (i.e., PTSD and/or depression) participated in group webSTAIR. Mixed effects analyses were conducted to assess changes in PTSD and depression at pre-, mid-, and post-treatment. Baseline symptom severity was assessed as a predictor of module completion and group attendance. The project was part of a VHA quality improvement project, and IRB approval was waived by the affiliated university.

RESULTS

Analyses revealed significant pre-to-post improvement in both PTSD and depression outcomes with a large effect size for PTSD (Hedges' gav = 0.88) and medium to large for depression (Hedges' gav = 0.73). Of participants who completed the baseline assessment, 90% began webSTAIR; of those, 71% completed the program. Baseline symptoms of PTSD and depression did not predict group attendance or module completion.

CONCLUSIONS

Good outcomes and a satisfactory retention rate suggest that group webSTAIR may provide easily accessible, high-quality, and effective treatment for patients presenting with trauma-related problems without increasing therapist or system burdens. The results suggest the value of conducting a randomized controlled trial to test the effectiveness of group webSTAIR relative to PCMHI usual care or other evidence-based, disorder-specific (e.g., PTSD) treatments for trauma-exposed individuals in PCMHI.

The impact of screening positive for hazardous alcohol use on the diagnostic accuracy of the PTSD Checklist for DSM-5 among veterans

The Posttraumatic Stress Disorder (PTSD) Checklist for DSM-5 (PCL-5) is a widely used self-report measure of PTSD symptoms that has demonstrated strong psychometric properties across settings and samples. Co-occurring hazardous alcohol use and PTSD are prevalent among veterans, and the effects of alcohol use may impact the performance of the PCL-5. However, this possibility is untested. In this study, we evaluated the PCL-5 diagnostic accuracy for veterans who did and did not screen positive for hazardous alcohol use according to the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C). Participants were 385 veterans recruited from Veterans Affairs primary care clinics. Results indicated that PCL-5 performance, AUC = .904, 95% CI [.870, .937], did not differ as a product of hazardous alcohol use. PCL-5 diagnostic utility was comparably high for veterans with, AUC = .904; 95% CI [.846, .962], and without, AUC = .904 95% CI [.861, .946], positive AUDIT-C screens. Although optimally efficient cutoff scores for veterans who screened positive were higher (i.e., 34-36) than for those with negative screens (i.e., 30), neither were significantly different from the overall PCL-5 cutoff score (i.e., 32), suggesting that neither veterans with nor without positive AUDIT-C screens require differential PCL-5 cutoff scores. The results do underscore the importance of using PCL-5 cutoff scores in concert with clinical judgment when establishing a provisional PTSD diagnosis and highlight the need for additional study of the impact of comorbidities on PCL-5 diagnostic accuracy and cutoff scores.

Adverse COVID-19 outcomes in American Veterans with age-related macular degeneration: a case-control study

OBJECTIVES

Prior studies suggest that patients with age-related macular degeneration (AMD) have poorer COVID-19 outcomes. This study aims to evaluate whether AMD is associated with adverse COVID-19 outcomes in a large clinical database.

DESIGN

Case-control study.

SETTING

We obtained demographic and clinical data from a national US Veterans Affairs (VA) database for all Veterans aged 50 years or older with positive COVID-19 testing prior to 2 May 2021.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome measure was hospitalisation. Secondary outcome measures were intensive care unit admission, mechanical ventilation and death. Potential associations between AMD and outcome measures occurring within 60 days of COVID-19 diagnosis were evaluated using multiple logistic regression analyses.

RESULTS

Of the 171 325 patients in the study cohort, 7913 (5%) had AMD and 2152 (1%) had severe AMD, defined as advanced atrophic or exudative AMD disease coding. Multiple logistic regression adjusting for age, Charlson Comorbidity Index, sex, race, ethnicity and COVID-19 timing showed that an AMD diagnosis did not significantly increase the odds of hospitalisation (p=0.11). Using a Bonferroni-adjusted significance level of 0.006, AMD and severe AMD also were not significant predictors for the secondary outcomes, except for AMD being modestly protective for death (p=0.002).

