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Srivastava P, Modi V, Lier AJ. Sexually Transmitted Infection (STI) Incidence, STI Screening, and Human Immunodeficiency Virus Preexposure Prophylaxis Uptake in United States Veterans With Opioid Use Disorder in Long Island, New York. Open Forum Infect Dis 2024; 11:ofae429. [PMID: 39086462 PMCID: PMC11289836 DOI: 10.1093/ofid/ofae429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2024] [Accepted: 07/18/2024] [Indexed: 08/02/2024] Open
Abstract
Background Opioid use disorder (OUD) confers increased risk of contracting bloodborne and sexually transmitted infections (STIs). Limited data exist on infectious disease screening and preexposure prophylaxis (PrEP) usage among United States Veterans (USVs) with OUD, including persons who inject drugs (PWID). This study aimed to evaluate the epidemiology of human immunodeficiency virus (HIV), hepatitis C virus (HCV), bacterial STIs, and PrEP uptake in USVs with OUD, including PWID. Methods A retrospective chart review of USVs with OUD seeking care at Northport Veterans Affairs Medical Center between 2012 and 2022 was completed. Sociodemographics, HIV, HCV, STI testing rates and diagnosis, and PrEP uptake were compared between USVs, stratified by injection drug use history. Results We identified 502 USVs with OUD; 43% had a history of injection drug use. Overall, 2.2% of USVs had HIV and 28.7% had HCV. An STI was diagnosed in 10% of USVs, most frequently syphilis (1.8%). PWID were more likely to be tested for HIV (93.5% PWID vs. 73.1% non-PWID; P < .001), HCV (95.8% PWID vs. 80.8% non-PWID; P < .001), and syphilis (80% PWID vs. 69.2% non-PWID; P = .006). Total gonorrhea and chlamydia testing rates were 31.9% and 33.7%, respectively, without difference between the groups. PrEP was prescribed in 1.2% of USVs. Conclusions In USVs with OUD, gonorrhea and chlamydia screening occurred less frequently than syphilis, HCV, and HIV. PWID were more likely to be screened for HIV, HCV, and syphilis. PrEP uptake was low. Both PWID and non-PWID may benefit from increased STI screening and linkage to PrEP.
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Affiliation(s)
- Pronoma Srivastava
- Department of Internal Medicine, Renaissance School of Medicine at Stony Brook University, Stony Brook, New York, USA
| | - Viraj Modi
- Department of Medicine, Northport Veterans Affairs Medical Center, Northport, New York, USA
| | - Audun J Lier
- Department of Medicine, Northport Veterans Affairs Medical Center, Northport, New York, USA
- Division of Infectious Diseases, Department of Medicine, Northport Veterans Affairs Medical Center, Northport, New York, USA
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Jacobs MA, Gao Y, Schmidt S, Shireman PK, Mader M, Duncan CA, Hausmann LRM, Stitzenberg KB, Kao LS, Vaughan Sarrazin M, Hall DE. Social Determinants of Health and Surgical Desirability of Outcome Ranking in Older Veterans. JAMA Surg 2024:2821819. [PMID: 39083255 PMCID: PMC11292565 DOI: 10.1001/jamasurg.2024.2489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 05/08/2024] [Indexed: 08/03/2024]
Abstract
Importance Evaluating how social determinants of health (SDOH) influence veteran outcomes is crucial, particularly for quality improvement. Objective To measure associations between SDOH, care fragmentation, and surgical outcomes using a Desirability of Outcome Ranking (DOOR). Design, Setting, And Participants This was a cohort study of US veterans using data from the Veterans Affairs (VA) Surgical Quality Improvement Program (VASQIP; 2013-2019) limited to patients aged 65 years or older with inpatient stays between 2 and 30 days, merged with multiple data sources, including Medicare. Race and ethnicity data were retrieved from VASQIP, Medicare and Medicaid beneficiary summary files, the Veterans Health Administration Corporate Data Warehouse, and the United States Veterans Eligibility Trends and Statistics file. Data were analyzed between September 2023 and February 2024. Exposure Living in a highly deprived neighborhood (Area Deprivation Index >85), race and ethnicity used as a social construct, rurality, and care fragmentation (percentage of non-VA care days). Main Outcomes and Measures DOOR is a composite, patient-centered ranking of 26 outcomes ranging from no complication (1, best) to 90-day mortality or near-death complications (6, worst). A series of proportional odds regressions was used to assess the impact of SDOH and care fragmentation adjusted for clinical risk factors, including presentation acuity (presenting with preoperative acute serious conditions and urgent or emergent surgical procedures). Results The cohort had 93 644 patients (mean [SD] age, 72.3 [6.2] years; 91 443 [97.6%] male; 74 624 [79.7%] White). Veterans who identified as Black (adjusted odds ratio [aOR], 1.06; 95% CI, 1.02-1.10; P = .048) vs White and veterans with higher care fragmentation (per 20% increase in VA care days relative to all care days: aOR, 1.01; 95% CI, 1.01-1.02; P < .001) were associated with worse (higher) DOOR scores until adjusting for presentation acuity. Living in rural geographic areas was associated with better DOOR scores than living in urban areas (aOR, 0.93; 95% CI, 0.91-0.96; P < .001), and rurality was associated with lower presentation acuity (preoperative acute serious conditions: aOR, 0.88; 95% CI, 0.81-0.95; P = .001). Presentation acuity was higher in veterans identifying as Black, living in deprived neighborhoods, and with increased care fragmentation. Conclusions and Relevance Veterans identifying as Black and veterans with greater proportions of non-VA care had worse surgical outcomes. VA programs should direct resources to reduce presentation acuity among Black veterans, incentivize veterans to receive care within the VA where possible, and better coordinate veterans' treatment and records between care sources.
