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Abel EA, Travaglini LE, Snow JL, Goulet JL. The association of pain screening and pain level with suicide among US veterans with comorbid musculoskeletal and bipolar disorder diagnoses. J Affect Disord 2024; 369:429-435. [PMID: 39389110 DOI: 10.1016/j.jad.2024.10.028] [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] [Received: 03/28/2024] [Revised: 10/03/2024] [Accepted: 10/07/2024] [Indexed: 10/12/2024]
Abstract
BACKGROUND High suicide rates are documented among persons with bipolar disorder diagnoses and pain diagnoses, but few studies have examined the association of pain with suicide mortality in individuals with comorbid pain and bipolar disorders. This study assessed the association of pain screening and pain severity with suicide mortality among veterans with comorbid bipolar and musculoskeletal disorder (MSD) diagnoses. METHODS A retrospective cohort study was conducted on 168,021 patients within the Veterans Health Administration (VHA) who received an MSD diagnosis from 2000 to 2015 and had a bipolar disorder diagnosis. Pain severity, comorbidities, demographics, and suicide mortality were extracted from VHA databases. Poisson regression examined relative risk of suicide by the presence pain screening and pain severity ratings. RESULTS Pain was assessed in 72.73 % of veterans. Suicide risk was greater in those not assessed (0.98 % versus 0.77 % in assessed group). However, this result did not persist after adjusting for covariates (RR = 1.06). Among those assessed, higher suicide risk was associated with moderate (RR = 1.10), severe pain (RR = 1.06), and no pain (reference) relative to mild pain (RR = 0.99). Major depression, substance use disorders, and prescribed opioids and benzodiazepines increased risk. LIMITATIONS Data were obtained from medical records; diagnoses were not confirmed via formal assessment, and no information was available on actual medication use or purpose. Over 25 % of the sample were missing pain severity ratings, which could have affected results. CONCLUSIONS Suicide risk factors among persons with bipolar disorder are complex and multifactorial. Providers should prioritize suicide prevention efforts following new onset or worsening pain.
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Affiliation(s)
- Erica A Abel
- Pain Research, Informatics, Multimorbidities and Education Center, VA Connecticut Healthcare System, West Haven, CT, United States; Yale Center for Medical Informatics, Yale School of Medicine, New Haven, CT, United States; Department of Psychiatry, Yale School of Medicine, New Haven, CT, United States
| | - Letitia E Travaglini
- VA Capital Healthcare Network (VISN 5) Mental Illness, Research, Education, and Clinical Center (MIRECC), Baltimore, MD, United States
| | - Jennifer L Snow
- Pain Research, Informatics, Multimorbidities and Education Center, VA Connecticut Healthcare System, West Haven, CT, United States; Yale Center for Medical Informatics, Yale School of Medicine, New Haven, CT, United States
| | - Joseph L Goulet
- Pain Research, Informatics, Multimorbidities and Education Center, VA Connecticut Healthcare System, West Haven, CT, United States; Yale Center for Medical Informatics, Yale School of Medicine, New Haven, CT, United States; Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, United States.
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Scharer JL, Gass JC, Shepardson RL, Maisto SA, Funderburk JS. Factors Influencing Patient Receptivity to Brief Alcohol Interventions in Primary Care: An Application of Conjoint Analysis. Subst Use Misuse 2023; 59:90-96. [PMID: 37791686 DOI: 10.1080/10826084.2023.2262008] [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] [Indexed: 10/05/2023]
Abstract
Background: Brief alcohol interventions (BAIs) are an evidence-based practice for addressing hazardous alcohol use in primary care settings. However, numerous barriers to implementation of BAIs in routine practice have been identified, including concerns about patient receptivity to BAIs. Despite this being a commonly identified barrier to BAI implementation, little BAI implementation research has focused on patient receptivity. Objectives: This study aimed to identify the treatment preferences of primary care patients who screened positive for hazardous alcohol use and to evaluate factors that may influence patients' receptivity to BAIs delivered in primary care. We conducted a mailed survey of primary care patients (N = 245) who screened positive for hazardous alcohol use on annual screening measures based on electronic medical record data. Patients completed measures assessing treatment preferences and a conjoint analysis questionnaire designed to evaluate the relative importance of three factors (focus of the BAI, tailoring of the BAI, and familiarity with the provider delivering the BAI) for patient receptivity. Results: Conjoint analysis results revealed that familiarity with provider (with patients preferring BAIs delivered by providers they have previously met) was the most important factor in predicting patients' receptivity to BAIs. Additionally, patients preferred to discuss alcohol use in the context of another concern (focus of the BAI) and preferred personalized information tailored based on their specific health concerns (tailoring of the BAI), although these factors were not statistically significant when accounting for familiarity with provider. Conclusions: Findings of the present study have potential to inform future research on implementation of BAIs.
