Veteran-centered barriers to VA mental healthcare services use

"Just Food doesn't Do It": Understanding Food Insecurity Among Rural Veterans in the United States

Food security among rural veteran populations is an understudied subject. This study uses qualitative data from 106 semi-structured interviews conducted with staff from programs at the United States Department of Veterans Affairs (VA) and other federal agencies, staff from non-governmental organizations (NGOs), food security researchers, and food insecure veterans to identify the barriers to and facilitators for rural veteran food security. Barriers identified included external, structural barriers that exist in rural areas; internal barriers to using food assistance, such as feeling stigmatized; and barriers related to other social determinants of health, including a lack of education, employment, or housing stability.

Black veteran use of video telehealth for mental health care

Black veterans experience disparities in mental health (MH) care access and are disproportionately affected by COVID-19. Video telehealth to home (VTH) may reduce disparities by addressing barriers, particularly with pandemic-related shifts to remotely delivered care. Considering potential needs for tailored implementation across racial/ethnic groups, we examined differences in VTH use by non-Hispanic Black veterans versus all other races/ethnicities and among Black (Hispanic and non-Hispanic) veterans by age, rurality, and gender during the pandemic. We extracted a cohort of Veterans Health Administration-enrolled veterans receiving at least one MH encounter between October 2019 and September 2020 (n = 1,627,791) from electronic health records. Multilevel linear growth curve models examined the percentage of VTH use for non-Hispanic Black versus other races/ethnicities before and after pandemic onset. Black veteran-only subgroup analyses examined differences by ethnicity in percentage of VTH MH encounters since pandemic onset by age, rurality, and gender, using regression and analysis of covariance models. Despite significant increases in VTH during the pandemic, on average, VTH use was consistently lower for non-Hispanic Black veterans across both periods. During the pandemic, differences in VTH use between non-Hispanic Black and non-Black veterans accelerated over time. VTH use was greater during the pandemic for Black veterans who were Hispanic, younger, urban, and female. Adoption of VTH for MH was low for non-Hispanic Black veterans before COVID-19 and during COVID-19 compared to non-Black groups. Future VTH research and implementation efforts should question why adoption remains low, work to meet cultural needs, and promote equitable adoption for Black veterans. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Cyr K, Liu JJW, Baker C, Nazarov A, Richardson JD. A rapid review of the barriers and facilitators of mental health service access among Veterans and their families

Introduction

Transitioning to civilian life after military service can be challenging for both Veterans and their families. Accessible mental health services are crucial during this period to provide support. The objective of this review was to conduct a rapid review to capture the barriers and identify facilitators that influence access to mental health services for Veterans and their families during the post-service transition period.

Methods

This review was conducted using the Cochrane Handbook for Systematic Reviews of Interventions as a methodological framework and followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses - Rapid Review (PRISMA-RR).

Results

A total of 60 articles and 67 independent samples were included in the final data analyses. Across the included articles, this review identified 23 barriers and 14 facilitator themes. Issues navigating the mental health care system was identified as the main challenge among Veterans and their families, and those who received support navigating the system identified this as a significant facilitator. Applying the Theoretical Domains Framework, most of the identified barriers and facilitators were categorized into environmental context and resources domain.

Discussion

The heterogeneity in Veterans' and Veteran families' experiences with mental health care-seeking may suggest that access to mental health care for Veterans and Veteran families cannot be solved by addressing one type of barrier alone. Instead, coordinated efforts to address prioritized systemic, logistical, social, and inter-/intrapersonal obstacles are essential for improving access and optimizing mental health care outcomes. These insights underscore the complexity of considerations for Veterans and families accessing mental health care.

Rural veteran perception of healthcare access in South Carolina and Florida: a qualitative study

BACKGROUND

Access to mental and physical healthcare in rural areas is challenging for Veterans and their families but essential for good health. Even though recent research has revealed some of the challenges rural Veterans face accessing healthcare, a complete understanding of the gap in access is still unclear.

METHODS

This qualitative study aimed to explore participants' perceptions of healthcare access. Structured interviews were conducted with 124 Veterans and spouses of Veterans from rural qualifying counties in South Carolina and Florida.