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Affiliation(s)
- Michael A. Jacobs
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Yubo Gao
- Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Medical Center, Iowa City, Iowa
- Department of Internal Medicine, Carver College of Medicine, The University of Iowa, Iowa City
| | - Susanne Schmidt
- Department of Population Health Sciences, University of Texas Health San Antonio, San Antonio
| | - Paula K. Shireman
- Department of Medical Physiology, College of Medicine, Texas A&M University, Bryan
- Department of Primary Care and Rural Medicine, College of Medicine, Texas A&M University, Bryan
| | | | - Carly A. Duncan
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Leslie R. M. Hausmann
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | | | - Lillian S. Kao
- Department of Surgery, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston
| | - Mary Vaughan Sarrazin
- Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Medical Center, Iowa City, Iowa
- Department of Internal Medicine, Carver College of Medicine, The University of Iowa, Iowa City
| | - Daniel E. Hall
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Geriatric Research Education and Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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Bowersox NW, Smith CM, Austin K, Bradford DW, Browne J, Nelson SM, Szymanski BR, Glynn SM. Mortality and suicidality in veterans health administration patients with newly-identified early episode psychosis. Schizophr Res 2024; 264:362-369. [PMID: 38219412 DOI: 10.1016/j.schres.2024.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 12/15/2023] [Accepted: 01/01/2024] [Indexed: 01/16/2024]
Abstract
Within the Veterans Affairs (VA), management of self-harm is a major clinical priority. However, there is limited information on risks for self-harm among VA patients with emerging psychotic disorders relative to VA patients with other emerging mental health conditions. Using information from fiscal years 2010 through 2018, a national cohort of VA patients 30 or younger was classified based on mental health diagnoses into three groups: 1) early episode psychosis (EEP), 2) non-early episode psychosis mental health (non-EEP MH), or 3) no mental health (no MH). Analyses focused on cohort members' risk for all-cause mortality, suicide mortality, and non-fatal suicide attempts (NFSA) during the year following initial diagnosis of mental health conditions (or first year of VA care, for the no MH group). In unadjusted analyses, the EEP group had elevated rates of all-cause mortality, suicide mortality, and NFSA relative to the non-EEP MH and no MH groups and the non-EEP MH had elevated rates of all-cause mortality, suicide mortality, and NFSA relative to the no MH group. After adjusting for demographics and care receipt, EEP status was unrelated to all-cause mortality but associated with increased suicide mortality risk and NFSA. Non-EEP MH status was associated with reduced risk of all-cause mortality but increased risk for NFSA. In the year following first diagnosis, VA patients with EEP are at increased risk for suicide mortality and self-harm even after accounting for other risk factors. Clinical services targeting this crucial time can help promote safety for this vulnerable group.
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Affiliation(s)
- Nicholas W Bowersox
- Serious Mental Illness Treatment Resource and Evaluation Center, Office of Mental Health and Suicide Prevention, Department of Veterans Affairs Central Office, Washington, DC, USA; Department of Psychiatry, University of Michigan Medical School, Ann Arbor, MI, USA.
| | - Colin M Smith
- Duke Hubert-Yeargan Center for Global Health, Durham, NC, USA
| | - Karen Austin
- Serious Mental Illness Treatment Resource and Evaluation Center, Office of Mental Health and Suicide Prevention, Department of Veterans Affairs Central Office, Washington, DC, USA
| | - Daniel W Bradford
- Office of Mental Health and Suicide Prevention, Department of Veterans Affairs Central Office, Washington, DC, USA; Duke University Medical Center, Durham, NC, USA
| | - Julia Browne
- Center of Innovation in Long Term Services and Supports, VA Providence Healthcare System, Providence, RI, USA; Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, RI, USA
| | - Sharon M Nelson
- Center for Evaluation and Implementation Resources, VA Ann Arbor Center for Clinical Management Research, Ann Arbor, MI, USA; Psychology Department, Pennsylvania State University, University Park, PA, USA
| | - Benjamin R Szymanski
- Serious Mental Illness Treatment Resource and Evaluation Center, Office of Mental Health and Suicide Prevention, Department of Veterans Affairs Central Office, Washington, DC, USA
| | - Shirley M Glynn
- VA Greater Los Angeles Healthcare System at West Los Angeles, Los Angeles, CA, USA; Semel Institute of Neuroscience and Human Behavior, University of California, Los Angeles, Los Angeles, CA, USA
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Pless Kaiser A, Moye J, Baird L, Sager Z, Wachterman M. Factors Associated With Distress Related to Posttraumatic Stress Disorder at the End of Life Among U.S. Veterans. J Pain Symptom Manage 2023; 66:102-115. [PMID: 37084828 PMCID: PMC10524384 DOI: 10.1016/j.jpainsymman.2023.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 03/15/2023] [Accepted: 04/08/2023] [Indexed: 04/23/2023]
Abstract
CONTEXT Posttraumatic stress disorder (PTSD) may emerge or re-emerge at end of life (EOL), increasing patient suffering. Understanding factors associated with PTSD at EOL may assist clinicians in identifying high risk veterans. OBJECTIVES To determine rates of and variables associated with PTSD-related distress at EOL. METHODS Retrospective observational cohort study including veterans who died within a Veterans Affairs (VA) inpatient setting between October 1, 2009 and September 30, 2018 whose next-of-kin completed the Bereaved Family Survey (BFS; N = 42,474). Our primary outcome was PTSD-related distress at EOL, as reported by veteran decedents' next-of-kin on the BFS. Predictors of interest included combat exposure, demographic variables, medical and psychiatric comorbidity, primary serious illness, and palliative care support. RESULTS Veteran decedents were majority male (97.7%), non-Hispanic white (77.2%), 65 years or older (80.5%), without combat exposure (80.1%). Almost one in ten (8.9%) veteran decedents experienced PTSD-related distress at EOL. In adjusted analyses, combat exposure, younger age, male sex, and non-white race were associated with PTSD-related distress at EOL. High overall medical comorbidity, dementia, and psychiatric comorbidities including both substance use disorder and depression, were also associated with PTSD-related distress at EOL. Palliative care consultation and emotional support were associated with decreased odds of PTSD-related distress, while pain was associated with increased odds of PTSD-related distress at EOL. CONCLUSION Trauma and PTSD screening, pain management, and providing palliative care and emotional support at EOL, particularly in at-risk groups such as veterans from racial/ethnic minority backgrounds and those with dementia, are critical to decreasing PTSD-related distress at EOL.