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Affiliation(s)
- Jacob L Scharer
- Veterans Affairs Center for Integrated Healthcare, Syracuse VA Medical Center (116C), Syracuse, New York, USA
| | - Julie C Gass
- VA Center for Integrated Healthcare, VA Western New York Healthcare System (116N), Buffalo, New York, USA
- Department of Psychology, University at Buffalo - The State University of New York, Buffalo, New York, USA
| | - Robyn L Shepardson
- Veterans Affairs Center for Integrated Healthcare, Syracuse VA Medical Center (116C), Syracuse, New York, USA
- Department of Psychology, Syracuse University, Syracuse, New York, USA
| | - Stephen A Maisto
- Veterans Affairs Center for Integrated Healthcare, Syracuse VA Medical Center (116C), Syracuse, New York, USA
- Department of Psychology, Syracuse University, Syracuse, New York, USA
| | - Jennifer S Funderburk
- Veterans Affairs Center for Integrated Healthcare, Syracuse VA Medical Center (116C), Syracuse, New York, USA
- Department of Psychology, Syracuse University, Syracuse, New York, USA
- Department of Psychiatry, University of Rochester, Rochester, New York, USA
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Nichter B, Stein MB, Monteith LL, Herzog S, Holliday R, Hill ML, Norman SB, Krystal JH, Pietrzak RH. Risk factors for suicide attempts among U.S. military veterans: A 7-year population-based, longitudinal cohort study. Suicide Life Threat Behav 2022; 52:303-316. [PMID: 34873738 DOI: 10.1111/sltb.12822] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 08/31/2021] [Accepted: 08/31/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND Population-based data on risk factors for suicide attempts among veterans remains limited. METHODS A national probability sample of 2307 veterans was followed over the course of four timepoints spanning seven years to examine how a range of baseline risk factors predict incident suicide attempt. Suicide attempt data were aggregated into a single follow-up timepoint. RESULTS Sixty-two veterans (3.1%) reported attempting suicide during the 7-year period. The strongest risk factors for suicide attempts were higher baseline levels of loneliness, lower baseline levels of adaptive psychosocial traits (e.g., dispositional gratitude), baseline thoughts of self-harm, and greater post-baseline trauma exposures (12.3%-41.3% of explained variance). Veterans with multiple co-occurring risk factors were at greatest risk for attempts; of veterans with 0, 1, 2, 3, and all 4 of these factors, the predicted probability of suicide attempt was 2.0%, 5.3%, 13.5%, 30.4%, and 55.0%, respectively. CONCLUSIONS Baseline loneliness, dispositional gratitude, thoughts of self-harm, and new-onset traumas emerged as the strongest risk factors for suicide attempts among veterans, underscoring the potential importance of targeting these factors in prevention efforts. Veterans with multiple co-occurring risk factors have substantially greater risk for suicide attempts, suggesting that examination of multiple coinciding vulnerability factors may help improve suicide risk prediction models.
