Comparing behavioral health models for reducing risky drinking among older male veterans

Mental Health Needs of Aging Veterans: Recent Evidence and Clinical Recommendations

Objectives: Large numbers of older Americans have a history of military service, which may be positively or negatively associated with mental health in late life. We reviewed literature with the aim of better understanding the mental health needs of older Veterans.Methods: Articles included those published in 2009-2018 and focused on prevalence/risk for mental illness and suicide among older Veterans; utilization of mental health services; effectiveness of evidence-based behavioral treatments; and pertinent care delivery models.Results: Older Veterans are generally resilient. A significant minority experience mental health concerns that are associated with poor outcomes including a substantial number of suicides. Most published research is based on the approximately one third of Veterans who use the Veterans Health Administration (VHA) for care. Older Veterans with mental health diagnoses are less likely to utilize mental health services compared to younger Veterans, but as likely to benefit once engaged. Integrated care models in primary and geriatric care settings are promising.Conclusions: Aging Veterans are a large subset of Americans whose mental health needs are complex and deserve attention.Clinical Implications: Clinicians should ask about history of military service (i.e., Veteran status) and utilize available resources when providing care for older Veterans.

Evaluating the Efficacy of a Mobile App (Drinks:Ration) and Personalized Text and Push Messaging to Reduce Alcohol Consumption in a Veteran Population: Protocol for a Randomized Controlled Trial

Background

Alcohol misuse is higher in the UK Armed Forces than in the general population. Previous research has shown that interventions delivered via smartphones are efficacious in promoting self-monitoring of alcohol use, have utility in reducing alcohol consumption, and have a broad reach.

Objective

This single-blinded randomized controlled trial (RCT) aims to assess the efficacy of a 28-day brief alcohol intervention delivered via a smartphone app (Drinks:Ration) in reducing weekly self-reported alcohol consumption between baseline and 3-month follow-up among veterans who drink at a hazardous or harmful level and receive or have received support for mental health symptoms in a clinical setting.

Methods

In this two-arm, single-blinded RCT, a smartphone app that includes interactive features designed to enhance participants’ motivation and personalized messaging is compared with a smartphone app that provides only government guidance on alcohol consumption. The trial will be conducted in a veteran population that has sought help through Combat Stress, a UK veteran’s mental health charity. Recruitment, consent, and data collection will be carried out automatically through the Drinks:Ration platform. The primary outcome is the change in self-reported weekly alcohol consumption between baseline (day 0) and 3-month follow-up (day 84) as measured using the Time-Line Follow back for Alcohol Consumption. Secondary outcome measures include (1) change in the baseline to 3-month follow-up (day 84) Alcohol Use Disorder Identification Test score and (2) change in the baseline to 3-month follow-up (day 84) World Health Organization Quality of Life-BREF score to assess the quality of adjusted life years. Process evaluation measures include (1) app use and (2) usability ratings as measured by the mHealth App Usability Questionnaire. The primary and secondary outcomes will also be reassessed at the 6-month follow-up (day 168) to assess the longer-term benefits of the intervention, which will be reported as a secondary outcome.

Results

The study will begin recruitment in October 2020 and is expected to require 12 months to complete. The study results will be published in 2022.

Conclusions

This study assesses whether a smartphone app is efficacious in reducing self-reported alcohol consumption in a veteran population that has sought help through Combat Stress using personalized messaging and interactive features. This innovative approach, if successful, may provide a means to deliver a low-cost health promotion program that has the potential to reach large groups, in particular those who are geographically dispersed, such as military personnel.

Trial Registration

ClinicalTrials.gov NCT04494594; https://clinicaltrials.gov/ct2/show/NCT04494594

International Registered Report Identifier (IRRID)

PRR1-10.2196/19720

Behavioral health and new models of service delivery for an aging world: Public/private partnerships to develop best practices of care for older adults

Individual and societal initiatives in areas of research, education, and health care policy have resulted in unprecedented gains in life expectancy. It is true that today more people in the world are living longer and have opportunities for higher quality lives than ever before. However, the resulting rapid rise in number of older adults has become a source of concern: Experts of many countries, in anticipation of looming problems, such as overburdened health care and pension systems, are now seeking opportunities to work together to find common solutions for globally-shared problems. The good news is that while all countries are experiencing change brought on by aging populations, the rate of change varies substantially from country to country; differences in historical events have produced differences in demographic profiles. Some countries have relatively large numbers of older adults, comprising large percentages of their populations; others have fewer older adults, with slower growth in numbers and percentages of older adults relative to other age groups. These differences have led to variations for the type and pace of response mounted by individual countries for problems associated with increasingly large older adult populations. In turn, these variations in response provide opportunities for countries to learn from one another. This brief review will outline potential issues associated with aging populations and discuss strengths and challenges for the integration of primary medical care with behavioral health as an innovative, best practices approach to the provision of care for aging persons of the world.