CONCLUSIONS

After adjusting for other variables, neither AMD nor severe AMD was a risk factor for adverse COVID-19 outcomes in the VA healthcare system. These findings indicate that an AMD diagnosis alone should not alter recommended ophthalmic management based on COVID-19 adverse outcome risk.

Prevalence of sexual desire and arousal difficulties among women veterans: A retrospective cohort design

Low sexual desire and arousal are associated with several negative health outcomes, including reduced quality of life, depression, anxiety, and relationship discord. Although women veterans have high rates of risk factors for sexual dysfunctions (e.g., elevated rates of trauma, depression, anxiety), research on their sexual functioning is lacking. Using a retrospective cohort design, we examined the prevalence of documented sexual desire and arousal disorder diagnoses or symptoms, using International Classification of Diseases, 10th Revision codes, among 790,726 women veterans receiving care in the Veterans Health Administration (VHA). In fiscal year 2020, these symptoms and disorders were documented for only 0.19% (n = 1,494) of women veterans receiving care and symptoms of low sexual desire were documented more frequently than formal desire and arousal diagnoses. Most women veterans with desire and arousal problems were married (53.88%), and most (52.28%) were prescribed antidepressants. Mental health (MH) treatment for desire and arousal difficulties was commonly delivered in person (as compared to telephone or telehealth). Psychologists primarily treated desire and arousal concerns, providing an average of 2.81 MH encounters (SD = 7.53) compared to an average of 1.62 (SD = 5.25) MH encounters by social workers and 1.22 (SD = 2.53) by psychiatrists. Problems with low sexual desire and arousal are likely underassessed and undertreated within the VHA. Better assessment of women veterans' low desire and arousal is warranted to improve their well-being and quality of life. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Association of Integrated Mental Health Services with Physical Health Quality Among VA Primary Care Patients

BACKGROUND

Integrated care for comorbid depression and chronic medical disease improved physical and mental health outcomes in randomized controlled trials. The Veterans Health Administration (VA) implemented Primary Care-Mental Health Integration (PC-MHI) across all primary care clinics nationally to increase access to mental/behavioral health treatment, alongside physical health management.

OBJECTIVE

To examine whether widespread, pragmatic PC-MHI implementation was associated with improved care quality for chronic medical diseases.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study included 828,050 primary care patients with at least one quality metric among 396 VA clinics providing PC-MHI services between October 2013 and September 2016.

MAIN MEASURE(S)

For outcome measures, chart abstractors rated whether diabetes and cardiovascular quality metrics were met for patients at each clinic as part of VA's established quality reporting program. The explanatory variable was the proportion of primary care patients seen by integrated mental health specialists in each clinic annually. Multilevel logistic regression models examined associations between clinic PC-MHI proportion and patient-level quality metrics, adjusting for regional, patient, and time-level effects and clinic and patient characteristics.

KEY RESULTS

Median proportion of patients seen in PC-MHI per clinic was 6.4% (IQR=4.7-8.7%). Nineteen percent of patients with diabetes had poor glycemic control (hemoglobin A1c >9%). Five percent had severely elevated blood pressure (>160/100 mmHg). Each two-fold increase in clinic PC-MHI proportion was associated with 2% lower adjusted odds of poor glycemic control (95% CI=0.96-0.99; p=0.046) in diabetes. While there was no association with quality for patients diagnosed with hypertension, patients without diagnosed hypertension had 5% (CI=0.92-0.99; p=0.046) lower adjusted odds of having elevated blood pressures.

CONCLUSIONS AND RELEVANCE

Primary care clinics where integrated mental health care reached a greater proportion of patients achieved modest albeit statistically significant gains in key chronic care quality metrics, providing optimism about the expected effects of large-scale PC-MHI implementation on physical health.