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Affiliation(s)
- Brandon Nichter
- Department of Psychiatry, University of California San Diego, La Jolla, California, USA
| | - Murray B Stein
- Department of Psychiatry, University of California San Diego, La Jolla, California, USA.,VA San Diego Healthcare System, San Diego, California, USA
| | - Lindsey L Monteith
- VA Rocky Mountain Mental Illness Research, Education, and Clinical Center for Veteran Suicide Prevention, Aurora, Colorado, USA.,Department of Psychiatry, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Sarah Herzog
- Columbia University Irving Medical Center, Columbia University, New York, New York, USA.,Division of Molecular Imaging and Neuropathology, New York State Psychiatric Institute, New York, New York, USA
| | - Ryan Holliday
- VA Rocky Mountain Mental Illness Research, Education, and Clinical Center for Veteran Suicide Prevention, Aurora, Colorado, USA.,Department of Psychiatry, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Melanie L Hill
- Department of Psychiatry, University of California San Diego, La Jolla, California, USA.,VA San Diego Healthcare System, San Diego, California, USA
| | - Sonya B Norman
- Department of Psychiatry, University of California San Diego, La Jolla, California, USA.,VA Center of Excellence for Stress and Mental Health, San Diego, California, USA.,National Center for PTSD, White River Junction, Vermont, USA
| | - John H Krystal
- National Center for PTSD, VA Connecticut Healthcare System, West Haven, Connecticut, USA.,Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut, USA
| | - Robert H Pietrzak
- National Center for PTSD, VA Connecticut Healthcare System, West Haven, Connecticut, USA.,Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut, USA.,Department of Social and Behavioral Sciences, Yale School of Public Health, New Haven, Connecticut, USA
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Tang S, Reily NM, Arena AF, Sheanoda V, Han J, Draper B, Batterham PJ, Mackinnon AJ, Christensen H. Predictors of not receiving mental health services among people at risk of suicide: A systematic review. J Affect Disord 2022; 301:172-188. [PMID: 35032506 DOI: 10.1016/j.jad.2022.01.054] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 12/12/2021] [Accepted: 01/11/2022] [Indexed: 12/19/2022]
Abstract
BACKGROUND The majority of people who die by suicide are unknown to formal mental health services. The current review identified predictors of non-receipt of mental health services among individuals experiencing suicidal thoughts or behaviours. Such data provides insight into the needs and preferences of these individuals and inform improvements to existing services. METHODS PsycInfo, PubMed/Medline, CINAHL, and Web of Science were systematically searched from 1st January 1980 up to 20th September 2021. Included studies examined predictors of not receiving formal mental health services among people at risk of suicide. Study quality was assessed by adapting the Joanna-Briggs Institute Checklist for Analytical Cross-Sectional Studies. Findings were presented with narrative synthesis. PROSPERO registration: CRD42021256795. RESULTS Included studies (n = 35, sample range = 46-19,243) were predominately conducted in the United States. Non-receipt of services in nationally representative studies was varied (25.7-91.8%). Results indicate that non-receipt of mental health services among people with suicidality is associated with minority ethnicity, better perceived general health, lower psychological distress, lower severity of suicidality, no mental health diagnosis, lower perceived need for treatment and lower use of medical services. LIMITATIONS Limitations included few studies conducted in low-middle income countries, limited literature on key predictors of interest, and exclusion of informal sources of support. CONCLUSION Individuals with suicidality who are unknown to mental health services have diverse attributes. For some, non-use of services may result from low suicidal distress and perceived need for treatment. Further research is needed to understand why these predictors are associated with service non-use.
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Affiliation(s)
| | | | | | | | - Jin Han
- Black Dog Institute, UNSW Sydney, NSW, Australia
| | - Brian Draper
- School of Psychiatry, Faculty of Medicine, UNSW Sydney, NSW, Australia
| | - Philip J Batterham
- Black Dog Institute, UNSW Sydney, NSW, Australia; Centre for Mental Health Research, Research School of Population Health, Australian National University, Canberra, ACT, Australia
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Nichter B, Monteith LL, Norman SB, Maguen S, Hill ML, Herzog S, Pietrzak RH. Differentiating U.S. military veterans who think about suicide from those who attempt suicide: A population-based study. Gen Hosp Psychiatry 2021; 72:117-123. [PMID: 34450447 DOI: 10.1016/j.genhosppsych.2021.08.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 08/03/2021] [Accepted: 08/12/2021] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Several vulnerability factors for suicidal behavior in U.S. veterans have been identified. However, little is known about factors that differentiate veterans who contemplate suicide from those who attempt suicide. This study examined sociodemographic and clinical characteristics that distinguish veterans who think about suicide from those who attempt suicide. METHOD Data were analyzed from the 2019-2020 National Health and Resilience in Veterans Study, which surveyed a population-based sample of 4069 veterans. Analyses estimated the lifetime prevalence of suicide ideation (SI) and suicide attempts (SA); and examined differences between veterans with a history of attempt(s), and SI without a history of attempt(s). RESULTS A total 25.9% of U.S. veterans reported lifetime SI and 3.9% reported a SA. Several factors distinguished veterans with a history of SA from those with SI only: the strongest were younger age (odds ratio [OR] = 0.97, 95% CI = 0.95-0.98), nonsuicidal self-injury (OR = 1.81, 95% CI = 1.11-3.03), adverse childhood experiences (OR = 1.14; 95% CI = 1.06-1.23), alcohol use disorder (OR = 1.99; 95% CI = 1.28-3.12), lower household income (OR = 0.62; 95% CI = 0.40-0.95), and physical disability (OR = 1.69; 95% CI = 1.07-2.70). CONCLUSIONS Although a quarter of U.S. veterans contemplate suicide in their lifetimes, the majority do not attempt suicide. Specific sociodemographic and clinical features may differentiate veterans who contemplate versus attempt suicide.
