Clinical and functional effects of the COVID-19 pandemic and social distancing on vulnerable veterans with psychosis or recent homelessness

Financial health and psychiatric symptoms among veterans with psychosis or recent homelessness during the COVID-19 pandemic

The COVID-19 pandemic disproportionately impacted the physical health of some vulnerable groups, but further study is needed to investigate the pandemic's impact on financial health and mental well-being. We analyzed data from 158 participants, consisting of 59 veterans with a psychotic disorder (PSY), 49 recently housed veterans (RHV), and a control group of 50 veterans (CTL) who were assessed five times from May 2020-July 2021. This study compared the financial health of these three groups and examined the relation between financial health and psychiatric symptoms. Although the CTL group reported significantly higher income and savings than the PSY and RHV groups, the CTL group reported greater negative financial shocks than the PSY group. The RHV group reported greater material hardship but greater propensity to plan for finances and less financial shocks than the PSY group. Across all three groups, there was a reduction in financial shocks over time and no group showed more change than another. Across time, material hardship, financial shocks, and propensity to plan for finances were each significantly associated with symptoms of major depression. Together, these findings suggest the COVID-19 pandemic did not greatly impact the financial health of PSY and RHV groups possibly because of their limited income and resilience to adversity. Financial health was related to mental health supporting the U.S. government's strategic plan to include financial empowerment services in efforts to improve mental health and reduce veteran suicide. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Sustained mental health and functional responses to the COVID-19 pandemic in Black and White Veterans with psychosis or recent homelessness

The COVID-19 pandemic disproportionately impacted marginalized populations including Black Americans, people with serious mental illness, and individuals experiencing homelessness. Although the double disadvantage hypothesis would suggest that individuals with multiple minoritized statuses would experience worse psychosocial impacts from the pandemic, this may not be the case for vulnerable Black Veterans. The present study investigated the sustained mental health and functional responses to the pandemic in Black and White Veterans with psychosis or recent homelessness and in a control group of Veterans enrolled in the Department of Veterans Affairs healthcare services. Clinical interviews and questionnaires were administered remotely by telephone at five time points from May 2020 through July 2021, including a retrospective time point for March 2020 (i.e., before the pandemic started). Overall, there was a striking absence of systematic differences by race in the trajectories of psychiatric symptoms and functioning among Veterans during the study period. These findings are consistent with a report on initial responses to the pandemic that revealed only a few select differences by race among Veteran groups. The lack of racial disparities is inconsistent with the double disadvantage hypothesis. Although further investigation is needed, one possible interpretation is that the wrap-around services offered by the Veterans Health Administration may have mitigated expected differences by race among Veterans with psychosis or homelessness. Future research should continue to examine whether VA services mitigate disparities in mental health and psychosocial outcomes.

The impact of psychological strengths on Veteran populations' mental health trajectories during the COVID-19 pandemic

PURPOSE

Mental health trajectories during the COVID-19 pandemic have been examined in Veterans with tenuous social connections, i.e., those with recent homelessness (RHV) or a psychotic disorder (PSY), and in control Veterans (CTL). We test potential moderating effects on these trajectories by psychological factors that may help individuals weather the socio-emotional challenges associated with the pandemic (i.e., 'psychological strengths').

METHODS

We assessed 81 PSY, 76 RHV, and 74 CTL over 5 periods between 05/2020 and 07/2021. Mental health outcomes (i.e., symptoms of depression, anxiety, contamination concerns, loneliness) were assessed at each period, and psychological strengths (i.e., a composite score based on tolerance of uncertainty, performance beliefs, coping style, resilience, perceived stress) were assessed at the initial assessment. Generalized models tested fixed and time-varying effects of a composite psychological strengths score on clinical trajectories across samples and within each group.

RESULTS

Psychological strengths had a significant effect on trajectories for each outcome (ps < 0.05), serving to ameliorate changes in mental health symptoms. The timing of this effect varied across outcomes, with early effects for depression and anxiety, later effects for loneliness, and sustained effects for contamination concerns. A significant time-varying effect of psychological strengths on depressive symptoms was evident in RHV and CTL, anxious symptoms in RHV, contamination concerns in PSY and CTL, and loneliness in CTL (ps < 0.05).

CONCLUSION

Across vulnerable and non-vulnerable Veterans, presence of psychological strengths buffered against exacerbations in clinical symptoms. The timing of the effect varied across outcomes and by group.