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Affiliation(s)
- Anica Pless Kaiser
- VA Boston Healthcare System (A.P.K., J.M., L.B., Z.S., M.W.), Boston Massachusetts, USA; VA National Center for PTSD (A.P.K.), Boston Massachusetts, USA; Boston University Chobanian & Avedisian School of Medicine (A.P.K.), Boston Massachusetts, USA.
| | - Jennifer Moye
- VA Boston Healthcare System (A.P.K., J.M., L.B., Z.S., M.W.), Boston Massachusetts, USA; New England Geriatric Research Education and Clinical Center (J.M., Z.S.), Boston Massachusetts, USA; Harvard Medical School (J.M., J.S., M.W.), Boston Massachusetts, USA
| | - Lola Baird
- VA Boston Healthcare System (A.P.K., J.M., L.B., Z.S., M.W.), Boston Massachusetts, USA
| | - Zachary Sager
- VA Boston Healthcare System (A.P.K., J.M., L.B., Z.S., M.W.), Boston Massachusetts, USA; New England Geriatric Research Education and Clinical Center (J.M., Z.S.), Boston Massachusetts, USA; Harvard Medical School (J.M., J.S., M.W.), Boston Massachusetts, USA; Dana-Farber Cancer Institute (Z.S., M.W.), Boston Massachusetts, USA
| | - Melissa Wachterman
- VA Boston Healthcare System (A.P.K., J.M., L.B., Z.S., M.W.), Boston Massachusetts, USA; Harvard Medical School (J.M., J.S., M.W.), Boston Massachusetts, USA; Center for Healthcare Organization & Implementation Research (M.W.), Boston Massachusetts, USA; Dana-Farber Cancer Institute (Z.S., M.W.), Boston Massachusetts, USA
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Moye J, O’Malley KA, Auguste EJ, Driver JA, Owsiany MT, Paik JM. Trauma re-engagement and PTSD in older medically ill veterans: implications for trauma-informed care. Aging Ment Health 2023; 27:957-964. [PMID: 35603825 PMCID: PMC10281592 DOI: 10.1080/13607863.2022.2068135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 04/12/2022] [Indexed: 11/01/2022]
Abstract
OBJECTIVES We characterize rates and correlates of PTSD and of trauma re-engagement without PTSD in medically ill older Veterans, as well as supportive strategies, with the goal of advancing trauma-informed care. METHODS We interviewed medically ill older Veterans (N = 88, M age 75.13, SD = 6.14) with primary care screening measures for PTSD and trauma re-engagement, and open-ended questions to assess supportive strategies. RESULTS One-fifth (20.5%) presented with probable PTSD, associated with greater trauma exposures (r=.57, p<.001), whereas two-fifths (43.2%) reported re-engagement with military memories without PTSD, associated with having a spouse/partner (t = 2.27, p=.028). Of those who experienced trauma, half reported thinking more about the trauma recently and becoming more emotional on certain days. In response to the question 'What gives you strength as you think about the future with your illness' Veterans described support of family, healthcare, worldview, personal control, acceptance, and health behaviors. CONCLUSION Memories of trauma are common with medical illness. Age-friendly trauma-informed care could consider factors that patients describe as sources of strength with illness.