Behavioral Health Service Use by Military Children During Afghanistan and Iraq Wars

Medical claims were analyzed from 2810 military children who visited a civilian emergency department (ED) or hospital from 2000 to 2014 with behavioral health as the primary diagnosis and TRICARE as the primary/secondary payer. Visit prevalence was estimated annually and categorized: 2000-2002 (pre-deployment), 2003-2008 (first post-deployment), 2009-2014 (second post-deployment). Age was categorized: preschoolers (0-4 years), school-aged (5-11 years), adolescents (12-17 years). During Afghanistan and Iraq wars, 2562 military children received 4607 behavioral health visits. School-aged children's mental health visits increased from 61 to 246 from pre-deployment to the second post-deployment period. Adolescents' substance use disorder (SUD) visits increased almost 5-fold from pre-deployment to the first post-deployment period. Mental disorders had increased odds (OR = 2.93, 95% CI 1.86-4.61) of being treated during hospitalizations than in EDs. Adolescents had increased odds of SUD treatment in EDs (OR = 2.92, 95% CI 1.85-4.60) compared to hospitalizations. Implications for integrated behavioral health and school behavioral health interventions are discussed.

A Smartphone App and Personalized Text Messaging Framework (InDEx) to Monitor and Reduce Alcohol Use in Ex-Serving Personnel: Development and Feasibility Study

BACKGROUND

Self-reported alcohol misuse remains high in armed forces personnel even after they have left service. More than 50% of ex-serving personnel meet the criteria for hazardous alcohol use; however, many fail to acknowledge that they have a problem. Previous research indicates that interventions delivered via smartphone apps are suitable in promoting self-monitoring of alcohol use, have a broad reach, and may be more cost-effective than other types of brief interventions. There is currently no such intervention specifically designed for the armed forces.

OBJECTIVE

This study sought to describe the development of a tailored smartphone app and personalized text messaging (short message service, SMS) framework and to test the usability and feasibility (measured and reported as user engagement) of this app in a hard-to-engage ex-serving population.

METHODS

App development used Agile methodology (an incremental, iterative approach used in software development) and was informed by behavior change theory, participant feedback, and focus groups. Participants were recruited between May 2017 and June 2017 from an existing United Kingdom longitudinal military health and well-being cohort study, prescreened for eligibility, and directed to download either Android or iOS versions of the "Information about Drinking for Ex-serving personnel" (InDEx) app. Through the app, participants were asked to record alcohol consumption, complete a range of self-report measures, and set goals using implementation intentions (if-then plans). Alongside the app, participants received daily automated personalized text messages (SMS) corresponding to specific behavior change techniques with content informed by the health action process approach with the intended purpose of promoting the use of the drinks diary, suggesting alternative behaviors, and providing feedback on goals setting.

RESULTS

Invitations to take part in the study were sent to ex-serving personnel, 22.6% (31/137) of whom accepted and downloaded the app. Participants opened the InDEx app a median of 15.0 (interquartile range [IQR] 8.5-19.0) times during the 4 week period (28 days), received an average of 36.1 (SD 3.2) text messages (SMS), consumed alcohol on a median of 13.0 (IQR 11.0-15.0) days, and consumed a median of 5.6 (IQR 3.3-11.8) units per drinking day in the first week, which decreased to 4.7 (IQR 2.0-6.9) units by the last week and remained active for 4.0 (IQR 3.0-4.0) weeks.

CONCLUSIONS

Personnel engaged and used the app regularly as demonstrated by the number of initializations, interactions, and time spent using InDEx. Future research is needed to evaluate the engagement with and efficacy of InDEx for the reduction of alcohol consumption and binge drinking in an armed forces population.