RESULTS

The study's results revealed five main dimensions of access: geographic proximity, transportation, communication, cultural competence, and resources. Distance to service needed can negatively impact access for Veterans and their families in general, especially for those whose health is declining or who cannot drive because of their age. Lack of transportation, problems with transportation services, and lack of public transportation can lead to delays in care. Additionally, the lack of communication with the Veterans Affairs (VA) Health System and with the healthcare team, as well as inefficient communication among the healthcare team, lack of coordination of care between the VA health system and community providers, and the lack of cultural competence of healthcare providers and contracted personnel made access to services even more challenging.

CONCLUSIONS

Improving communication can help to develop a sense of trust between Veterans and the VA, and between Veterans and spouses with the healthcare team. It can also lead to increased patient satisfaction. Ensuring healthcare providers and contracted personnel are culturally competent to talk and treat Veterans can improve patient trust and adherence to treatment. Lastly, resource-related challenges included financial problems, lack of prompt access to appointments, lack of providers, limited access to local clinics and hospitals, limited local programs available, and reimbursement issues.

Brief Peer-Supported webSTAIR for Trauma-Exposed Veterans in the Community: Randomized Controlled Trial

BACKGROUND

Peer-supported mobile health (mhealth) programs hold the promise of providing a low-burden approach to increasing access to care and improving mental health. While peer support has been shown to improve engagement into care, there is limited investigation about the impact of peers on symptom outcome. Trauma-exposed populations frequently suffer from co-occurring posttraumatic stress and depressive symptoms as well as difficulties in day-to-day functioning. This study evaluated the potential benefits of a peer-supported transdiagnostic mhealth program on symptom outcomes and functioning.

OBJECTIVE

This randomized controlled trial tested the effectiveness of Brief Peer-Supported (BPS) webSTAIR, a 6-module transdiagnostic online program derived from Skills Training in Affective and Interpersonal Regulation (STAIR) compared to waitlist control (WL) in a community sample of Veterans who screened positive for either post-traumatic stress disorder (PTSD) and/or depression.

METHODS

A total of 178 eligible Veterans were enrolled in the study using a 2:1 randomization scheme with 117 assigned to BPS webSTAIR and 61 assigned to WL. PTSD and depressive symptoms as well as emotion regulation, and psychosocial functioning were assessed via phone at pretreatment, posttreatment, and 8-week follow-up. Mixed-effects models were used to assess change in outcome measures across timepoints and evaluate the impact of module completion on outcomes. Exploratory analyses were conducted to determine whether the type and number of peer interactions influenced outcomes.

RESULTS

Significant interaction effects were observed for all outcomes such that participants randomized to BPS webSTAIR reported significantly greater improvement at posttreatment compared to WL with moderate effect sizes for PTSD (PCL-5 d = -0.48) depression (PHQ- 8 d = -0.64), emotion regulation (DERS-16 d = 0.61) and functional impairment (WSAS d = 0.61); gains were maintained at 8-week follow-up. Those who completed more modules reported greater improvement on all outcomes. An initial cohort of participants who were required to engage with a peer coach to progress through the modules interacted more frequently with peers but completed fewer modules compared to a later cohort for whom peer engagement was optional.

CONCLUSIONS

BPS webSTAIR was effective in improving PTSD and depression symptoms, emotion regulation, and psychosocial functioning in community Veterans. Peer-supported transdiagnostic mhealth programs may be a particularly efficient, effective, and low-burden approach to improving mental health among trauma-exposed populations. Investigation of peer-supported programs among other populations is necessary to evaluate the generalizability of the findings. Analyses comparing peer support that was required versus optional indicated that some veterans may not need or want peer support. Future research should evaluate how best to deliver peer support and for whom it is most beneficial. If successful, peer-supported tech programs may increase the VA workforce as well as improve veteran mental health services and outcomes.

CLINICALTRIAL

ClinicalTrials.gov NCT04286165.

Optimizing clinical outcomes with stellate ganglion block and trauma-informed care: A review article

BACKGROUND

For decades, thousands of active-duty service members have sought treatment for trauma exposure. Stellate ganglion block (SGB) is a fast-acting nerve block documented in medical literature for nearly a century that has shown promise as a potentially life-altering treatment for post-traumatic stress (PTS).