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Affiliation(s)
- Jennifer Moye
- VA New England Geriatric Research Education and Clinical Center (GRECC), Boston, MA, USA
- VA Boston Healthcare System, Boston, MA, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Kelly A. O’Malley
- VA Boston Healthcare System, Boston, MA, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Elizabeth J. Auguste
- VA New England Geriatric Research Education and Clinical Center (GRECC), Boston, MA, USA
- VA Boston Healthcare System, Boston, MA, USA
| | - Jane A. Driver
- VA New England Geriatric Research Education and Clinical Center (GRECC), Boston, MA, USA
- VA Boston Healthcare System, Boston, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Montgomery T. Owsiany
- VA New England Geriatric Research Education and Clinical Center (GRECC), Boston, MA, USA
- VA Boston Healthcare System, Boston, MA, USA
| | - Julie M. Paik
- VA New England Geriatric Research Education and Clinical Center (GRECC), Boston, MA, USA
- VA Boston Healthcare System, Boston, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
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6
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Trivedi RB, Rossi FS, Javier SJ, Greene L, Singer SJ, Vanneman ME, Goldstein M, Zulman DM. Association Between Mental Health Conditions and Outpatient Care Fragmentation: a National Study of Older High-Risk Veterans. J Gen Intern Med 2022; 37:4071-4079. [PMID: 35869316 PMCID: PMC9708986 DOI: 10.1007/s11606-022-07705-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 06/16/2022] [Indexed: 01/09/2023]
Abstract
BACKGROUND Healthcare fragmentation may lead to adverse consequences and may be amplified among older, sicker patients with mental health (MH) conditions. OBJECTIVE To determine whether older Veterans with MH conditions have more fragmented outpatient non-MH care, compared with older Veterans with no MH conditions. DESIGN Retrospective cohort study using FY2014 Veterans Health Administration (VHA) administrative data linked to Medicare data. PARTICIPANTS 125,481 VHA patients ≥ 65 years old who were continuously enrolled in Medicare Fee-for-Service Parts A and B and were at high risk for hospitalization. MAIN OUTCOME AND MEASURES The main outcome was non-MH care fragmentation as measured by (1) non-MH provider count and (2) Usual Provider of Care (UPC), the proportion of care with the most frequently seen non-MH provider. We tested the association between no vs. any MH conditions and outcomes using Poisson regression and fractional regression with logit link, respectively. We also compared Veterans with no MH condition with each MH condition and combinations of MH conditions, adjusting for sociodemographics, comorbidities, and drive-time to VHA specialty care. KEY RESULTS In total, 47.3% had at least one MH condition. Compared to those without MH conditions, Veterans with MH conditions had less fragmented care, with fewer non-MH providers (IRR = 0.96; 95% CI: 0.96-0.96) and more concentrated care with their usual provider (OR = 1.08 for a higher UPC; 95% CI: 1.07, 1.09) in adjusted models. Secondary analyses showed that those with individual MH conditions (e.g., depression) had fewer non-MH providers (IRR range: 0.86-0.98) and more concentrated care (OR range: 1.04-1.20). A similar pattern was observed when examining combinations of MH conditions (IRR range: 0.80-0.90; OR range: 1.16-1.30). CONCLUSIONS Contrary to expectations, having a MH condition was associated with less fragmented non-MH care among older, high-risk Veterans. Further research will determine if this is due to different needs, underuse, or appropriate use of healthcare.
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Affiliation(s)
- Ranak B Trivedi
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Ci2i Bldg 324 B-134, 795 Willow Rd MPD-152, Menlo Park, CA, 94025, USA.
- Division of Public Mental Health and Population Sciences, Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA, USA.
| | - Fernanda S Rossi
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Ci2i Bldg 324 B-134, 795 Willow Rd MPD-152, Menlo Park, CA, 94025, USA
- Center for Primary Care and Outcomes Research (PCOR), Stanford University School of Medicine, Stanford, CA, USA
| | - Sarah J Javier
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Ci2i Bldg 324 B-134, 795 Willow Rd MPD-152, Menlo Park, CA, 94025, USA
- Center for Primary Care and Outcomes Research (PCOR), Stanford University School of Medicine, Stanford, CA, USA
| | - Liberty Greene
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Ci2i Bldg 324 B-134, 795 Willow Rd MPD-152, Menlo Park, CA, 94025, USA
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, USA
| | - Sara J Singer
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, USA
| | - Megan E Vanneman
- Informatics, Decision-Enhancement and Analytic Sciences Center (IDEAS), VA Salt Lake City Health Care System, Salt Lake City, UT, USA
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
- Division of Health System Innovation and Research, Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Mary Goldstein
- Center for Primary Care and Outcomes Research (PCOR), Stanford University School of Medicine, Stanford, CA, USA
- Office of Geriatrics and Extended Care, Department of Veterans Affairs, Washington, DC, USA
| | - Donna M Zulman
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, Ci2i Bldg 324 B-134, 795 Willow Rd MPD-152, Menlo Park, CA, 94025, USA
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, USA
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Jones AL, Rafferty J, Cochran SD, Abelson J, Hanna MR, Mays VM. Prevalence, Severity and Burden of Post-Traumatic Stress Disorder in Black Men and Women Across the Adult Life span. J Aging Health 2022; 34:401-412. [PMID: 35510479 PMCID: PMC9175561 DOI: 10.1177/08982643221086071] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objectives: To examine post-traumatic stress disorder (PTSD) among Black adults in younger, middle, and older ages. Methods: Using nationally representative data from the National Survey of American Life, we estimated lifetime and 12-month prevalence of PTSD in Black men and women ages 18-34, 35-49, and 50+. We determined PTSD persistence and severity by age group, then associations of PTSD with socio-economic status, chronic stress, and racial discrimination in middle age. Results: The lifetime prevalence of PTSD was higher in Black women/men ages 18-34 (prevalence=14.0%/6.3%) and 35-49 (12.8%/4.6%) versus 50 and older (8.7%/5.1%). Those ages 35-49 were more likely than younger/older Black adults to have severe interference in work, relationships, and activities domains. In middle age, PTSD was associated with unemployment, lower education, poverty, and stress in Black men, and unemployment, divorce, poverty, stress, and discrimination in Black women. Discussion: Black women experience a disproportionate burden of PTSD in middle age.