Purchased Behavioral Health Care Received by Military Health System Beneficiaries in Civilian Medical Facilities, 2000-2014

Introduction

Behavioral health conditions are a significant concern for the U.S. military and the Military Health System (MHS) because of decreased military readiness and increased health care utilization. Although MHS beneficiaries receive direct care in military treatment facilities, a disproportionate majority of behavioral health treatment is purchased care received in civilian facilities. Yet, limited evidence exists about purchased behavioral health care received by MHS beneficiaries. This longitudinal study (1) estimated the prevalence of purchased behavioral health care and (2) identified patient and visit characteristics predicting receipt of purchased behavioral health care in acute care facilities from 2000 to 2014.

Materials and Methods

Medical claims with Major Diagnostic Code 19 (mental disorders/diseases) or 20 (alcohol/drug disorders) as primary diagnoses and TRICARE as the primary/secondary payer were analyzed for MHS beneficiaries (n = 17,943) receiving behavioral health care in civilian acute care facilities from January 1, 2000, to December 31, 2014. The primary dependent variable, receipt of purchased behavioral health care, was modeled for select mental health and substance use disorders from 2000 to 2014 using generalized estimating equations. Patient characteristics included time, age, sex, and race/ethnicity. Visit types included inpatient hospitalization and emergency department (ED). Time was measured in days and visits were assumed to be correlated over time. Behavioral health care was described by both frequency of patients and visit type. The University of South Carolina Institutional Review Board approved this study.

Results

From 2000 to 2014, purchased care visits increased significantly for post-traumatic stress disorder, adjustment, anxiety, mood, bipolar, tobacco use, opioid/combination opioid dependence, nondependent cocaine abuse, psychosocial problems, and suicidal ideation among MHS beneficiaries. The majority of care was received for mental health disorders (78.8%) and care was most often received in EDs (56%). Most commonly treated diagnoses included mood, tobacco use, and alcohol use disorders. ED visits were associated with being treated for anxiety (excluding post-traumatic stress disorder; Adjusted odds ratio [AOR]: 9.14 [95% confidence interval (CI): 8.26, 10.12]), alcohol use disorders (AOR = 1.67 [95% CI: 1.53, 1.83]), tobacco use (AOR = 1.16 [95% CI: 1.06, 1.26]), nondependent cocaine abuse (AOR = 5.47 [95% CI: 3.28, 9.12]), nondependent mixed/unspecified drug abuse (AOR = 7.30 [95% CI: 5.11, 10.44]), and psychosis (AOR = 1.38 [95% CI: 1.20, 1.58]). Compared with adults age 60 yr and older, adolescents (ages 12-17 yr), and adults under age 60 yr were more likely to be treated for suicidal ideation, adjustment, mood, bipolar, post-traumatic stress disorder, nondependent cocaine, and mixed/unspecified drug abuse. Adults under age 60 yr also had increased odds of being treated for tobacco use disorders, alcohol use disorders, and opioid/combination opioid dependence compared with adults age 60 yr and older.

Conclusions

Over the past 15 yr, purchased behavioral health care received by MHS beneficiaries in acute care facilities increased significantly. MHS beneficiaries received the majority of purchased behavioral health care for mental health disorders and were treated most often in the ED. Receiving behavioral health care in civilian EDs raises questions about access to outpatient behavioral health care and patient-centered care coordination between civilian and military facilities. Given the influx of new Veterans Health Administration users from the MHS, findings have implications for military, veteran, and civilian facilities providing behavioral health care to military and veteran populations.

A Maisonneuve Fracture in an Active Duty Sailor: A Case Report

Maisonneuve fractures are relatively well known in the sports medicine, and orthopedic communities, however, can be commonly missed among primary care providers. The following case outlines an active duty 35-yr-old female patient who presented with acute pain on the left ankle and lower leg after she misjudged a step. The injury is a combination of high fibular and medial malleolar fractures with a disruption of the tibiofibular syndesmosis ligaments. This is a result of extreme external rotation and pronation of a fixed foot. The proper diagnosis is reliant on ankle and tibiofibular films, to include orthogonal views. This case serves as a reminder to always examine joints above and below the injury site, obtain orthogonal views of a fracture, as well as the unstable nature of syndesmosis injuries. This fracture is commonly a sports-related injury; thus, it is particularly important for military providers to be aware of Maisonneuve fractures and the common pitfalls in diagnosis and treatment.