OBJECTIVE

This review aims to answer the practical questions of those who support individuals suffering from trauma: (1) SGB's safety profile (2) efficacy data (3) potential advantages and limitations, (4) a cross-cultural application example, (5) and the use of SGB in combination with talk therapy to optimize clinical outcomes.

METHODS

The current body of literature, to include several large case series, meta-analyses, and a sufficiently powered randomized controlled trial, were reviewed, and presented to describe the history of SGB for emotional trauma symptoms and address the objectives of this review.

RESULTS

Critical consideration is given to the safety and efficacy data on SGB and the evolution in safety-related technologies. Advantages such as decreased barriers to care, rapid onset, and decreased dropout and limitations such as treatment non-response, potential adverse effects, and misconceptions about the treatment are then described. Finally, the cross-cultural application of SGB is explored based on the deployment of SGB in Israel.

CONCLUSION

SGB is associated with level 1B evidence and a reassuring safety profile. Evolving the model of care through the combined use of effective biological treatments like SGB with trauma informed talk therapy offers a hopeful path forward for supporting those who suffer from post-traumatic stress.

Exploring how military culture shapes veterans' perception of aortic aneurysm repair: A qualitative study

BACKGROUND

Veterans represent a distinct cultural group whose perceptions of illness and treatment are influenced by military culture. The study explores how prior military service shapes Veterans' assumptions and behaviors in the setting of aneurysm repair surgery.

STUDY DESIGN

We conducted content and thematic analysis of a case series of 10 transcripts from telephone interviews with older (76.7 ± 4.3 years) African American and White male Veterans now residing in the Southern U.S. who underwent open or endovascular aneurysm surgery at Veterans Affairs Medical Centers or university affiliates between 2004 and2019.

RESULTS

Throughout the continuum of care, Veterans described deferring to authority and not questioning provider's decisions ["I just can't make a judgment on that, because I'm not a doctor"]. Veterans valued commitment and articulated pride in keeping logistically challenging surveillance appointments [I always took them very seriously. . . If I'm scheduled for something by the doctor, I always make it."]. The routine structure of VA care aligned with Veterans military experiences, facilitating compliance with doctor's orders. However, procedural deviations in VA care were disconcerting for patients ["They haven't reached out to me in at least three years, since my surgery; I was being seen once a year and then all of a sudden, they just quit."]. While Veterans praised VA care, they exhibited sensitivity to signs of untoward treatment from clinical and support staff "…my surgeon, he never talked to me before, nor after, no anytime…I thought that maybe that wasn't right".

CONCLUSIONS

Military culture embodies rank, order, and respect, and remains a source of strength and stability for Veterans in their medical care late in life. Cultural competency about how military service has shaped Veterans' expectations can enhance providers' awareness of patients' military mindsets and inform surgeons' efforts to engage Veterans in shared decision making.

A Systematic Review of the Department of Veterans Affairs Mental Health-Care Access Interventions for Veterans With PTSD

INTRODUCTION

Access to mental health care has been a priority area for the U.S. Department of Veterans Affairs (DVA) for decades. Access for veterans with PTSD is essential because untreated PTSD is associated with numerous adverse outcomes. Although interventions have been developed to improve access to DVA mental health care, the impact of these interventions on access for veterans with untreated PTSD has not been examined comprehensively, limiting guidance on appropriate implementation.

MATERIALS AND METHODS

We conducted a systematic review of PubMed and PTSDpubs between May 2019 and January 2022 to identify DVA access interventions for veterans with PTSD not engaged in DVA mental health care. We identified 17 interventions and 29 manuscripts reporting quantitative access outcomes. We categorized interventions into four major categories: Primary care mental health integration, other national initiatives, telemental health, and direct outreach. We evaluated five outcome domains: Binary attendance, number of sessions attended, wait time, number of patients seen, and care initiation. We assessed the risk of bias using the Cochrane Collaboration criteria.

RESULTS

Across articles, binary attendance generally improved, whereas the impact on the number of sessions attended was equivocal. Overall, the number of patients seen increased compared to control participants and retrospective data. The few articles that examined care initiation had mixed results. Only one article examined the impact on wait time.