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Affiliation(s)
- Audrey L Jones
- Informatics, Decision-Enhancement and Analytic Sciences Center, 20122Veteran Affairs Salt Lake City Health Care System, Salt Lake City, UT, USA
- Department of Internal Medicine, School of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Jane Rafferty
- Program for Research on Black Americans, 51331Institute of Social Research, Ann Arbor, MI, USA
- School of Social Work, 143265University of Michigan, Ann Arbor, MI, USA
| | - Susan D Cochran
- Departments of Epidemiology and Statistics, Fielding School of Public Health, 25808University of California, Los Angeles, CA, USA
- UCLA BRITE Center for Science, Research & Policy, Los Angeles, CA, USA
| | - Jamie Abelson
- Program for Research on Black Americans, 51331Institute of Social Research, Ann Arbor, MI, USA
- School of Social Work, 143265University of Michigan, Ann Arbor, MI, USA
| | - Matthew R Hanna
- Department of Psychology, 5926The New School for Social Research, New York, NY, USA
| | - Vickie M Mays
- UCLA BRITE Center for Science, Research & Policy, Los Angeles, CA, USA
- Departments of Psychology and Health Policy and Management, Fielding School of Public Health, 8783University of California, Los Angeles, CA, USA
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DiNardo MM, Greco C, Phares AD, Beyer NM, Youk AO, Obrosky DS, Morone NE, Owen JE, Saba SK, Suss SJ, Siminerio L. Effects of an integrated mindfulness intervention for veterans with diabetes distress: a randomized controlled trial. BMJ Open Diabetes Res Care 2022; 10:10/2/e002631. [PMID: 35346971 PMCID: PMC8961140 DOI: 10.1136/bmjdrc-2021-002631] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 02/27/2022] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION US military veterans have disproportionately high rates of diabetes and diabetes-related morbidity in addition to being at risk of comorbid stress-related conditions. This study aimed to examine the effects of a technology-supported mindfulness intervention integrated into usual diabetes care and education on psychological and biobehavioral outcomes. RESEARCH DESIGN AND METHODS Veterans (N=132) with type 1 or 2 diabetes participated in this two-arm randomized controlled efficacy trial. The intervention arm received a one-session mindfulness intervention integrated into a pre-existing program of diabetes self-management education and support (DSMES) plus one booster session and 24 weeks of home practice supported by a mobile application. The control arm received one 3-hour comprehensive DSMES group session. The primary outcome was change in diabetes distress (DD). The secondary outcomes were diabetes self-care behaviors, diabetes self-efficacy, post-traumatic stress disorder (PTSD), depression, mindfulness, hemoglobin A1C (HbA1C), body weight, and blood pressure. Assessments were conducted at baseline, 12 weeks, and 24 weeks. Participant satisfaction and engagement in home practice were assessed in the intervention group at 12 and 24 weeks. RESULTS Intention-to-treat group by time analyses showed a statistically significant improvement in DD in both arms without significant intervention effect from baseline to 24 weeks. Examination of distal effects on DD between weeks 12 and 24 showed significantly greater improvement in the intervention arm. Improvement in DD was greater when baseline HbA1C was <8.5%. A significant intervention effect was also shown for general dietary behaviors. The secondary outcomes diabetes self-efficacy, PTSD, depression, and HbA1C significantly improved in both arms without significant intervention effects. Mindfulness and body weight were unchanged in either group. CONCLUSIONS A technology-supported mindfulness intervention integrated with DSMES showed stronger distal effects on DD compared with DSMES control. Examination of longer-term outcomes, underlying mechanisms, and the feasibility of virtual delivery is warranted. TRIAL REGISTRATION NUMBER NCT02928952.
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Affiliation(s)
- Monica M DiNardo
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | - Carol Greco
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
- Center for Complementary Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Angela D Phares
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | - Nicole M Beyer
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | - Ada O Youk
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
- Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - D Scott Obrosky
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | - Natalia E Morone
- Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Jason E Owen
- National Center for PTSD, VA Palo Alto Health Care System, Palo Alto, California, USA
| | - Shaddy K Saba
- Suzanne Dworak-Peck School of Social Work, University of Southern California, Los Angeles, California, USA
| | - Stephen J Suss
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Linda Siminerio
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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Gene expression correlates of advanced epigenetic age and psychopathology in postmortem cortical tissue. Neurobiol Stress 2021; 15:100371. [PMID: 34458511 PMCID: PMC8377489 DOI: 10.1016/j.ynstr.2021.100371] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 07/02/2021] [Accepted: 07/23/2021] [Indexed: 11/22/2022] Open
Abstract
Psychiatric stress has been associated with accelerated epigenetic aging (i.e., when estimates of cellular age based on DNA methylation exceed chronological age) in both blood and brain tissue. Little is known about the downstream biological effects of accelerated epigenetic age on gene expression. In this study we examined associations between DNA methylation-derived estimates of cellular age that range from decelerated to accelerated relative to chronological age (“DNAm age residuals”) and transcriptome-wide gene expression. This was examined using tissue from three post-mortem cortical regions (ventromedial and dorsolateral prefrontal cortex and motor cortex, n = 97) from the VA National PTSD Brain Bank. In addition, we examined how posttraumatic stress disorder (PTSD) and alcohol-use disorders (AUD) moderated the association between DNAm age residuals and gene expression. Transcriptome-wide results across brain regions, psychiatric diagnoses, and cohorts (full sample and male and female subsets) revealed experiment-wide differential expression of 11 genes in association with PTSD or AUD in interaction with DNAm age residuals. This included the inflammation-related genes IL1B, RCOR2, and GCNT1. Candidate gene class analyses and gene network enrichment analyses further supported differential expression of inflammation/immune gene networks as well as glucocorticoid, circadian, and oxidative stress-related genes. Gene co-expression network modules suggested enrichment of myelination related processes and oligodendrocyte enrichment in association with DNAm age residuals in the presence of psychopathology. Collectively, results suggest that psychiatric stress accentuates the association between advanced epigenetic age and expression of inflammation genes in the brain. This highlights the role of inflammatory processes in the pathophysiology of accelerated cellular aging and suggests that inflammatory pathways may link accelerated cellular aging to premature disease onset and neurodegeneration, particularly in stressed populations. This suggests that anti-inflammatory interventions may be an important direction to pursue in evaluating ways to prevent or delay cellular aging and increase resilience to diseases of aging.
