Enhancing social functioning in older veterans with PTSD: Rationale and design of an intervention and initial RCT

BACKGROUND

Older Veterans with Posttraumatic Stress Disorder (PTSD) are often socially isolated and have complex comorbid physical health problems. Aging-related stressors can exacerbate PTSD symptoms. These factors contribute to greater impairment in social functioning and decreased quality of life (QoL). Evidence-based psychotherapies for PTSD often address these issues, but not all older Veterans with PTSD seek help for these challenges, some don't want to engage in trauma-focused treatment, some drop out prematurely, and some still have residual symptoms upon completion. Thus, additional interventions that directly target social functioning among older Veterans with PTSD are needed.

METHODS

In this paper we describe the development of and feasibility evaluation plan for, "Enhancing Social Functioning for older Veterans with PTSD (ESVP)," a social functioning group intervention for older (>60 years) Veterans with PTSD. This project involved four phases of work: 1) Intervention development, 2) Review of intervention and potential modifications using focus groups, 3) Intervention pilot testing and modification, and 4) A randomized feasibility trial comparing the intervention with a support group control. Intervention modules address interpersonal relationships, effective communication, anger management, social skills, social support/activities, and behavioral activation.

CONCLUSION

This project details the iterative process used to develop the ESVP intervention designed to enhance social functioning in older Veterans with PTSD, and to evaluate feasibility. Analyses are underway to examine feasibility of conducting ESVP with a sample of older Veterans with PTSD. Findings from the final project phase, the randomized feasibly trial, will inform the design and implementation of a future trial.

CLINICALTRIALS

gov Identifier: NCT02803125.

Peer Support Activities for Veterans, Serving Members, and Their Families: Results of a Scoping Review

For many, including military veterans and their families, support between individuals with shared lived experiences, or peer support, has long been utilized as a way to support each other through many different challenges. Building on other reviews and guided by the seven domains of well-being in the Canadian veteran well-being framework, the objective of this paper is to describe and catalogue the nature of peer support activities and related outcomes in the veteran, serving member, and family member populations. A scoping review following the five stages outlined by Arksey and O'Malley was conducted; it was guided by the question: What is currently known about peer support activities for veterans, serving members, and their families that has been evaluated in the literature? In total, 101 publications from 6 different countries were included in this review and catalogued based on publication characteristics, participant information, peer support activity information, and peer information. Peer support activities have the potential to positively influence the well-being of veterans, serving members, and their families on a holistic level across multiple domains. This scoping review highlights the existing gaps in the literature and provides an important foundation for future research on peer support for these populations, specifically in the Canadian context.

Achieving Whole Health: A Preliminary Study of TCMLH, a Group-Based Program Promoting Self-Care and Empowerment Among Veterans

OBJECTIVE

An emerging literature suggests patients with chronic illnesses can benefit from integrated, person-centric approaches to health care, including group-based programs. However, much of the research in this area is disease specific. The objective of this study was to collect preliminary evidence on the efficacy of Taking Charge of My Life and Health (TCMLH), a Whole Health group-based program that emphasizes self-care and empowerment on the overall health and well-being of veterans, a population burdened with high rates of multiple chronic conditions.

METHOD

Self-reported outcomes, including standardized survey measures, were collected at pretest, posttest, and 2-month follow-up from 77 participants across 15 groups at four VA sites. Random intercept mixed-model regressions were used to analyze data.

RESULTS

Results from this initial study showed high satisfaction with the program and facilitators, and high attendance. There were significant pre-post gains in self-care attitudes and behaviors, patient motivation, meaning and purpose, mental health, perceived stress, goal progress, and goal-specific hope. Outcomes were maintained at 2-month follow-up for patient motivation, perceived stress, goal-specific hope, and goal progress. Significant gains were observed in health care empowerment and physical health from pretest to follow-up.

CONCLUSIONS

Preliminary findings support the efficacy of TCMLH, a Whole Health group-based program that emphasizes patient empowerment, self-care practices, and peer support. Future research priorities include a rigorous evaluation with a larger sample size and control group to assess effectiveness.

An evaluation of the facilitator training to implement 'Taking charge of my life and health', a peer-led group program to promote self-care and patient empowerment in Veteran participants

OBJECTIVE

We developed a peer-led group program for Veterans called Taking Charge of My Life and Health (TCMLH) that emphasizes patient education, goal setting, shared decision making, and whole person care. Our aim was to conduct an evaluation of a facilitator training course to deliver TCMLH in VA sites.

METHODS

Repeated measures ANOVA models were used to examine change over three timepoints (pre-test, post-test, and two-month follow-up) in outcomes of attitudes, knowledge, skills, and self-efficacy related to patient empowerment, skills acquisition, self-care strategies, and curriculum facilitation. Qualitative data analysis of participant feedback was used to identify potential training adaptations and barriers to TCMLH delivery.