CONCLUSIONS

Access interventions for veterans with PTSD demonstrated varied success across interventions and outcomes. The national initiatives-particularly primary care mental health integration -were successful across several outcomes; telemental health demonstrated promise in improving access; and the success of direct outreach varied across interventions. Confidence in these findings is tempered by potential bias among studies. Limited literature on how these interventions impact relevant preattendance barriers, along with incomplete data on how many perform nationally, suggests that additional work is needed to ensure that these interventions increase access for veterans with PTSD nationwide.

Peer-Written Caring Letters for Veterans after a Suicidal Crisis

OBJECTIVE

In the evidence-based suicide prevention intervention, Caring Letters, healthcare providers send brief, caring messages to patients following psychiatric inpatient care, a time of elevated suicide risk. However, recent studies with military populations have found mixed results. An adaptation of Caring Letters employed a peer framework in which veterans from the community wrote brief caring messages to veterans discharging from psychiatric inpatient treatment after a suicidal crisis.

METHODS

The present study utilized content analysis to assess 90 caring messages generated by 15 peer veterans recruited from veteran service organizations (e.g., American Legion).

RESULTS

Three themes emerged: (1) Shared Military Service, (2) Care, and (3) Overcoming Adversity. Peer-generated content varied in how the coded themes were expressed in the messages.

CONCLUSION

These veteran-to-veteran caring messages may bolster belongingness, social support, and destigmatize mental health struggles, and have the potential to augment existing Caring Letters effects and interventions.

Rural Native Veterans' Perceptions of Care in the Context of Navigator Program Development

INTRODUCTION

American Indian and Alaska Natives serve in the military at one of the highest rates of all racial and ethnic groups. For Veterans, the already significant healthcare disparities Natives experience are aggravated by barriers to accessing care, care navigation, and coordination of health care within the Veterans Health Administration (VHA) between the VHA and tribal health systems. To mitigate these barriers, the VHA is developing a patient navigation program designed specifically for rural Native Veterans. We describe formative work aimed at understanding and addressing barriers to VHA care from the perspective of rural Native Veterans and those who facilitate their care.

METHODS

Thirty-four individuals participated in semi-structured interviews (22 Veterans, 6 family members, and 6 Veteran advocates) drawn from 9 tribal communities across the US.

RESULTS

Participants described many barriers to using the VHA, including perceptions of care scarcity, long travel distances to the VHA, high travel costs, and bureaucratic barriers including poor customer service, scheduling issues, and long waits for appointments. Many Veterans preferred IHS/tribal health care over the VHA due to its proximity, simplicity, ease of use, and quality.

CONCLUSION

Rural Native Veterans must see a clear benefit to using the VHA given the many obstacles to its use. Veteran recommendations for addressing barriers to VHA care within a navigation program include assistance enrolling in, scheduling, and navigating VHA systems; paperwork assistance; cost reimbursement; and care coordination with the IHS/tribal health care.

VHA Whole Health Services and Complementary and Integrative Health Therapies: a Gateway to Evidence-Based Mental Health Treatment

BACKGROUND

Engagement in evidence-based psychotherapy (EBP) among veterans with behavioral health conditions is often low. The Veterans Health Administration (VHA) is implementing a "Whole Health (WH)" system of care, to identify veteran personal health goals, align care with those goals, and offer services designed to engage and empower veterans to achieve well-being.

OBJECTIVE

To examine the relationship between veteran WH utilization and subsequent engagement in EBP.

DESIGN

Retrospective analysis of VHA administrative records from 18 facilities implementing WH.

SUBJECTS

Veterans (n = 265,364) with a diagnosis of depression, post-traumatic stress disorder (PTSD), and/or anxiety who had a mental healthcare encounter but no EBP use in fiscal year (FY) 2018. Among this cohort, 33,146 (12.5%) began using WH in FY2019.

MAIN MEASURES

We examined use of an EBP for depression, anxiety, and/or PTSD within 1 year of the index date of WH use compared to use of an EBP anytime during FY2019 for veterans not identified as using WH. We used multiple logistic regression to examine the association between veteran WH use and EBP engagement.