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Coughlin LN, Pfeiffer P, Ganoczy D, Lin LA. Quality of Outpatient Depression Treatment in Patients With Comorbid Substance Use Disorder. Am J Psychiatry 2021; 178:414-423. [PMID: 33115247 PMCID: PMC8776315 DOI: 10.1176/appi.ajp.2020.20040454] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Clinical practice guidelines recommend concurrent treatment of co-occurring depression and substance use disorders; however, the degree to which patients with substance use disorders receive guideline-concordant treatment for depression is unknown. The authors investigated the provision of guideline-concordant depression treatment to patients with and without substance use disorders in a large integrated health care system. METHODS In a retrospective cohort study of 53,034 patients diagnosed with a depressive disorder in fiscal year 2017 in the U.S. Veterans Health Administration, the authors assessed the association of comorbid substance use disorders with guideline-concordant depression treatment, including both medication and psychotherapy, while adjusting for patient demographic and clinical characteristics. RESULTS Guideline-concordant depression treatment was lower across metrics for patients with co-occurring depression and substance use disorders compared to those without substance use disorders. Consistent findings emerged in covariate-adjusted models of antidepressant treatment, such that patients with substance use disorders had 21% lower odds of guideline-concordant acute treatment (adjusted odds ratio=0.79, 95% CI=0.73, 0.84) and 26% lower odds of continuation of treatment (adjusted odds ratio=0.74, 95% CI=0.69, 0.79). With regard to psychotherapy, patients with co-occurring depression and substance use disorders had 13% lower odds (adjusted odds ratio=0.87, 95% CI=0.82, 0.91) of adequate acute-phase treatment and 19% lower odds (adjusted odds ratio=0.81; 95% CI=0.73, 0.89) of psychotherapy continuation. CONCLUSIONS Despite the availability of effective treatments for depression, patients with co-occurring substance use disorders are less likely to receive guideline-concordant depression treatment. Efforts to improve the provision of care to those with co-occurring substance use disorders should focus on clinician-based interventions and use of integrated care models to improve the quality of depression treatment.
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Affiliation(s)
- Lara N Coughlin
- Addiction Center, Department of Psychiatry, University of Michigan, Ann Arbor (Coughlin, Lin); VA Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor (Pfeiffer, Ganoczy, Lin)
| | - Paul Pfeiffer
- Addiction Center, Department of Psychiatry, University of Michigan, Ann Arbor (Coughlin, Lin); VA Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor (Pfeiffer, Ganoczy, Lin)
| | - Dara Ganoczy
- Addiction Center, Department of Psychiatry, University of Michigan, Ann Arbor (Coughlin, Lin); VA Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor (Pfeiffer, Ganoczy, Lin)
| | - Lewei A Lin
- Addiction Center, Department of Psychiatry, University of Michigan, Ann Arbor (Coughlin, Lin); VA Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor (Pfeiffer, Ganoczy, Lin)
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11
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Szymanski BR, Hein TC, Schoenbaum M, McCarthy JF, Katz IR. Facility-Level Excess Mortality of VHA Patients With Mental Health or Substance Use Disorder Diagnoses. Psychiatr Serv 2021; 72:408-414. [PMID: 33502219 DOI: 10.1176/appi.ps.202000282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Individuals with mental or substance use disorders have higher mortality rates than people in the general population. How excess mortality varies across health care facilities is unknown. The authors sought to investigate facility-level mortality rates among Veterans Health Administration (VHA) patients who had received diagnoses of mental or substance use disorders. METHODS An electronic medical records-based retrospective cohort study was conducted, encompassing 8,812,373 unique users of 139 VHA facilities from 2011 to 2016. Covariates included age, sex, and past-year diagnoses of serious mental illness, posttraumatic stress disorder, major depressive disorder, other mental health conditions, or substance use disorders. The outcome was all-cause mortality per comprehensive Veterans Affairs/Department of Defense searches of the National Death Index. Proportional hazards regression was used to calculate overall and facility-specific hazard ratios (HRs) for each diagnosis group, adjusted for age, sex, and comorbid medical conditions. RESULTS Overall, all-cause mortality was statistically significantly elevated among VHA users with mental health diagnoses (HR=1.21, 95% confidence interval=1.20-1.22). HRs varied across facilities consistently over time. At the VHA facility level, diagnostic groups were significantly correlated with the degree of excess mortality. Results were similar in sensitivity analyses that excluded deaths from suicide or drug or alcohol overdose. CONCLUSIONS VHA users with mental or substance use disorder diagnoses had elevated mortality rates. Correlation in excess mortality across two periods indicated that facility differences in excess mortality were persistent and therefore potentially associated with facility- and community-level factors, which may help inform quality improvement efforts to reduce mortality rates.