Veterans and Nonveterans Coping With Stress During 4 Months of COVID-19

PURPOSE

Identifying how people have been coping with stress during the COVID-19 pandemic allows us to anticipate how the population may react to similar stressors over time. In this study, we assessed patterns of coping styles among veterans and nonveterans, and stability and change in these strategies at 3 time points during the pandemic.

METHODS

Using an online survey platform, we circulated a questionnaire at 3 time points during the period when COVID-19 vaccines became widely available (December 2-27, 2020; January 21-February 6, 2021; and March 8-23, 2021). The questionnaire asked participants about their extent of use of 11 coping strategies, and symptoms of anxiety and depression.

RESULTS

A total of 2,085 participants (50.8% veterans) completed the questionnaire at 1 or more time points and 930 participants (62.8% veterans) completed it at all 3 time points. Cluster analysis identified 3 distinct coping styles: adaptive, distressed, and disengaged. Compared with nonveterans, veterans more commonly had adaptive and disengaged coping styles, and less commonly had a distressed coping style. The majority of the cohort (71.3%) changed coping style at least once during the study period. Participants who used the same coping style across all 3 time points reported lower levels of anxiety and depression.

CONCLUSIONS

Our data demonstrate a need to better understand the dynamic nature of coping with pandemic-level stressors across time. We did not find patterns of change in coping styles, but our findings point to potential advantages of stability in coping style. It is possible that less adaptive styles that are more stable may be advantageous for mental health. This research has implications for supporting patients dealing with stress in family medicine.

Unconditional Cash Transfers and Association With Clinical Outcomes Among U.S. Veterans With Psychosis or Recent Homelessness

OBJECTIVE

Three rounds of stimulus checks were distributed to middle- and low-income U.S. adults during the COVID-19 pandemic. This 15-month longitudinal study examined rates of receipt of these stimulus checks, planned expenses, and associations with clinical outcomes among three veteran groups.

METHODS

In total, 158 veterans, consisting of 59 with a psychotic disorder, 49 recently homeless veterans, and a comparison group of 50 veterans without a history of psychosis or homelessness, were assessed five times between May 2020 and July 2021. Bivariate analyses were used to compare receipt of stimulus checks and planned expenses among the groups, and multivariable analyses examined how receipt of checks was related to mental health and substance use over time.

RESULTS

No group difference was found in receipt of stimulus checks, and 74%-84% of veterans reported receipt of more than one check. Most participants reported plans to use their stimulus checks to pay for bills, groceries, credit card debt, and rent or mortgage or to save the money. Over time, participants who received a greater number of stimulus checks reported significantly decreased symptoms of depression (B=-0.48) and anxiety (B=-0.84) and improved social functioning (B=0.24). For the recently homeless group, a greater number of stimulus checks received was associated with decreases in days of alcohol intoxication and drug use, but the reverse was found for the psychosis group.

CONCLUSIONS

Multiple short-term unconditional government cash transfers may improve mental and social functioning among vulnerable populations during major crises, a finding that contributes to the research literature and has policy implications for pandemic and emergency preparedness.

The effects of the COVID-19 pandemic on hallucinations and delusions in youth at clinical high-risk for psychosis and outpatients with schizophrenia

Although the COVID-19 pandemic has had detrimental effects on mental health in the general population, the impact on those with schizophrenia-spectrum disorders has received relatively little attention. Assessing pandemic-related changes in positive symptoms is particularly critical to inform treatment protocols and determine whether fluctuations in hallucinations and delusions are related to telehealth utilization and treatment adherence. In the current longitudinal study, we evaluated changes in the frequency of hallucinations and delusions and distress resulting from them across three-time points. Participants included: (1) outpatients with chronic schizophrenia (SZ: n = 32) and healthy controls (CN: n = 31); (2) individuals at clinically high risk for psychosis (CHR: n = 25) and CN (n = 30). A series of questionnaires were administered to assess hallucination and delusion severity, medication adherence, telehealth utilization, and protective factors during the pandemic. While there were no significant increases in the frequency of hallucinations and delusions in SZ and CHR, distress increased from pre-pandemic to early pandemic in both groups and then decreased at the third time point. Additionally, changes in positive symptom severity in SZ were related to psychiatric medication adherence. Findings suggest that positive symptoms are a critical treatment target during the pandemic and that ongoing medication services will be beneficial.