KEY RESULTS

Approximately 3.0% (n = 7,860) of the veterans in our overall cohort engaged in an EBP in the year following their index date. Controlling for key demographic, health, and utilization variables, WH users had 2.4 (95% CI: 2.2-2.5) times higher odds of engaging in an EBP the following year than those with no WH utilization. Associations between utilization of specific WH services (vs. no utilization of that service) and engagement in an EBP in the subsequent year ranged from 1.6 (95% CI: 1.0-2.6) to 3.5 (95% CI: 3.2-3.9) across the different types of WH services used.

CONCLUSIONS

WH use was associated with increased engagement in EBPs among veterans with depression, anxiety, and/or PTSD. Future interventions intended to promote veteran engagement in EBPs may benefit from leveraging WH services and therapies.

Relationship of social determinants of health with symptom severity among Veterans and non-Veterans with probable posttraumatic stress disorder or depression

PURPOSE

Social determinants of health (SDoH) refer to the conditions in the environments in which people live that affect health outcomes and risks. SDoH may provide proximal, actionable targets for interventions. This study examined how SDoH are associated with posttraumatic stress disorder (PTSD) and depression symptoms among Veterans and non-Veterans with probable PTSD or depression.

METHODS

Four multiple regressions were conducted. Two multiple regressions with Veterans examined the impact of SDoH on PTSD symptoms and on depression symptoms. Two multiple regressions with non-Veterans examined the impact of SDoH on PTSD symptoms and on depression symptoms. Independent variables included demographic characteristics, adverse experiences (in childhood and adulthood), and SDoH (discrimination, education, employment, economic instability, homelessness, justice involvement, and social support). Correlates that were statistically significant (p < 0.05) and clinically meaningful (rpart >|0.10|) were interpreted.

RESULTS

For Veterans, lower social support (rpart = - 0.14) and unemployment (rpart = 0.12) were associated with greater PTSD symptoms. Among non-Veterans, greater economic instability (rpart = 0.19) was associated with greater PTSD symptoms. In the depression models, lower social support (rpart = - 0.23) and greater economic instability (rpart = 0.12) were associated with greater depression for Veterans, while only lower social support was associated with greater depression for non-Veterans (rpart = - 0.14).

CONCLUSION

Among Veterans and non-Veterans with probable PTSD or depression, SDoH were associated with PTSD and depression symptoms, particularly social support, economic instability, and employment. Beyond direct treatment of mental health symptoms, addressing social support and economic factors such as instability and employment in the context of PTSD and depression are potential intervention targets that would benefit from future research.

Grit is associated with decreased mental health help-seeking among student veterans

Objective: To examine the role of grit as a mediator of the relationship between student-veteran status and not seeking mental health help. Participants: A diverse and nationally representative sample of students (8,203 women, 4,934 men) from 18 U.S. colleges and universities included in the Understanding Student Distress and Academic Success study was used. Method: Data were analyzed using structural equation modeling to assess associations between military service, grit, and help seeking. Results: Military service was positively associated with both facets of grit: consistency of interests (CI) and perseverance of effort (PE). CI, but not PE, mediated the relationship between military service and never having sought mental health help. Conclusions: These results suggest that grit mediates the relationship between military service and not seeking mental health help. Interventions for student-veterans that emphasize the utility of mental health treatment may be useful to diminish the negative influence of grit on help-seeking.

Virtual Worlds Technology to Enhance Training for Primary Care Providers in Assessment and Management of Posttraumatic Stress Disorder Using Motivational Interviewing: Pilot Randomized Controlled Trial

BACKGROUND

Many individuals with posttraumatic stress disorder (PTSD) first present to primary care rather than specialty mental health care. Primary care providers often lack the training required to assess and treat patients with PTSD. Virtual trainings have emerged as a convenient and effective way of training primary care providers in PTSD assessment and communication methods (ie, motivational interviewing [MI]).

OBJECTIVE

The aim of this study was to conduct a pilot randomized controlled trial of a synchronous Virtual Worlds (VW; a virtual world where learners were immersed as avatars) training versus an asynchronous web-based training on PTSD and MI, comparing the feasibility, acceptability, usability, and preliminary efficacy of 2 different training platforms among primary care providers.

