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Ferguson M, Rhodes K, Loughhead M, McIntyre H, Procter N. The Effectiveness of the Safety Planning Intervention for Adults Experiencing Suicide-Related Distress: A Systematic Review. Arch Suicide Res 2022; 26:1022-1045. [PMID: 33913799 DOI: 10.1080/13811118.2021.1915217] [Citation(s) in RCA: 38] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
The safety planning intervention (SPI) is gaining momentum in suicide prevention practice and research. This systematic review sought to determine the effectiveness of the SPI for adults experiencing suicide-related distress. Systematic searches of international, peer-reviewed literature were conducted in six databases (Cochrane Trials, Embase, Emcare, Medline, PsycINFO and Web of Science), including terms for safety planning, suicide, and suicide-related outcomes. A total of 565 results were included for screening. Result screening (title/abstract and full-text), data extraction and critical appraisal were conducted in duplicate. Twenty-six studies met the inclusion criteria. Studies were primarily quantitative (n = 20), largely with general adult or veteran samples; a small number of studies explored the perspectives of staff and significant others. Half of the studies included the SPI as a standalone intervention, while the other half examined the SPI in combination with other interventions. Most interventions were delivered in-person, with a hard-copy safety plan created, while a smaller number explored internet-based interventions. Primary measures included: suicidality (ideation, behavior, deaths; 10 studies), suicide-related outcomes (depression, hopelessness; 5 studies) and treatment outcomes (hospitalizations, treatment engagement; 7 studies). The evidence supports improvements in each of these domains, with complementary findings from the remaining quantitative and qualitative studies suggesting that the SPI is a feasible and acceptable intervention. While positive, these findings are limited by the heterogeneity of interventions and study designs, making the specific impact of the SPI difficult to both determine and generalize. Conversely, this also points to the flexibility of the SPI.HighlightsThe Safety Planning Intervention (SPI) is a valuable indicated intervention for general adult and veteran populations experiencing suicide-related distress, primarily in face-to-face, clinical settings.Quantitative findings indicate associations between the SPI and improvements in suicidal ideation and behavior, decreases in depression and hopelessness, along with reductions in hospitalizations and improvements in treatment attendance.Qualitative studies suggest the SPI is acceptable and feasible, with areas for development.SPIs have been shown to be adaptable to the clinical area in its modality (digital or paper-based), delivery (face-to-face or online), facilitation (clinician or self-administered) and multiplicity (as stand-alone or combined intervention).
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Barnes SM, Borges LM, Smith GP, Walser RD, Forster JE, Bahraini NH. Acceptance and Commitment Therapy to Promote Recovery from suicidal crises: A Randomized Controlled Acceptability and Feasibility Trial of ACT for life. JOURNAL OF CONTEXTUAL BEHAVIORAL SCIENCE 2021. [DOI: 10.1016/j.jcbs.2021.02.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Matarazzo BB, Gerard GR, Jankovsky MC, Oslin DW, Brenner LA. Feasibility and Acceptability of the HOME Program for Veterans Recently Discharged from a Psychiatric Hospitalization. ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2021; 48:974-982. [PMID: 33523330 DOI: 10.1007/s10488-021-01109-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/10/2021] [Indexed: 11/27/2022]
Abstract
Enrollment in the Home-Based Mental Health Evaluation (HOME) Program is associated with higher rates of treatment engagement following psychiatric hospitalization discharge, as compared to enhanced care as usual. We aim to describe feasibility and acceptability data related to implementation of the HOME Program at two Department of Veterans Affairs Medical Centers (VAMCs) to inform future program refinement and implementation. Process evaluation data regarding feasibility and acceptability were collected in the context of an interventional multi-site trial. Data regarding enrollment in the study and the intervention were collected by study staff. Additional acceptability and feasibility data were obtained via the Client Satisfaction Questionnaire-8 (CSQ-8) and Narrative Evaluation of Intervention Interview (NEII). Between 82 and 91% of enrolled Veterans participated in at least one post-discharge telephone contact. Site differences existed with respect to completion of home visits. CSQ-8 results suggested high levels of satisfaction with the HOME Program. Themes identified via the NEII reflect that as a result of participation in the HOME Program, Veterans felt hopeful and cared for and learned how to keep themselves safe following hospital discharge. Process evaluation data from a clinical trial of the HOME Program demonstrated that the intervention was feasible to implement at two VAMCs and was acceptable to participants. These data inform considerations for future research and implementation efforts.Trial Registration ClinicalTrials.gov Identifier: NCT03347552.