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Affiliation(s)
- Benjamin R Szymanski
- Serious Mental Illness Treatment Resource and Evaluation Center, U.S. Department of Veterans Affairs, Ann Arbor, Michigan (Szymanski, Hein, McCarthy); Division of Services and Intervention Research, National Institute of Mental Health, Bethesda, Maryland (Schoenbaum); Department of Psychiatry, University of Michigan, Ann Arbor (McCarthy); Office of Mental Health and Suicide Prevention, U.S. Department of Veterans Affairs, Philadelphia (Katz)
| | - Tyler C Hein
- Serious Mental Illness Treatment Resource and Evaluation Center, U.S. Department of Veterans Affairs, Ann Arbor, Michigan (Szymanski, Hein, McCarthy); Division of Services and Intervention Research, National Institute of Mental Health, Bethesda, Maryland (Schoenbaum); Department of Psychiatry, University of Michigan, Ann Arbor (McCarthy); Office of Mental Health and Suicide Prevention, U.S. Department of Veterans Affairs, Philadelphia (Katz)
| | - Michael Schoenbaum
- Serious Mental Illness Treatment Resource and Evaluation Center, U.S. Department of Veterans Affairs, Ann Arbor, Michigan (Szymanski, Hein, McCarthy); Division of Services and Intervention Research, National Institute of Mental Health, Bethesda, Maryland (Schoenbaum); Department of Psychiatry, University of Michigan, Ann Arbor (McCarthy); Office of Mental Health and Suicide Prevention, U.S. Department of Veterans Affairs, Philadelphia (Katz)
| | - John F McCarthy
- Serious Mental Illness Treatment Resource and Evaluation Center, U.S. Department of Veterans Affairs, Ann Arbor, Michigan (Szymanski, Hein, McCarthy); Division of Services and Intervention Research, National Institute of Mental Health, Bethesda, Maryland (Schoenbaum); Department of Psychiatry, University of Michigan, Ann Arbor (McCarthy); Office of Mental Health and Suicide Prevention, U.S. Department of Veterans Affairs, Philadelphia (Katz)
| | - Ira R Katz
- Serious Mental Illness Treatment Resource and Evaluation Center, U.S. Department of Veterans Affairs, Ann Arbor, Michigan (Szymanski, Hein, McCarthy); Division of Services and Intervention Research, National Institute of Mental Health, Bethesda, Maryland (Schoenbaum); Department of Psychiatry, University of Michigan, Ann Arbor (McCarthy); Office of Mental Health and Suicide Prevention, U.S. Department of Veterans Affairs, Philadelphia (Katz)
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Schindler AG, Baskin B, Juarez B, Janet Lee S, Hendrickson R, Pagulayan K, Zweifel LS, Raskind MA, Phillips PEM, Peskind ER, Cook DG. Repetitive blast mild traumatic brain injury increases ethanol sensitivity in male mice and risky drinking behavior in male combat veterans. Alcohol Clin Exp Res 2021; 45:1051-1064. [PMID: 33760264 DOI: 10.1111/acer.14605] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 03/16/2021] [Accepted: 03/17/2021] [Indexed: 01/04/2023]
Abstract
BACKGROUND Mild traumatic brain injury (mTBI) is common in civilians and highly prevalent among military service members. mTBI can increase health risk behaviors (e.g., sensation seeking, impulsivity) and addiction risk (e.g., for alcohol use disorder (AUD)), but how mTBI and substance use might interact to promote addiction risk remains poorly understood. Likewise, potential differences in single vs. repetitive mTBI in relation to alcohol use/abuse have not been previously examined. METHODS Here, we examined how a history of single (1×) or repetitive (3×) blast exposure (blast-mTBI) affects ethanol (EtOH)-induced behavioral and physiological outcomes using an established mouse model of blast-mTBI. To investigate potential translational relevance, we also examined self-report responses to the Alcohol Use Disorders Identification Test-Consumption questions (AUDIT-C), a widely used measure to identify potential hazardous drinking and AUD, and used a novel unsupervised machine learning approach to investigate whether a history of blast-mTBI affected drinking behaviors in Iraq/Afghanistan Veterans. RESULTS Both single and repetitive blast-mTBI in mice increased the sedative properties of EtOH (with no change in tolerance or metabolism), but only repetitive blast potentiated EtOH-induced locomotor stimulation and shifted EtOH intake patterns. Specifically, mice exposed to repetitive blasts showed increased consumption "front-loading" (e.g., a higher rate of consumption during an initial 2-h acute phase of a 24-h alcohol access period and decreased total daily intake) during an intermittent 2-bottle choice condition. Examination of AUDIT-C scores in Iraq/Afghanistan Veterans revealed an optimal 3-cluster solution: "low" (low intake and low frequency), "frequent" (low intake and high frequency), and "risky" (high intake and high frequency), where Veterans with a history of blast-mTBI displayed a shift in cluster assignment from "frequent" to "risky," as compared to Veterans who were deployed to Iraq/Afghanistan but had no lifetime history of TBI. CONCLUSIONS Together, these results offer new insight into how blast-mTBI may give increase AUD risk and highlight the increased potential for adverse health risk behaviors following repetitive blast-mTBI.