METHODS

Participating primary care providers were randomized to a VW and a web-based PTSD training. Outcomes were collected at baseline, posttraining, and 90-days follow-up. Standardized patient interviews measured participants' communication skills in assessing and managing patients with PTSD symptoms.

RESULTS

Compared to the web-based training, the VW training platform achieved larger learning gains in MI (ie, partnership and empathy) and in discussing pharmacotherapy and psychotherapy for PTSD. Both VW and web-based trainings led to increases in PTSD knowledge and primary care providers' self-confidence.

CONCLUSIONS

The asynchronous web-based PTSD training improved PTSD-related knowledge and self-confidence but was not as effective as the VW immersive experience in teaching MI or clinical management. Because VW training is synchronous and new for many learners, it required more time, facilitation, and technical support. As computer technology improves, VW educational interventions may become more feasible, particularly in teaching clinical skills.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03898271; https://tinyurl.com/mu479es5.

"I don't just say, Hi! I'm gay": Sexual Orientation Disclosures in Oncology Clinic Settings Among Sexual Minority Women Treated for Breast Cancer in the U.S. South

OBJECTIVES

Few studies examine sexual orientation disclosures (SODs) among women with breast cancer; fewer examine the impact of culture and geography on disclosure processes. This study explores how sexual minority women (SMW) in the Southern United States engage in SODs with oncology clinicians.

DATA SOURCES

We conducted in-depth interviews with SMW (eg, lesbian, bisexual) treated for early-stage (stages I-III), hormone receptor-positive breast cancer (N = 12), using a semistructured interview guide. Participants completed an online survey prior to the 60-minute interview. Data was analyzed using an adapted pile sorting approach and thematic analysis conventions.

CONCLUSION

Average age of participants was 49.5 years (range: 30-69), all self-identified as cisgender; 83.3% as lesbian, 58.3% were married, 91.7% had completed a 4-year college degree or higher, 66.7% identified as non-Hispanic White, 16.7% as Black, and 16.7% as Hispanic/Latina. Half of the sample had not engaged in SODs with an oncology clinician. Key themes were: (1) religious and political conservatism in the South create SOD barriers; (2) oncologist-specific barriers to SODs; (3) "straight passing" as a discrimination mitigation strategy; and (4) SOD facilitators in oncology settings (ie, strategic disclosures, medical privilege, and lesbian, gay, bisexual, and transgender-friendly branding of oncology centers).

IMPLICATIONS FOR NURSING PRACTICE

SMW with breast cancer living in the U.S. South navigate unique interpersonal barriers to SODs in oncology settings. Clinicians could encourage SODs by fostering inclusive environments via nonheteronormative language, inclusive intake forms, and respect for SMW's SOD navigation processes. Oncology clinicians require culturally relevant, geographic-specific communication training to facilitate SODs among SMW.

Impact of Military Affiliation on Exercise Perceptions Among Survivors of Sexual Violence

INTRODUCTION

Military service members disproportionately experience sexual violence (SV) and its related health concerns. Although recent work has shown physical activity to be an effective strategy for improving physical and mental health among trauma-exposed military populations, little of this work has focused specifically on military service members with a history of SV. To address these gaps in knowledge and practice, this study identified the most salient perceived benefits/barriers of exercise among men and women survivors of SV with military affiliations. Additionally, these analyses explore willingness to engage in exercise programs, and preferences for the structure/content of these programs, among men and women survivors of SV with military affiliations.

MATERIALS AND METHODS

An online, cross-sectional survey of women (n = 355) and men (n = 198) survivors of SV was completed using Amazon Mechanical Turk. Inclusion criteria were men and women, age between 18 and 65 years, self-reported history of SV, and located in the United States. Information on sociodemographics and post-traumatic stress disorder symptoms was collected alongside perceived barriers and benefits to exercise, willingness to engage in exercise programs, and preferences for the structure/content of these programs. Analyses were stratified by sex. Comparisons by history of military involvement (active duty military or veteran; no military involvement/civilian) were reported.