Women Veterans' Healthcare Needs, Utilization, and Preferences in Veterans Affairs Primary Care Settings

BACKGROUND

The Veterans Health Administration (VA) is the largest integrated health system in the US and provides access to comprehensive primary care. Women Veterans are the fastest growing segment of new VA users, yet little is known about the characteristics of those who routinely access VA primary care in general or by age group.

OBJECTIVE

Describe healthcare needs, utilization, and preferences of women Veterans who routinely use VA primary care.

PARTICIPANTS

1,391 women Veterans with 3+ primary care visits within the previous year in 12 VA medical centers (including General Primary Care Clinics, General Primary Care Clinics with designated space for women, and Comprehensive Women's Health Centers) in nine states.

METHODS

Cross-sectional survey (45% response rate) of sociodemographic characteristics, health status (including chronic disease, mental health, pain, and trauma exposure), utilization, care preferences, and satisfaction. Select utilization data were extracted from administrative data. Analyses were weighted to the population of routine users and adjusted for non-response in total and by age group.

KEY RESULTS

While 43% had health coverage only through VA, 62% received all primary care in VA. In the prior year, 56% used VA mental healthcare and 78% used VA specialty care. Common physical health issues included hypertension (42%), elevated cholesterol (39%), pain (35%), and diabetes (16%). Many screened positive for PTSD (41%), anxiety (32%), and depression (27%). Chronic physical and mental health burdens varied by age. Two-thirds (62%) had experienced military sexual trauma. Respondents reported satisfaction with VA women's healthcare and preference for female providers.

CONCLUSIONS

Women Veterans who routinely utilize VA primary care have significant multimorbid physical and mental health conditions and trauma histories. Meeting women Veterans' needs across the lifespan will require continued investment in woman-centered primary care, including integrated mental healthcare and emphasis on trauma-informed, age-specific care, guided by women's provider preferences.

Electronic Population-Based Depression Detection and Management Through Universal Screening in the Veterans Health Administration

IMPORTANCE

In 2016, the US Preventive Services Task Force newly recommended universal screening for depression, with the expectation that screening would be associated with appropriate treatment. Few studies have been able to assess the population-based trajectory from screening to receipt of follow-up and treatment for individuals with depression.

OBJECTIVE

To examine adherence to guidelines for follow-up and treatment among primary care patients who newly screened positive for depression in the Veterans Health Administration (VA).

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study used VA electronic data to identify patients who newly screened positive for depression on the 2-item Patient Health Questionnaire at 82 primary care VA clinics in California, Arizona, and New Mexico between October 1, 2015, and September 30, 2019. Data analysis was performed from December 2020 to August 2021.

MAIN OUTCOMES AND MEASURES

Receipt of guideline-concordant care for screen-positive patients who were determined by clinicians as having depression was assessed. Timely follow-up (within 84 days of screening) was defined as receiving 3 or more mental health specialty visits, 3 or more psychotherapy visits, or 3 or more primary care visits with a depression diagnosis according to the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision. Completing at least minimal treatment (within 12 months) was defined as having 60 days or more of antidepressant prescriptions filled, 4 or more mental health specialty visits, or 3 or more psychotherapy visits.

RESULTS

The final cohort included 607 730 veterans (mean [SD] age, 59.4 [18.2] years; 546 516 men [89.9%]; 339 811 non-Hispanic White [55.9%]); 8%, or 82 998 of 997 185 person-years, newly screened positive for depression. Clinicians identified fewer than half with depression (15 155 patients), of whom 32% (5034 of 15 650 person-years) met treatment guidelines for timely follow-up and 77% (12 026 of 15 650 person-years) completed at least minimal treatment. Younger age (odds ratio, 0.990; 95% CI, 0.986-0.993; P < .001), Black race (odds ratio, 1.19; 95% CI, CI 1.05-1.34; P = .01), and having comorbid psychiatric diagnoses were significantly associated with timely follow-up. Individual quality metric components (eg, medication or psychotherapy) were associated differently with overall quality results among patient groups, except for age.