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Affiliation(s)
- Brandon Nichter
- Department of Psychiatry, University of California San Diego, La Jolla, CA, USA.
| | - Lindsey L Monteith
- VA Rocky Mountain Mental Illness Research, Education, and Clinical Center for Veteran Suicide Prevention, Aurora, CO, USA; Department of Psychiatry, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Sonya B Norman
- Department of Psychiatry, University of California San Diego, La Jolla, CA, USA; National Center for PTSD, White River Junction, VT, USA; VA Center of Excellence for Stress and Mental Health, San Diego, CA, USA
| | - Shira Maguen
- San Francisco VA Health Care System, San Francisco, CA, USA; University of California - San Francisco, San Francisco, USA
| | - Melanie L Hill
- Department of Psychiatry, University of California San Diego, La Jolla, CA, USA; VA San Diego Healthcare System, San Diego, CA, USA
| | - Sarah Herzog
- Department of Psychiatry, Columbia University, Irving Medical Center, New York, NY, USA; Division of Molecular Imaging and Neuropathology, New York State Psychiatric Institute, New York, NY, USA
| | - Robert H Pietrzak
- National Center for PTSD, VA Connecticut Healthcare System, West Haven, CT, USA; Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA
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Abstract
Suicide is a preventable health problem. Multiple definitions and inconsistent use of the term suicidality can result in failure to properly recognize suicide risk and behavior and confuses suicide research. Clarification of the suicidality concept is needed to facilitate the care for individuals at risk for suicide. Using Rodgers' evolutionary concept analysis method, this analysis describes the breadth and scope of the suicidality concept. Findings indicate suicidality covers a spectrum of suicidal risk and levels of emotional suffering and intent. The analysis does not draw definite conclusions, but outlines a direction for further research.
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Affiliation(s)
- Tamara Pike Keefner
- Nursing, South Dakota State University - College of Nursing, Rapid City, South Dakota, USA
| | - Thomas Stenvig
- Graduate Nursing, South Dakota State University - College of Nursing, Brookings, Rapid City, South Dakota, USA
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7
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Liu RT, Bettis AH, Burke TA. Characterizing the phenomenology of passive suicidal ideation: a systematic review and meta-analysis of its prevalence, psychiatric comorbidity, correlates, and comparisons with active suicidal ideation. Psychol Med 2020; 50:367-383. [PMID: 31907085 PMCID: PMC7024002 DOI: 10.1017/s003329171900391x] [Citation(s) in RCA: 85] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Compared to active ideation, passive ideation remains relatively understudied and its clinical importance poorly defined. The weight that should be accorded passive ideation in clinical risk assessment is therefore unclear. METHODS We conducted a systematic review and meta-analysis of the prevalence of passive ideation, its psychiatric comorbidity, associated sociodemographic characteristics, as well as psychological and environmental correlates. For reference, pooled effects were also calculated for direct comparisons of passive and active ideation with respect to potential correlates. Relevant articles published since inception to 9 September 2019 were identified through a systematic search of MEDLINE and PsycINFO. RESULTS A total of 86 studies were included in this review. The prevalence of passive ideation was high across sample types, ranging from 5.8% for 1-year prevalence to 10.6% for lifetime prevalence in the general population. Passive ideation was strongly associated with sexual minority status, psychiatric comorbidity, psychological characteristics implicated in risk, and suicide attempts. Preliminary evidence exists for a large association with suicide deaths. The effect sizes for individual correlates of passive and active ideation were largely equivalent and mostly non-significant in head-to-head comparisons. CONCLUSIONS Passive ideation is a prevalent clinical phenomenon associated with significant psychiatric comorbidity. Current evidence also suggests notable similarities exist between passive and active ideation in terms of psychiatric comorbidity and psychological and other characteristics traditionally associated with risk.