RESULTS

Both military-involved men (n = 68) and women (n = 139) were more likely to prefer at-home and online exercise options when compared to civilians (Ps < .05; Cramer's Vs 0.19-0.36). Additionally, both men and women with military involvement reported strongly favoring exercising with an instructor over no instructor and preferred that this instructor identifies with their same gender (Ps < .01; Cramer's Vs 0.28-0.36). Women with military involvement also preferred shorter program durations and exercising alone or in a group online or in person, whereas men with military involvement were open to longer program durations, when compared to their civilian counterparts (Ps < .05; Cramer's Vs 0.19-0.37). Women and men with military involvement were more likely than their civilian counterparts to perceive that exercise benefits their psychological outlook and social interactions. They were also more likely than civilians to indicate poor exercise environment, high time expenditure, and family discouragement as perceived barriers to exercise (Ps < .05; Cohen's ds 0.21-0.97). Military-involved women were also more likely than civilian women to endorse the perceived barrier of hard physical exercise (P < .05; Cohen's d = 0.25).

CONCLUSIONS

This study identified perceived benefits and barriers to exercise, along with willingness to engage in exercise programs, and exercise preferences among men and women survivors of SV with military involvement. Targeting these factors in intervention planning will be important for physical activity promotion and program engagement among veterans to reduce the disproportionate impact of SV and disease burden among U.S. service members and veterans.

Myocardial Infarction Across COVID-19 Pandemic Phases: Insights From the Veterans Health Affairs System

Background Cardiovascular procedural treatments were deferred at scale during the COVID-19 pandemic, with unclear impact on patients presenting with non-ST-segment-elevation myocardial infarction (NSTEMI). Methods and Results In a retrospective cohort study of all patients diagnosed with NSTEMI in the US Veterans Affairs Healthcare System from January 1, 2019 to October 30, 2022 (n=67 125), procedural treatments and outcomes were compared between the prepandemic period and 6 unique pandemic phases: (1) acute phase, (2) community spread, (3) first peak, (4) post vaccine, (5) second peak, and (6) recovery. Multivariable regression analysis was performed to assess the association between pandemic phases and 30-day mortality. NSTEMI volumes dropped significantly with the pandemic onset (62.7% of prepandemic peak) and did not revert to prepandemic levels in subsequent phases, even after vaccine availability. Percutaneous coronary intervention and coronary artery bypass grafting volumes declined proportionally. Compared with the prepandemic period, patients with NSTEMI experienced higher 30-day mortality during Phases 2 and 3, even after adjustment for COVID-19-positive status, demographics, baseline comorbidities, and receipt of procedural treatment (adjusted odds ratio for Phases 2 and 3 combined, 1.26 [95% CI, 1.13-1.43], P<0.01). Patients receiving Veterans Affairs-paid community care had a higher adjusted risk of 30-day mortality compared with those at Veterans Affairs hospitals across all 6 pandemic phases. Conclusions Higher mortality after NSTEMI occurred during the initial spread and first peak of the pandemic but resolved before the second, higher peak-suggesting effective adaptation of care delivery but a costly delay to implementation. Investigation into the vulnerabilities of the early pandemic spread are vital to informing future resource-constrained practices.

Engaging Operational Partners Is Critical for Successful Implementation of Research Products: a Coincidence Analysis of Access-Related Projects in the Veterans Affairs Healthcare System

BACKGROUND/OBJECTIVE

The Veterans Health Administration (VHA) has prioritized timely access to care and has invested substantially in research aimed at optimizing veteran access. However, implementing research into practice remains challenging. Here, we assessed the implementation status of recent VHA access-related research projects and explored factors associated with successful implementation.

DESIGN

We conducted a portfolio review of recent VHA-funded or supported projects (1/2015-7/2020) focused on healthcare access ("Access Portfolio"). We then identified projects with implementable research deliverables by excluding those that (1) were non-research/operational projects; (2) were only recently completed (i.e., completed on or after 1/1/2020, meaning that they were unlikely to have had time to be implemented); and (3) did not propose an implementable deliverable. An electronic survey assessed each project's implementation status and elicited barriers/facilitators to implementing deliverables. Results were analyzed using novel Coincidence Analysis (CNA) methods.