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Affiliation(s)
- Bridget B Matarazzo
- Rocky Mountain Mental Illness, Research, Education and Clinical Center (MIRECC) for Veteran Suicide Prevention, US Department of Veterans Affairs, 1700 N. Wheeling St, Aurora, CO, 80045, USA.
- Department of Psychiatry, Anschutz School of Medicine, University of Colorado, Aurora, CO, USA.
| | - Georgia R Gerard
- Rocky Mountain Mental Illness, Research, Education and Clinical Center (MIRECC) for Veteran Suicide Prevention, US Department of Veterans Affairs, 1700 N. Wheeling St, Aurora, CO, 80045, USA
| | - Molly C Jankovsky
- Rocky Mountain Mental Illness, Research, Education and Clinical Center (MIRECC) for Veteran Suicide Prevention, US Department of Veterans Affairs, 1700 N. Wheeling St, Aurora, CO, 80045, USA
| | - David W Oslin
- Veterans Integrated Service Network (VISN) 4 MIRECC, US Department of Veterans Affairs, Philadelphia, PA, USA
- Department of Psychiatry, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
| | - Lisa A Brenner
- Rocky Mountain Mental Illness, Research, Education and Clinical Center (MIRECC) for Veteran Suicide Prevention, US Department of Veterans Affairs, 1700 N. Wheeling St, Aurora, CO, 80045, USA
- Departments of Physical Medicine and Rehabilitation, Psychiatry, and Neurology, Anschutz School of Medicine, University of Colorado, Aurora, CO, USA
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Monteith LL, Wendleton L, Bahraini NH, Matarazzo BB, Brimner G, Mohatt NV. Together With Veterans: VA National Strategy Alignment and Lessons Learned from Community-Based Suicide Prevention for Rural Veterans. Suicide Life Threat Behav 2020; 50:588-600. [PMID: 31950557 DOI: 10.1111/sltb.12613] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Accepted: 10/28/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Rural veterans are at increased risk for dying by suicide compared with urban veterans, yet interventions for preventing suicide among rural veterans have been limited. OBJECTIVES (1) Describe how Together With Veterans (TWV), a community-based intervention to prevent suicide among veterans in rural communities, aligns with the VA National Strategy for Preventing Veteran Suicide; (2) share lessons learned while beginning to implement TWV in rural communities. METHODS Together With Veterans is being implemented in four rural communities and comprises six suicide prevention best practices: (1) reducing stigma and promoting help-seeking; (2) lethal means safety, with an emphasis on firearms; (3) gatekeeper training; (4) training primary care providers; (5) improving access to crisis services; and (6) enhancing support for high-risk veterans. RESULTS Together With Veterans best practices align with most, but not all, of the strategies in the VA National Strategy for Preventing Veteran Suicide. Community veteran partners have shown a willingness to collaborate and provide local leadership, enthusiasm, and a sense of duty. CONCLUSIONS By supporting and facilitating local veteran leaders and their community partners in increasing suicide prevention knowledge, public awareness, and resources, we propose that TWV offers an acceptable and feasible approach that builds on the strengths of rural communities. Systematic evaluation is warranted.