RESULTS

Our sample comprised 70 trainees who completed all three assessments. Participants reported high levels of training satisfaction, quality, and utility, and sustained improvements in knowledge of Whole Health, self-efficacy for group facilitation, and self-efficacy for using Whole Health concepts and tools. Implementation barriers included challenges related to group management and site logistics.

CONCLUSION

The facilitator training course improved knowledge and self-efficacy associated with successful peer-led program delivery and identified opportunities to improve the training course and TCMLH dissemination.

PRACTICE IMPLICATIONS

Findings provide insights on the design and implementation of training models to support peer-led programs.

Literature on peer-based community physical activity programmes for mental health service users: a scoping review

Physical activity is a key determinant of mental health; community programmes aim to increase health and well-being on a community wide scale with emphasis on social interaction. Regular physical activity participation in community settings yields additional social benefits, such as peer support. This scoping review aimed to explore existing literature that has included peer support as a component of community-based physical activity programmes for MHSU. Published literature was examined using electronic databases (SportDiscus, Web of Science, MEDLINE, and PsycINFO), reference lists, and hand searching of journals. Thirteen eligible articles included; adults aged 18 and over, a peer support component, physical activity and/or sport, participants with mental health diagnoses and were community-based. Research published between 2007 and 2019, peer-reviewed and written in English was included. Nine studies found a significant increase in perceived social support, seven studies reported increased mental wellbeing and five studies reported increased physical activity levels. Effectiveness of reviewed programmes were categorised as; overall improvements in physical activity levels, improvements to mental health, exercise related psychosocial benefits, knowledge relating to self-care, and improved social connections. Community-based physical activity programmes produced psychosocial benefits and positive behaviour change for MHSU, warranting greater focus towards implementing effective peer support into community programmes.

Positive psychotherapy for depression and self-efficacy in undergraduate nursing students: A randomized, controlled trial

Nursing students across the globe experience depressive symptoms, and many interventions have been used to alleviate their depression. However, few interventions focus on students' personal strengths and advantages. The aim of the present study was to explore the effects of an 8-week group positive psychotherapy (PPT) programme on depression and self-efficacy in full-time undergraduate nursing students. A randomized, controlled trial was conducted for 76 nursing students (34 in the experimental group, 42 in the control group). The Beck Depression Inventory-II and the General Self-Efficacy Scale were used to collect data prior to, immediately after PPT, 3 months', and 6 months' post-PPT. Repeated-measures analysis of variance indicated that the intervention significantly alleviated depression and improved self-efficacy (each P < 0.05); the effect of time and time-group interaction was also significant (each P < 0.05). The findings suggest that PPT could significantly relieve depressive symptoms and improve self-efficacy. We recommend that PPT is effective in alleviating depression and improving self-efficacy in undergraduate nursing students. Academic mental health nurses should appreciate the value of PPT and consider incorporating it in psychological support methods in order to facilitate nursing students' mental health.

Efficacy of client feedback in group psychotherapy with soldiers referred for substance abuse treatment

This study investigated whether routine monitoring of client progress, often called "client feedback," via an abbreviated version of the Partners for Change Outcome Management System (PCOMS) resulted in improved outcomes for soldiers receiving group treatment at an Army Substance Abuse Outpatient Treatment Program (ASAP). Participants (N = 263) were active-duty male and female soldiers randomized into a group feedback condition (n = 137) or a group treatment-as-usual (TAU) condition (n = 126). Results indicated that clients in the feedback condition achieved significantly more improvement on the outcome rating scale (d = 0.28), higher rates of clinically significant change, higher percentage of successful ratings by both clinicians and commanders, and attended significantly more sessions compared to the TAU condition. Despite a reduced PCOMS protocol and a limited duration of intervention, preliminary results suggest that the benefits of client feedback appear to extend to group psychotherapy with clients in the military struggling with substance abuse.

Primary care-based educational interventions to decrease risk factors for metabolic syndrome for adults with major psychotic and/or affective disorders: a systematic review

BACKGROUND

Individuals with major psychotic and/or affective disorders are at increased risk for developing metabolic syndrome due to lifestyle- and treatment-related factors. Numerous pharmacological and non-pharmacological interventions have been tested in inpatient and outpatient mental health settings to decrease these risk factors. This review focuses on primary care-based non-pharmacological (educational or behavioral) interventions to decrease metabolic syndrome risk factors in adults with major psychotic and/or affective disorders.

METHODS

The authors conducted database searches of PsychINFO, MEDLINE and the Cochrane Database of Systematic Reviews, as well as manual searches and gray literature searches to identify included studies.

RESULTS

The authors were unable to identify any studies meeting a priori inclusion criteria because there were no primary care-based studies.

