Feasibility and acceptability of shared decision-making to promote alcohol behavior change among women Veterans: Results from focus groups

Alcohol Treatment Access and Engagement Among Women in the USA: a Targeted Review of the Literature 2012-2022

Purpose of Review

The purpose of this review is to examine recent literature (2012-2022) on alcohol treatment access and engagement in women in the U.S. and propose future directions for research and clinical practice.

Recent Findings

A targeted literature review resulted in 27 studies encompassing screening and brief intervention (SBIRT), treatment utilization, treatment engagement, and barriers to treatment. Recent literature demonstrates overall low rates of screening and brief interventions and treatment utilization in the population with women less likely to be screened and utilize alcohol treatment. The magnitude of these gender differences varies with race/ethnicity. Extensive barriers to care include provider knowledge, structural barriers, and attitudinal barriers and these vary with service setting, gender, and race/ethnicity.

Summary

There is an increasing prevalence of alcohol use and Alcohol Use Disorder (AUD) in women with low rates of screening, brief treatment, treatment, and engagement which have resulted from extensive barriers to care. Possible areas of further inquiry include the impact of race/ethnicity on gender differences, improving provider and system level policies to promote SBIRT and treatment engagement and utilization, further developing digital interventions, and implementation research to investigate factors associated with optimizing effectiveness of gender-responsive and culturally tailored interventions that address the unique needs of women.

The Effect of Shared Decision-Making by Mental Health Nurses on Medication Adherence in Patients with Alcohol Use Disorders: Provider-Patient Communication Pathway Model

The involvement of patients with mental health issues in their own treatment decision-making has often been overlooked. This study aimed to investigate the impact of shared decision-making between mental health nurses and patients with alcohol use disorders (AUD) on medication adherence. The provider-patient communication pathway model was utilized to examine the ways in which therapeutic communication strategies employed by mental health nurses positively influence medication adherence. The study employed a percentile bootstrap method and pairwise comparison tests in structural equation modeling. The results revealed that shared decision-making between AUD patients and mental health nurses directly enhanced medication adherence, as well as indirectly influenced adherence through the mediating factors of therapeutic alliance and alcohol abstinence self-efficacy. These findings hold both theoretical and practical implications for involving patients with AUD in therapeutic decision-making within psychiatric and mental health nursing settings, as well as for improving medication adherence among this patient population.

Trends, challenges, and priorities for shared decision making in mental health: The first umbrella review

BACKGROUND

Shared decision making (SDM) is a health communication model promoting patient-centered care that has not been routinely utilized in mental health. Inconsistent definitions, models, measurement tools, and lack of sufficient evidence for the effectiveness of SDM interventions are potential contributors to the limited use of SDM in mental health.

AIMS

(1) Provide the first systematic analysis of global development trends and challenges of SDM research; (2) clarify the meaning, role, and measurement of SDM in mental health; (3) create a theoretical framework for key effective SDM components to guide future development and implementation of SDM interventions.

METHODS

A comprehensive search strategy was conducted in CINAHL, PubMed, Scopus, MEDLINE, EMBASE, Cochrane Library, Web of Science, Scopus, and PsycInfo. Included reviews focused on SDM interventions for prevention and/or treatment of mental illness in adults. A narrative synthesis was performed to capture the range of interventions, populations, measurement tools, comparisons, and outcomes.

RESULTS

10 systematic reviews of SDM in mental health were included with 100 nested studies spanning from 2006 to 2020. All reviews focused on dyadic and psychopharmacological decision-making. Primary outcomes of SDM in mental health interventions include treatment satisfaction, medication adherence, symptom severity, quality of life, and hospital readmissions. Participant-related factors unique to SDM in mental health, such as stigma and mental capacity, were not reported.

CONCLUSIONS

The current landscape of SDM in mental health is overwhelmingly disconnected from the needs and experiences of potential end-users; clients, clinicians, and family members. Most SDM interventions and tools were adapted from physical health and are mainly geared to psychopharmacological decision-making. The SDM in Mental Health Framework (SDM-MH), developed here, expands the scope of decisions to non-psychopharmacological discussions, diversifies the pool of SDM participants and settings, and offers potential primary target outcomes of SDM in mental health to reduce heterogeneity across studies.

Cognitive Processing Therapy or Relapse Prevention for comorbid Posttraumatic Stress Disorder and Alcohol Use Disorder: A randomized clinical trial

OBJECTIVE

To compare a Posttraumatic Stress Disorder (PTSD) treatment (Cognitive Processing Therapy; CPT), an Alcohol Use Disorder (AUD) treatment (Relapse Prevention; RP), and assessment-only (AO) for those meeting diagnostic criteria for both PTSD and AUD.

METHOD

Participants with current PTSD/AUD (N = 101; mean age = 42.10; 56% female) were initially randomized to CPT, RP, or AO and assessed post-treatment or 6-weeks post-randomization (AO). AO participants were then re-randomized to CPT or RP. Follow-ups were at immediate post-treatment, 3-, and 12-months. Mixed effects intent-to-treat models compared conditions on changes in PTSD symptom severity, drinking days, and heavy drinking days.

RESULTS

At post-treatment, participants assigned to CPT showed significantly greater improvement than those in AO on PTSD symptom severity (b = -9.72, 95% CI [-16.20, -3.23], d = 1.22); the RP and AO groups did not differ significantly on PTSD. Both active treatment conditions significantly decreased heavy drinking days relative to AO (CPT vs. AO: Count Ratio [CR] = 0.51, 95% CI [0.30, 0.88]; RP vs. AO: CR = 0.34, 95% CI [0.19, 0.59]). After re-randomization both treatment conditions showed substantial improvements in PTSD symptoms and drinking between pre-treatment and post-treatment over the 12-month follow-up period, with RP showing an advantage on heavy drinking days.