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Affiliation(s)
- Lindsey L Monteith
- Rocky Mountain Mental Illness Research, Education, and Clinical Center for Suicide Prevention, Aurora, Colorado, USA.,Department of Psychiatry, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Leah Wendleton
- Rocky Mountain Mental Illness Research, Education, and Clinical Center for Suicide Prevention, Aurora, Colorado, USA
| | - Nazanin H Bahraini
- Rocky Mountain Mental Illness Research, Education, and Clinical Center for Suicide Prevention, Aurora, Colorado, USA.,Department of Psychiatry, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA.,Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Bridget B Matarazzo
- Rocky Mountain Mental Illness Research, Education, and Clinical Center for Suicide Prevention, Aurora, Colorado, USA.,Department of Psychiatry, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Gina Brimner
- Western Interstate Commission for Higher Education Behavioral Health Program, Boulder, Colorado, USA
| | - Nathaniel V Mohatt
- Rocky Mountain Mental Illness Research, Education, and Clinical Center for Suicide Prevention, Aurora, Colorado, USA.,Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA.,Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut, USA
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Kessler RC, Bauer MS, Bishop TM, Demler OV, Dobscha SK, Gildea SM, Goulet JL, Karras E, Kreyenbuhl J, Landes SJ, Liu H, Luedtke AR, Mair P, McAuliffe WHB, Nock M, Petukhova M, Pigeon WR, Sampson NA, Smoller JW, Weinstock LM, Bossarte RM. Using Administrative Data to Predict Suicide After Psychiatric Hospitalization in the Veterans Health Administration System. Front Psychiatry 2020; 11:390. [PMID: 32435212 PMCID: PMC7219514 DOI: 10.3389/fpsyt.2020.00390] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Accepted: 04/17/2020] [Indexed: 12/11/2022] Open
Abstract
There is a very high suicide rate in the year after psychiatric hospital discharge. Intensive postdischarge case management programs can address this problem but are not cost-effective for all patients. This issue can be addressed by developing a risk model to predict which inpatients might need such a program. We developed such a model for the 391,018 short-term psychiatric hospital admissions of US veterans in Veterans Health Administration (VHA) hospitals 2010-2013. Records were linked with the National Death Index to determine suicide within 12 months of hospital discharge (n=771). The Super Learner ensemble machine learning method was used to predict these suicides for time horizon between 1 week and 12 months after discharge in a 70% training sample. Accuracy was validated in the remaining 30% holdout sample. Predictors included VHA administrative variables and small area geocode data linked to patient home addresses. The models had AUC=.79-.82 for time horizons between 1 week and 6 months and AUC=.74 for 12 months. An analysis of operating characteristics showed that 22.4%-32.2% of patients who died by suicide would have been reached if intensive case management was provided to the 5% of patients with highest predicted suicide risk. Positive predictive value (PPV) at this higher threshold ranged from 1.2% over 12 months to 3.8% per case manager year over 1 week. Focusing on the low end of the risk spectrum, the 40% of patients classified as having lowest risk account for 0%-9.7% of suicides across time horizons. Variable importance analysis shows that 51.1% of model performance is due to psychopathological risk factors accounted, 26.2% to social determinants of health, 14.8% to prior history of suicidal behaviors, and 6.6% to physical disorders. The paper closes with a discussion of next steps in refining the model and prospects for developing a parallel precision treatment model.
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Affiliation(s)
- Ronald C Kessler
- Deparment of Health Care Policy, Harvard Medical School, Boston, MA, United States
| | - Mark S Bauer
- Department of Psychiatry, Harvard Medical School, Boston, MA, United States.,Center for Healthcare Organization & Implementation Research, VA Boston Healthcare System, Boston, MA, United States
| | - Todd M Bishop
- Center of Excellence for Suicide Prevention, Canandaigua VA Medical Center, Canandaigua, NY, United States
| | - Olga V Demler
- Division of Preventive Medicine, Brigham and Women's Hospital, Boston, MA, United States.,Department of Medicine, Harvard Medical School, Boston, MA, United States
| | - Steven K Dobscha
- VA Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, OR, United States.,Department of Psychiatry, Oregon Health & Science University, Portland, OR, United States