Psychological consequences among veterans during the COVID-19 pandemic: A scoping review

Although there is an increasing number of studies reporting the psychological impact of COVID-19 on the general population and healthcare workers, relatively less attention has been paid to the veterans. This study aimed to review the existing literature regarding the psychological consequences of COVID-19 on veterans. A systematic search was conducted on PubMed, Embase, and the Cochrane Library from inception to December 3, 2022. A total of twenty-three studies were included with moderate-quality of evidence. Veterans experienced more mental health problems than civilians. The prevalence rates of alcohol use, anxiety, depression, post-traumatic stress disorder, stress, loneliness, and suicide ideation significantly increased during the pandemic, ranging from 9.6% to 47.4%, 9.4% to 53.5%, 8.6% to 55.1%, 4.1% to 58.0%, 4.3% to 39.4%, 15.9% to 28.4%, and 7.8% to 22.0%, respectively. The main risk factors of negative consequences included pandemic-related stress, poor family relationships, lack of social support, financial problems, and preexisting mental disorders. In contrast, higher household income and greater community interaction and support appeared to be resilience factors. In conclusion, the COVID-19 pandemic has increased adverse mental health consequences among veterans. Tackling mental health issues due to the COVID-19 pandemic among veterans should be a priority.

Mental Health Impact of Early Stages of the COVID-19 Pandemic on Individuals with Pre-Existing Mental Disorders: A Systematic Review of Longitudinal Research

In view of disease-related threats, containment measures, and disrupted healthcare, individuals with pre-existing mental illness might be vulnerable to adverse effects of the COVID-19 pandemic. Previous reviews indicated increased mental distress, with limited information on peri-pandemic changes. In this systematic review, we aimed to identify longitudinal research investigating pre- to peri-pandemic and/or peri-pandemic changes of mental health in patients, focusing on the early phase and considering specific diagnoses. PsycINFO, Web of Science, the WHO Global literature on coronavirus disease database, and the Cochrane COVID-19 Study Register weresearched through 31 May 2021. Studies were synthesized using vote counting based on effect direction. We included 40 studies mostly from Western, high-income countries. Findings were heterogeneous, with improving and deteriorating mental health observed compared to pre-pandemic data, partly depending on underlying diagnoses. For peri-pandemic changes, evidence was limited, with some suggestion of recovery of mental distress. Study quality was heterogeneous; only few studies investigated potential moderators (e.g., chronicity of mental illness). Mental health effects on people with pre-existing conditions are heterogeneous within and across diagnoses for pre- to peri-pandemic and peri-pandemic comparisons. To improve mental health services amid future global crises, forthcoming research should understand medium- and long-term effects, controlling for containment measures.

Mental Health Reform: Design and Implementation of a System to Optimize Outcomes for Veterans and Their Families

The social, health, and economic burden of mental health problems in the veteran community is heavy. Internationally, the array of services and support available to veterans and their families are extensive but vary in quality, are often disconnected, complex to navigate, and lack clear coordination. This paper describes a conceptual framework to guide the design and implementation of a system of services and supports to optimize the mental health and wellbeing of all veterans and their families. The framework recognizes the diversity of veterans across intersecting identities that uniquely shape experiences of posttraumatic mental health and wellbeing. It brings together several strands of research: the values and principles that should underpin the system; the needs of diverse veterans and their families; challenges in the current services and supports; evidence-based interventions; and principles of effective implementation. Central to the future system design is a next generation stepped model of care that organizes best and next practice interventions in a coherent system, matches service provision to level of need and addresses access and navigation. Practical guidance on implementation provides an aspirational and flexible structure for system evolution, and a template for all stakeholders-individuals, groups, agencies and organizations-to effect system change.

Socioeconomic challenges during the COVID-19 pandemic for Veterans with psychosis or recent homelessness

The COVID-19 pandemic and social distancing have directly impacted the socioeconomic well-being of most Americans. Veterans with psychosis (PSY) and Veterans who were recently housed (RHV) through a supportive housing programme may be especially vulnerable to experiencing negative socioeconomic effects of the pandemic. In this study, we investigated socioeconomic experiences and challenges during the pandemic in these two putatively vulnerable Veteran groups and in Veterans with no history of PSY or homeless (i.e., control Veterans, CTL). A total of 231 Veterans (81 PSY, 76 RHV, 64 CTL) participated in the baseline assessment, and 203 in the follow-up assessment (74 PSY, 63 RHV, 66 CTL). At both assessment points we obtained socioeconomic information, including personal finances, financial concerns, housing concerns, experience of material hardships, and employment status. All groups of Veterans reported socioeconomic challenges during the pandemic, but the pattern of effects differed across groups. Although RHV was in a similar position to the PSY group with respect to personal finances, they reported lower levels of financial well-being and were more prone to experiencing material hardships compared to the other two groups. CTL was most vulnerable to experiencing negative financial shocks. Contrary to expectations, PSY did not experience disproportionate material hardships compared to CTL. Veterans face significant socioeconomic challenges during the COVID-19 pandemic. However, RHV disproportionately experienced certain concerns and hardships, and these are a target for intervention by clinicians and service providers. PSY generally fared better than anticipated, possibly reflecting longstanding engagement with VA services that could serve to buffer the socioeconomic impact of the pandemic.