CONCLUSION

Treatments targeting one or the other aspects of the PTSD/AUD comorbidity may have salutary effects on both PTSD and drinking outcomes. These preliminary results suggest that people with this comorbidity may have viable treatment options whether they present for mental health or addiction care.

TRIAL REGISTRATION

The trial is registered at clinicaltrials.gov (NCT01663337).

Guiding Principles for Managing Co-occurring Alcohol/Other Drug and Mental Health Conditions: a Scoping Review

This scoping review aimed to synthesise the published literature on guiding principles for managing co-occurring alcohol/other drug (AOD) and mental health conditions in AOD treatment settings. Systematic search of key electronic databases (January 1, 2010, to February 17, 2021) produced 4583 articles, and independent title/abstract and full text screening left 43 articles for inclusion. Fifteen guiding principles were identified, most commonly: build a strong therapeutic relationship (n = 24 articles), provide holistic care (n = 12), involve peer support (n = 7), ensure continuity of care (n = 6), support the professional development and competence of workers (n = 6), and provide trauma-informed care (n = 5). Remaining principles were identified in < 5 articles. Limited empirical literature examined the impact of guiding principles on patient- and treatment-related outcomes. This review provides the first comprehensive synthesis of the international literature to derive guiding principles for managing co-occurring AOD and mental health conditions in AOD treatment. Further empirical research is needed to determine the effectiveness of principles at improving outcomes.

Unique health stressors impacting female veterans

ABSTRACT

Over 30,000 female soldiers leave the US military each year. This article examines health concerns unique to female veterans and outlines ways for nurses to recognize and address the psychological, physical, and other medical concerns of female soldiers transitioning to civilian healthcare.

Barriers and facilitators to changing drinking and receiving alcohol-related care: Interviews with Veterans Health Administration primary care patients who indicated interest but did not enroll in an alcohol care management intervention trial

Background: Most people with alcohol use disorder do not receive treatment, and primary care (PC)-based management of alcohol use disorder is a key strategy to close this gap. Understanding PC patients' perspectives on changing drinking and receiving alcohol-related care is important for this goal, particularly among those who decline alcohol-related care. This study examined perspectives on barriers and facilitators to changing drinking and receiving alcohol-related care among Veterans Health Administration (VA) PC patients who indicated interest but did not enroll in the Choosing Healthier drinking Options In primary CarE trial (CHOICE), which tested a PC-based alcohol care management intervention. Methods: VA PC patients with frequent heavy drinking who indicated interest in CHOICE but did not enroll were invited to participate. Twenty-seven patients completed in-person, semi-structured interviews. Interview transcripts were analyzed using iterative deductive and inductive content analysis. Results: Participants were mostly men (96%) and White (59%), and the mean age was 48. Seventy-four percent met criteria for alcohol use disorder, and the median number of past-week standard drinks was 41.5. Participants reported fewer alcohol-related problems, lower importance of/readiness to change drinking, and higher confidence in their ability to change than patients who enrolled in the CHOICE trial. Barriers fell into 5 domains: drinking fulfills need(s); reducing drinking or treatment is not needed; treatment is not effective/not acceptable; alcohol-related stigma; and practical barriers. Facilitators fell into 4 domains: reasons to change drinking; social support; treatment is acceptable/meets patients' needs; and practical facilitators. Participants discussed how Veteran identity and military experiences impacted drinking and willingness to receive care, which amplified multiple barriers/facilitators. Conclusions: This study identified barriers and facilitators to changing drinking and receiving alcohol-related care among VA PC patients who indicated interest but did not enroll in an alcohol care management trial. Findings can inform patient-centered interventions and support clinicians in engaging patients in care.

Mental Health Clinician Community Clergy Collaboration to Address Moral Injury Symptoms: A Feasibility Study

Moral injury (MI) symptoms (guilt, shame, isolation) can be associated with military experiences. While a degree of overlap is recognized between MI and posttraumatic stress disorder (PTSD) symptoms, MI symptoms do not always respond to evidence-based treatments for PTSD. Mental Health Clinician Community Chaplain Collaboration (MC4) was delivered by community clergy to address MI symptoms through facilitation of forgiveness and community reintegration. Thirteen veterans participated and the results suggested that MC4 was generally feasible and acceptable. However, it is unlikely community clergy time could keep up with demand. Shifting intervention delivery to Department of Veterans Affairs (VA) chaplains will alleviate many barriers experienced in this feasibility study.

Technology-Based Substance Use Interventions: Opportunities for Gender-Transformative Health Promotion

Drawing on data from a scoping review on sex, gender and substance use, this narrative review explores the use of gender-informed and technology-based approaches in substance use prevention and health promotion interventions. With an ever-changing landscape of new technological developments, an understanding of how technology-based interventions can address sex, gender, and intersecting equity considerations related to substance use is warranted. Current technology-based approaches to substance use prevention and health promotion are described and assessed for gender-specific and gender transformative outcomes, and limitations are discussed related to inclusivity, access, confidentiality, and a dearth of research on technological approaches that integrate gender-based analysis. A call for action designed to advance technology-based health promotion, prevention and brief interventions that address gender equity simultaneously with substance use is proposed.