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Affiliation(s)
- Abigail G Schindler
- VA Northwest Geriatric Research Education and Clinical Center, VA Puget Sound Health Care System, Seattle, WA, USA.,VA Northwest Mental Illness Research, Education, and Clinical Center, VA Puget Sound Health Care System, Seattle, WA, USA.,Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA.,Graduate Program in Neuroscience, University of Washington, Seattle, WA, USA
| | - Britahny Baskin
- VA Northwest Geriatric Research Education and Clinical Center, VA Puget Sound Health Care System, Seattle, WA, USA.,Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA.,Graduate Program in Neuroscience, University of Washington, Seattle, WA, USA
| | - Barbara Juarez
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA
| | - Suhjung Janet Lee
- VA Northwest Geriatric Research Education and Clinical Center, VA Puget Sound Health Care System, Seattle, WA, USA
| | - Rebecca Hendrickson
- VA Northwest Mental Illness Research, Education, and Clinical Center, VA Puget Sound Health Care System, Seattle, WA, USA.,Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA
| | - Kathleen Pagulayan
- VA Northwest Mental Illness Research, Education, and Clinical Center, VA Puget Sound Health Care System, Seattle, WA, USA.,Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA
| | - Larry S Zweifel
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA.,Graduate Program in Neuroscience, University of Washington, Seattle, WA, USA.,Department of Pharmacology, University of Washington, Seattle, WA, USA
| | - Murray A Raskind
- VA Northwest Mental Illness Research, Education, and Clinical Center, VA Puget Sound Health Care System, Seattle, WA, USA.,Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA
| | - Paul E M Phillips
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA.,Graduate Program in Neuroscience, University of Washington, Seattle, WA, USA.,Department of Pharmacology, University of Washington, Seattle, WA, USA
| | - Elaine R Peskind
- VA Northwest Geriatric Research Education and Clinical Center, VA Puget Sound Health Care System, Seattle, WA, USA.,Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA
| | - David G Cook
- VA Northwest Geriatric Research Education and Clinical Center, VA Puget Sound Health Care System, Seattle, WA, USA.,Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA.,Graduate Program in Neuroscience, University of Washington, Seattle, WA, USA.,Department of Pharmacology, University of Washington, Seattle, WA, USA.,Department of Medicine, University of Washington, Seattle, WA, USA
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Liu CF, Hebert P, Wong ES, Nelson K, Maynard C. Midlife mortality in White non-Hispanic male veterans enrolled in Department of Veterans Affairs primary care, 2003-2014. Heliyon 2020; 6:e03328. [PMID: 32051882 PMCID: PMC7002889 DOI: 10.1016/j.heliyon.2020.e03328] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Revised: 11/27/2019] [Accepted: 01/27/2020] [Indexed: 11/30/2022] Open
Abstract
Background After years of decline in mortality rates in the United States, there have been increases in mortality rates in White non-Hispanic Americans ages 45–54, due to increases in deaths from suicide, poisoning, and alcoholic liver disease. Objectives To determine whether White non-Hispanic middle age male Veterans enrolled in Department of Veterans Affairs (VA) primary care had increased mortality, as found in the general population. Research design Repeated cross-sectional analysis over 12 years to describe trends in death rates for men across 3 race/ethnicity groups (White non-Hispanic, Black non-Hispanic, Hispanic) and 2 age groups (45–54, 55–64) for the Veteran and general US male populations. Subjects 60 million patient-years for Veterans enrolled in VA primary care from 2003 to 2014 and 1.8 million who died during the study period. Measures All-cause and cause specific death rates for alcoholic liver disease, poisoning, and suicide. Results For White non-Hispanic male Veterans ages 55–64, the increase in all-cause mortality from 2003 to 2014 (+309 deaths/100,000) was accompanied by significant changes in deaths due to poisoning (+30/100,000), alcoholic liver disease (+23/100,000), and suicide (+17/100,000). For US men ages 55–64, all-cause mortality decreased slightly from 2003-2014 (-22 deaths/100,000). However, there were increases in death rates due to poisoning (+17/100,000), alcoholic liver disease (+14/100,000) and suicide (+11/100,000). Conclusions These disturbing findings for White non-Hispanic Veteran men ages 55–64 suggest the critical importance of suicide prevention programs as well as the importance of high quality integrated health care for both Veteran and non-Veteran men.
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Affiliation(s)
- Chuan-Fen Liu
- Department of Veterans Affairs Puget Sound Health Care System, Seattle, WA, United States.,Department of Health Services, University of Washington, Seattle, WA, United States
| | - Paul Hebert
- Department of Veterans Affairs Puget Sound Health Care System, Seattle, WA, United States.,Department of Health Services, University of Washington, Seattle, WA, United States
| | - Edwin S Wong
- Department of Veterans Affairs Puget Sound Health Care System, Seattle, WA, United States.,Department of Health Services, University of Washington, Seattle, WA, United States
| | - Karin Nelson
- Department of Veterans Affairs Puget Sound Health Care System, Seattle, WA, United States.,Department of Medicine, University of Washington, Seattle, WA, United States
| | - Charles Maynard
- Department of Veterans Affairs Puget Sound Health Care System, Seattle, WA, United States.,Department of Health Services, University of Washington, Seattle, WA, United States
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