| | - Sarah M Gildea
- Deparment of Health Care Policy, Harvard Medical School, Boston, MA, United States
| | - Joseph L Goulet
- Pain, Research, Informatics, Multimorbidities & Education Center, VA Connecticut Healthcare System, West Haven, CT, United States.,Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, United States
| | - Elizabeth Karras
- Center of Excellence for Suicide Prevention, Canandaigua VA Medical Center, Canandaigua, NY, United States
| | - Julie Kreyenbuhl
- VA Capitol Healthcare Network (VISN 5), Mental Illness Research, Education, and Clinical Center (MIRECC), Baltimore, MD, United States.,Department of Psychiatry, Division of Psychiatric Services Research, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Sara J Landes
- South Central Mental Illness Research Education Clinical Center (MIRECC), Central Arkansas Veterans Healthcare System, North Little Rock, AR, United States.,Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR, United States
| | - Howard Liu
- Deparment of Health Care Policy, Harvard Medical School, Boston, MA, United States.,Center of Excellence for Suicide Prevention, Canandaigua VA Medical Center, Canandaigua, NY, United States
| | - Alex R Luedtke
- Department of Statistics, University of Washington, Seattle, WA, United States.,Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, United States
| | - Patrick Mair
- Department of Psychology, Harvard University, Cambridge, MA, United States
| | | | - Matthew Nock
- Department of Psychology, Harvard University, Cambridge, MA, United States
| | - Maria Petukhova
- Deparment of Health Care Policy, Harvard Medical School, Boston, MA, United States
| | - Wilfred R Pigeon
- Center of Excellence for Suicide Prevention, Canandaigua VA Medical Center, Canandaigua, NY, United States.,Department of Psychiatry, University of Rochester Medical Center, Rochester, NY, United States
| | - Nancy A Sampson
- Deparment of Health Care Policy, Harvard Medical School, Boston, MA, United States
| | - Jordan W Smoller
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, United States
| | - Lauren M Weinstock
- Department of Psychiatry & Human Behavior, Alpert Medical School of Brown University, Providence, RI, United States
| | - Robert M Bossarte
- Center of Excellence for Suicide Prevention, Canandaigua VA Medical Center, Canandaigua, NY, United States.,West Virginia University Injury Control Research Center and Department of Behavioral Medicine and Psychiatry, West Virginia University School of Medicine, Morgantown, WV, United States
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Matarazzo BB, Forster JE, Hostetter TA, Billera M, Adler G, Ganzini LK, Oslin DW, Brenner LA. Efficacy of the Home-Based Mental Health Evaluation (HOME) Program for Engaging Patients in Care After Hospitalization. Psychiatr Serv 2019; 70:1094-1100. [PMID: 31451065 DOI: 10.1176/appi.ps.201900002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The risk of suicide is elevated in the days and weeks after discharge from a psychiatric hospitalization, and lack of treatment engagement posthospitalization is also associated with suicide. The authors sought to determine whether the Home-Based Mental Health Evaluation [HOME] Program is efficacious in helping patients engage in care after psychiatric hospitalization. METHODS This study was a nonrandomized, controlled, two-arm (HOME Program versus enhanced care as usual [E-CARE]) trial that took place at four Department of Veterans Affairs medical centers. Participants (N=302) were patients admitted to a psychiatric inpatient unit. The HOME Program consists of phone- and home-based contacts that include suicide risk assessment, safety planning, and problem-solving around barriers to care. The primary outcome was treatment engagement, as documented in the electronic medical record. RESULTS Veterans in the HOME Program group were 1.33 (95% confidence interval [CI]=1.29-1.37) times more likely to engage in treatment, compared with veterans in the E-CARE group (p<0.001). HOME Program participants were estimated to have attended 55% more individual appointments (95% CI=12%-113%, p=0.02), compared with those in the E-CARE group. The adjusted difference in median time to treatment engagement was 15 days (95% CI=3.5-27.0) such that HOME Program participants engaged in treatment more quickly than participants at the E-CARE sites. CONCLUSIONS Findings suggest that participation in the HOME Program can help individuals at high risk of suicide engage in care after psychiatric hospitalization.