CONCLUSIONS AND RELEVANCE

In this cohort study, most patients met the guidelines for completing at least minimal treatment, but only a minority received timely follow-up after screening positive and being identified as having depression. More research is needed to understand whether the discrepancy between patients who screened positive and patients identified as having depression reflects a gap in recognition of needed care.

Economic analyses of behavioral health intervention implementation: Perspective on stakeholder engagement

To provide full potential benefits to patients, behavioral health interventions often require comprehensive and systematic implementation efforts. The costs of these efforts should therefore be included when organizations decide to fund or adopt a new intervention. However, existing guidelines for conducting economic analyses like cost-effectiveness analyses and budget impact analyses are not well-suited to the complexity of the behavioral healthcare pathway and its many stakeholders. Stakeholder engagement, when used effectively with recent innovations in economic analysis, advance more equitable access to interventions for individuals living with behavioral health conditions. But early and ongoing stakeholder engagement has not yet been incorporated into best-practice guidelines for economic evaluation. We discuss our perspective, as researchers and clinicians in a large integrated health system, on how the integration of stakeholder engagement with existing economic analysis methods could improve decision-making about implementation of behavioral health interventions.

Diagnostic Accuracy and Acceptability of the Primary Care Posttraumatic Stress Disorder Screen for the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) Among US Veterans

Importance

Posttraumatic stress disorder (PTSD) is a serious mental health disorder that can be effectively treated with empirically based practices. PTSD screening is essential for identifying undetected cases and providing patients with appropriate care.

Objective

To determine whether the Primary Care PTSD screen for the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) (PC-PTSD-5) is a diagnostically accurate and acceptable measure for use in Veterans Affairs (VA) primary care clinics.

Design, Setting, and Participants

This cross-sectional, diagnostic accuracy study enrolled participants from May 19, 2017, to September 26, 2018. Participants were recruited from primary care clinics across 2 VA Medical Centers. Session 1 was conducted in person, and session 2 was completed within 30 days via telephone. A consecutive sample of 1594 veterans, aged 18 years or older, who were scheduled for a primary care visit was recruited. Data analysis was performed from March 2019 to August 2020.

Exposures

In session 1, participants completed a battery of questionnaires. In session 2, a research assistant administered the PC-PTSD-5 to participants, and then a clinician assessor blind to PC-PTSD-5 results conducted a structured diagnostic interview for PTSD.

Main Outcomes and Measures

The range of PC-PTSD-5 cut points overall and across gender was assessed, and diagnostic performance was evaluated by calculating weighted κ values.

Results

In total, 495 of 1594 veterans (31%) participated, and 396 completed all measures and were included in the analyses. Participants were demographically similar to the VA primary care population (mean [SD] age, 61.4 [15.5] years; age range, 21-93 years) and were predominantly male (333 participants [84.1%]) and White (296 of 394 participants [75.1%]). The PC-PTSD-5 had high levels of diagnostic accuracy for the overall sample (area under the receiver operating characteristic curve [AUC], 0.927; 95% CI, 0.896-0.959), men (AUC, 0.932; 95% CI, 0.894-0.969), and women (AUC, 0.899, 95% CI, 0.824-0.974). A cut point of 4 ideally balanced false negatives and false positives for the overall sample and for men. However, for women, this cut point resulted in high numbers of false negatives (6 veterans [33.3%]). A cut point of 3 fit better for women, despite increasing the number of false positives. Participants rated the PC-PTSD-5 as highly acceptable.

Conclusions and Relevance

The PC-PTSD-5 is an accurate and acceptable screening tool for use in VA primary care settings. Because performance parameters will change according to sample, clinicians should consider sample characteristics and screening purposes when selecting a cut point.