The impact of the COVID-19 pandemic on mental health and functional outcomes in Veterans with psychosis or recent homelessness: A 15-month longitudinal study

Background

The COVID-19 pandemic has had unprecedented effects on mental health and community functioning. Negative effects related to disruption of individuals’ social connections may have been more severe for those who had tenuous social connections prior to the pandemic. Veterans who have recently experienced homelessness (RHV) or have a psychotic disorder (PSY) are considered particularly vulnerable because many had poor social connections prior to the pandemic.

Methods

We conducted a 15-month longitudinal study between May 2020 –July 2021 assessing clinical (e.g., depression, anxiety) and community (e.g., social functioning, work functioning) outcomes. Eighty-one PSY, 76 RHV, and 74 Veteran controls (CTL) were interviewed over 5 assessment periods. We assessed changes in mental health and community functioning trajectories relative to pre-pandemic retrospective ratings and examined group differences in these trajectories.

Results

All groups had significantly increased symptoms of depression, anxiety, and concerns with contamination at the onset of the pandemic. However, RHV and PSY showed faster returns to their baseline levels compared to CTL, who took nearly 15 months to return to baseline. With regards to functioning, both RHV and PSY, but not CTL, had significant improvements in family and social networks over time. Work functioning worsened over time only in PSY, and independent living increased over time in both RHV and PSY but not CTL.

Conclusions

These results reveal that vulnerable Veterans with access to VA mental health and case management services exhibited lower negative impacts of the COVID-19 pandemic on mental health and community functioning than expected.

Racial differences in the psychosocial response to the COVID-19 pandemic in veterans with psychosis or recent homelessness

The COVID-19 pandemic continues to disproportionately impact people of color and individuals experiencing psychosis and homelessness. However, it is unclear whether there are differences by race in psychosocial responses to the pandemic in vulnerable populations. The double jeopardy hypothesis posits that multiply marginalized individuals would experience worse psychosocial outcomes. The present study investigated the clinical and functional initial responses to the pandemic in both Black (n = 103) and White veterans (n = 98) with psychosis (PSY), recent homelessness (RHV), and in a control group (CTL) enrolled in Department of Veterans Affairs (VA) healthcare services. Clinical interviews were administered via phone at two time points: baseline (mid-May through mid-August 2020) and follow-up (mid-August through September 2020). The baseline interview also included retrospective measures of pre-COVID status from January 2020. There were no significant differences between Black and White veterans in depression, anxiety, or loneliness. However, Black veterans did endorse more fears of contamination, F(1, 196.29) = 9.48, p = .002. Across all groups, Black veterans had better family integration compared to White veterans, F(1, 199.98) = 7.62, p = .006. There were no significant differences by race in social integration, work/role productivity, or independent living. In sum, there were few significant differences between Black and White veterans in initial psychosocial response to the pandemic. The lack of racial disparities might reflect the presence of VA's wrap-around services. The findings also highlight the robust nature of social support in Black veterans, even in the context of a global pandemic. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

The COVID-19 Pandemic Introduces Diagnostic and Treatment Planning Complexity for Individuals at Clinical High Risk for Psychosis

COVID-19 has led to a great deal of general suffering and an increased prevalence of psychiatric illness worldwide. Within the area of psychosis-risk syndromes, a highly heterogeneous clinical population, the picture is quite nuanced as the social restrictions resulting from the pandemic have reduced stress for some and increased it for others. Further, a number of pandemic-related societal and cultural changes have obfuscated the diagnostic and treatment landscape in this area as well. In this opinion article, we describe several prototypical cases, representative of presentations seen in our clinical high-risk (CHR) research programs. The cases highlight considerable clinical variability and, in addition, speak to the current complexities faced by diagnosticians and treatment providers. In addition to discussing these issues, this piece introduces potential solutions highlighting the promise of incorporating data-driven strategies to identify more homogenous CHR subtypes and employ precision medicine.