CONCLUSIONS

This review was unable to demonstrate effectiveness of educational interventions in primary care. Interventions to decrease metabolic syndrome risk have been demonstrated to be effective in mental health and other outpatient settings. The prevalence of mental illness in primary care settings warrants similar interventions to improve health outcomes for this population.

Sleep and military members: emerging issues and nonpharmacological intervention

Background. Many individuals who work in the military experience sleep deficiency which presents a significant problem given the nature of their work. The cause of their sleep problems is likely multifactorial, stemming from the interplay between their personal health, habits and lifestyle juxtaposed with the stress of their military work such as emotional and physical trauma experienced in service. Objective. To present an overview of sleep deficiency in military members (MMs) and review of nonpharmacological treatment options. Discussion. Although there are a number of promising nonpharmacological treatment options available for people working in the military who experience problems sleeping, testing interventions within the context of the military are still in the early stages. Further research utilizing rigorous design and standardized, context appropriate outcome measures is needed to help treat this burgeoning problem.

The physical health of the seriously mentally ill: an overview of the literature

Despite the wealth of literature which attests to the relationship between serious mental illness (SMI) and physical ill health, the provision of optimum physical health care for mental health service users remains a challenge. In England the Department of Health has identified the evident health inequalities for people with SMI as a priority area for health improvement, publishing numerous policy directives aimed at addressing these inequalities. However, this is a highly complex process and little is known about why the rhetoric of holistic health care has proved unattainable thus far. In this paper we present an informed commentary of the contemporary literature with the aim of offering a more comprehensive understanding of the health inequalities faced by people with SMI. We searched relevant databases for publications related to: the causes of poor physical health among the mentally ill, strategies to address these health needs and the impact which professional education, culture and services structure has on this facet of service delivery. This enabled us to identify potential strategies that can be adopted by health care practitioners wishing to improve the health of this vulnerable group, and by educationalists to advance professionals' knowledge of this important and ostensibly neglected area.

Innovations aimed at improving the physical health of the seriously mentally ill: an integrative review

AIMS AND OBJECTIVES

The aim of this paper is to report an integrative review of the literature that focused on innovations aimed at enhancing the physical health of people with serious mental illness.

BACKGROUND

Despite the abundance of literature that highlights the relationship between serious mental illness and physical ill health, the provision of physical health care for the seriously mental ill remains a challenge. Many different strategies have been developed, which endeavour to address the poor physical health of people with serious mental illness. However, there is inadequate evidence to establish the success of these strategies.

DESIGN

Integrative literature review.

METHOD

The review was conducted using an adapted version of Whittemore and Knafl's review method to critically appraise and evaluate the literature. Results.  Three main themes derived for the types of intervention in the studies emerged from the review. These included assessment, health education/health promotion and multimodal interventions.

CONCLUSION

Although there is some evidence to demonstrate that health assessments are effective in highlighting physical health problems, the evidence to support health education and multimodal interventions is far from conclusive. Further research is needed, in particular larger intervention and longitudinal studies, to help nurses decide on the best possible interventions that will improve the physical health of the seriously mentally ill.

RELEVANCE TO CLINICAL PRACTICE

Whilst nurses' continued attempts to develop health-enhancing interventions are commendable, there needs to be a greater focus on conducting research to develop the evidence base to guide and support nurses in this area of their practice. Until robust and convincing evidence is available, policy relating to the advancement of the physical health of people with serious mental illness should be developed cautiously.

Implementing and maintaining nurse-led healthy living programs in forensic inpatient settings: an illustrative case study

BACKGROUND

Healthy living programs (HLPs) within the context of mental health units are an applied response to the concerns of metabolic syndrome and the associated physical illnesses to which people with serious mental illness are susceptible.

OBJECTIVE

To illustrate how nurses, with other health professionals and service users, have established and maintained HLPs in two locked forensic mental health units in New Zealand.

DESIGN

This illustrative case study adopts a multimodal approach to data collection and analysis. Across two programs, interviews were undertaken with service users (n = 15) and staff (n = 17), minutes of meetings were analyzed for major decision points, and clinical notes were reviewed to identify which service-user health status measures (body mass index, glucose tolerance test results, blood pressure, and medication use) were recorded.

RESULTS

Similarities were identified in the way the HLPs were implemented and maintained by champions who advocated for change, challenged staff attitudes, secured funding, and established new systems and protocols. Successful implementation depended on involvement of the multidisciplinary team. Each program operated within a different physical environment and adopted its own philosophical approach that shaped the style of the program. The HLPs had an impact on nurses, other staff, and on the culture of the institutions. The programs raised dilemmas about restrictions and risk versus autonomy and self-management.

CONCLUSION

Understanding the effects of the clinical and philosophical contexts in which HLPs are established and the way challenges and benefits are affected by context has practical significance for the future development of health programs in forensic settings, prisons, and general mental health units.