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Affiliation(s)
- Richard T Liu
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Bradley Hospital, 1011 Veterans Memorial Parkway, East Providence, RI02915, USA
| | - Alexandra H Bettis
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Bradley Hospital, 1011 Veterans Memorial Parkway, East Providence, RI02915, USA
| | - Taylor A Burke
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Bradley Hospital, 1011 Veterans Memorial Parkway, East Providence, RI02915, USA
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Ecker AH, Johnson AL, Sansgiry S, Fletcher TL, Hundt N, Petersen NJ, Sweeney AC, Chaison AD, York-Ward KM, Kauth MR, Kunik ME, Cully JA. Brief cognitive behavioral therapy reduces suicidal ideation in veterans with chronic illnesses. Gen Hosp Psychiatry 2019; 58:27-32. [PMID: 30844639 DOI: 10.1016/j.genhosppsych.2019.02.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Revised: 02/01/2019] [Accepted: 02/07/2019] [Indexed: 12/16/2022]
Abstract
OBJECTIVE We evaluated the effect of brief cognitive behavioral therapy (bCBT) on suicidal ideation among medically ill veterans receiving mental health treatment in primary care. METHODS Secondary analysis was conducted on data collected during a multisite, patient-randomized trial investigating the impact of bCBT (n = 180) on depression and anxiety symptoms, relative to enhanced usual care (EUC; n = 122), in patients with congestive heart failure and/or chronic obstructive pulmonary disease. BCBT was delivered by primary care mental health providers over 4 months, with follow-up posttreatment assessments of suicidal ideation, measured by the Patient Health Questionnaire-9 (item 9) at 4, 8, and 12 months. Suicidal ideation was the primary outcome examined in the current analysis. Generalized estimating equations modeling suicidal ideation were used to compare the study arms. RESULTS Participants receiving bCBT were less likely to have high suicidal ideation than participants receiving EUC posttreatment and at 8-month follow-up after accounting for baseline suicidal ideation. Within-group comparisons suggest participants receiving bCBT were less likely to have high suicidal ideation at 4, 8, and 12 months when compared with baseline. High suicidal ideation for EUC participants did not differ at 4, or 8 months, but they were less likely to have high suicidal ideation at 12 months. CONCLUSION bCBT in primary care reduces suicidal ideation and may help prevent future suicidal ideation.
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Affiliation(s)
- Anthony H Ecker
- Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, (MEDVAMC 152), 2002 Holcombe Blvd., Houston, TX 77030, USA; VA South Central Mental Illness Research, Education and Clinical Center (a virtual center), USA; Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030, USA.
| | - Adrienne L Johnson
- Michael E. DeBakey Veterans Affairs Medical Center, 2002 Holcombe Blvd., Houston, TX 77030, USA
| | - Shubhada Sansgiry
- Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, (MEDVAMC 152), 2002 Holcombe Blvd., Houston, TX 77030, USA; VA South Central Mental Illness Research, Education and Clinical Center (a virtual center), USA; Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030, USA
| | - Terri L Fletcher
- Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, (MEDVAMC 152), 2002 Holcombe Blvd., Houston, TX 77030, USA; VA South Central Mental Illness Research, Education and Clinical Center (a virtual center), USA; Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030, USA
| | - Natalie Hundt
- Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, (MEDVAMC 152), 2002 Holcombe Blvd., Houston, TX 77030, USA; VA South Central Mental Illness Research, Education and Clinical Center (a virtual center), USA; Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030, USA
| | - Nancy J Petersen
- Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, (MEDVAMC 152), 2002 Holcombe Blvd., Houston, TX 77030, USA; VA South Central Mental Illness Research, Education and Clinical Center (a virtual center), USA; Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030, USA
| | - Alison C Sweeney
- Michael E. DeBakey Veterans Affairs Medical Center, 2002 Holcombe Blvd., Houston, TX 77030, USA; Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030, USA
| | - Angelic D Chaison
- Michael E. DeBakey Veterans Affairs Medical Center, 2002 Holcombe Blvd., Houston, TX 77030, USA; Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030, USA
| | - Kaki M York-Ward
- Michael E. DeBakey Veterans Affairs Medical Center, 2002 Holcombe Blvd., Houston, TX 77030, USA; Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030, USA
| | - Michael R Kauth
- Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, (MEDVAMC 152), 2002 Holcombe Blvd., Houston, TX 77030, USA; VA South Central Mental Illness Research, Education and Clinical Center (a virtual center), USA; Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030, USA
| | - Mark E Kunik
- Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, (MEDVAMC 152), 2002 Holcombe Blvd., Houston, TX 77030, USA; VA South Central Mental Illness Research, Education and Clinical Center (a virtual center), USA; Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030, USA
| | - Jeffrey A Cully
- Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, (MEDVAMC 152), 2002 Holcombe Blvd., Houston, TX 77030, USA; VA South Central Mental Illness Research, Education and Clinical Center (a virtual center), USA; Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030, USA
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