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Affiliation(s)
- Bridget B Matarazzo
- Rocky Mountain Mental Illness, Research, Education and Clinical Center (MIRECC), U.S. Department of Veterans Affairs (VA), Aurora, Colorado (Matarazzo, Forster, Hostetter, Billera, Brenner); Department of Psychiatry (Matarazzo), and Department of Physical Medicine and Rehabilitation (Forster, Brenner), University of Colorado School of Medicine, Aurora; South Central MIRECC, VA, Houston, and Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston (Adler); Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon, and Department of Psychiatry, Oregon Health and Science University, Portland (Ganzini); MIRECC, Veterans Integrated Service Network 4, VA, Philadelphia, and Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia (Oslin)
| | - Jeri E Forster
- Rocky Mountain Mental Illness, Research, Education and Clinical Center (MIRECC), U.S. Department of Veterans Affairs (VA), Aurora, Colorado (Matarazzo, Forster, Hostetter, Billera, Brenner); Department of Psychiatry (Matarazzo), and Department of Physical Medicine and Rehabilitation (Forster, Brenner), University of Colorado School of Medicine, Aurora; South Central MIRECC, VA, Houston, and Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston (Adler); Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon, and Department of Psychiatry, Oregon Health and Science University, Portland (Ganzini); MIRECC, Veterans Integrated Service Network 4, VA, Philadelphia, and Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia (Oslin)
| | - Trisha A Hostetter
- Rocky Mountain Mental Illness, Research, Education and Clinical Center (MIRECC), U.S. Department of Veterans Affairs (VA), Aurora, Colorado (Matarazzo, Forster, Hostetter, Billera, Brenner); Department of Psychiatry (Matarazzo), and Department of Physical Medicine and Rehabilitation (Forster, Brenner), University of Colorado School of Medicine, Aurora; South Central MIRECC, VA, Houston, and Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston (Adler); Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon, and Department of Psychiatry, Oregon Health and Science University, Portland (Ganzini); MIRECC, Veterans Integrated Service Network 4, VA, Philadelphia, and Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia (Oslin)
| | - Melodi Billera
- Rocky Mountain Mental Illness, Research, Education and Clinical Center (MIRECC), U.S. Department of Veterans Affairs (VA), Aurora, Colorado (Matarazzo, Forster, Hostetter, Billera, Brenner); Department of Psychiatry (Matarazzo), and Department of Physical Medicine and Rehabilitation (Forster, Brenner), University of Colorado School of Medicine, Aurora; South Central MIRECC, VA, Houston, and Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston (Adler); Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon, and Department of Psychiatry, Oregon Health and Science University, Portland (Ganzini); MIRECC, Veterans Integrated Service Network 4, VA, Philadelphia, and Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia (Oslin)
| | - Geri Adler
- Rocky Mountain Mental Illness, Research, Education and Clinical Center (MIRECC), U.S. Department of Veterans Affairs (VA), Aurora, Colorado (Matarazzo, Forster, Hostetter, Billera, Brenner); Department of Psychiatry (Matarazzo), and Department of Physical Medicine and Rehabilitation (Forster, Brenner), University of Colorado School of Medicine, Aurora; South Central MIRECC, VA, Houston, and Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston (Adler); Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon, and Department of Psychiatry, Oregon Health and Science University, Portland (Ganzini); MIRECC, Veterans Integrated Service Network 4, VA, Philadelphia, and Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia (Oslin)
| | - Linda K Ganzini
- Rocky Mountain Mental Illness, Research, Education and Clinical Center (MIRECC), U.S. Department of Veterans Affairs (VA), Aurora, Colorado (Matarazzo, Forster, Hostetter, Billera, Brenner); Department of Psychiatry (Matarazzo), and Department of Physical Medicine and Rehabilitation (Forster, Brenner), University of Colorado School of Medicine, Aurora; South Central MIRECC, VA, Houston, and Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston (Adler); Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon, and Department of Psychiatry, Oregon Health and Science University, Portland (Ganzini); MIRECC, Veterans Integrated Service Network 4, VA, Philadelphia, and Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia (Oslin)
| | - David W Oslin
- Rocky Mountain Mental Illness, Research, Education and Clinical Center (MIRECC), U.S. Department of Veterans Affairs (VA), Aurora, Colorado (Matarazzo, Forster, Hostetter, Billera, Brenner); Department of Psychiatry (Matarazzo), and Department of Physical Medicine and Rehabilitation (Forster, Brenner), University of Colorado School of Medicine, Aurora; South Central MIRECC, VA, Houston, and Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston (Adler); Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon, and Department of Psychiatry, Oregon Health and Science University, Portland (Ganzini); MIRECC, Veterans Integrated Service Network 4, VA, Philadelphia, and Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia (Oslin)
| | - Lisa A Brenner
- Rocky Mountain Mental Illness, Research, Education and Clinical Center (MIRECC), U.S. Department of Veterans Affairs (VA), Aurora, Colorado (Matarazzo, Forster, Hostetter, Billera, Brenner); Department of Psychiatry (Matarazzo), and Department of Physical Medicine and Rehabilitation (Forster, Brenner), University of Colorado School of Medicine, Aurora; South Central MIRECC, VA, Houston, and Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston (Adler); Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon, and Department of Psychiatry, Oregon Health and Science University, Portland (Ganzini); MIRECC, Veterans Integrated Service Network 4, VA, Philadelphia, and Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia (Oslin)
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