PARTICIPANTS/KEY RESULTS

Among 286 Access Portfolio projects, 36 projects led by 32 investigators across 20 VHA facilities were included. Twenty-nine respondents completed the survey for 32 projects (response rate = 88.9%). Twenty-eight percent of projects reported fully implementing project deliverables, 34% reported partially implementing deliverables, and 37% reported not implementing any deliverables (i.e., resulting tool/intervention not implemented into practice). Of 14 possible barriers/facilitators assessed in the survey, two were identified through CNA as "difference-makers" to partial or full implementation of project deliverables: (1) engagement with national VHA operational leadership; (2) support and commitment from local site operational leadership.

CONCLUSIONS

These findings empirically highlight the importance of operational leadership engagement for successful implementation of research deliverables. Efforts to strengthen communication and engagement between the research community and VHA local/national operational leaders should be expanded to ensure VHA's investment in research leads to meaningful improvements in veterans' care. The Veterans Health Administration (VHA) has prioritized timely access to care and has invested substantially in research aimed at optimizing veteran access. However, implementing research findings into clinical practice remains challenging, both within and outside VHA. Here, we assessed the implementation status of recent VHA access-related research projects and explored factors associated with successful implementation. Only two factors were identified as "difference-makers" to adoption of project findings into practice: (1) engagement with national VHA leadership or (2) support and commitment from local site leadership. These findings highlight the importance of leadership engagement for successful implementation of research findings. Efforts to strengthen communication and engagement between the research community and VHA local/national leaders should be expanded to ensure VHA's investment in research leads to meaningful improvements in veterans' care.

Implementing Peer Specialists in Suicide Prevention Efforts in the Veterans Health Administration

OBJECTIVE

The Veterans Health Administration (VHA) recognizes peer support as an underused intervention in suicide prevention. PREVAIL is a peer-based suicide prevention intervention that was designed and piloted with non-veteran patients recently hospitalized for suicidal thoughts or behaviors. The purpose of this study was to elicit veteran and stakeholder feedback to inform the adaptation of PREVAIL for piloting with veterans flagged for high suicide risk.

METHODS

Semi-structured interviews were conducted with multiple stakeholders from a VHA medical center in the northeast. Interviews focused on the perceived benefits and concerns of peer specialists directly addressing suicide risk with veterans. Interviews were recorded, transcribed, and analyzed using rapid qualitative analysis.

RESULTS

Interviewees included clinical directors (n = 3), suicide prevention coordinators (n = 1), outpatient psychologists (n = 2), peer specialists (n = 1), and high-risk veterans (n = 2). Overall, peer specialists were viewed as possessing many distinct strengths in engaging and helping high-risk veterans as part of a team approach. Concerns included liability, adequate training, clinical supervision and support, and self-care for peer specialists.

CONCLUSIONS

Findings indicated support and confidence that peer support specialists would be a valuable addition and could help fill existing gap in VHA's suicide prevention efforts.

"It's a sign of weakness": Masculinity and help-seeking behaviors among male veterans accessing posttraumatic stress disorder care

OBJECTIVE

Male veterans delay posttraumatic stress disorder (PTSD) treatment and are less likely to engage in help-seeking behaviors or receive adequate mental health treatment. Male veterans face additional stigma seeking mental health care due to traditional masculine ideologies perpetuated by military culture. This study presents the perspectives of male veterans accessing Veterans Affairs (VA) PTSD services, focusing particularly on help-seeking behaviors and barriers to care.

METHOD

Semistructured interviews were conducted with 13 United States male veterans seeking treatment in VA primary care. Qualitative data analysis was coded using Atlas.ti, and thematic analysis was used to develop and refine themes. This study is part of a larger study examining veterans' initiation of PTSD treatment.

RESULTS

Findings indicate that male veterans in this sample may be reluctant to initiate PTSD care due to stigma, distrust of the military or mental health care, and a desire to avoid reliving their trauma. Significant others may encourage help-seeking behaviors among this population. Veterans also reported a need for mental health services that address PTSD from noncombat trauma and from military sexual trauma (MST).

CONCLUSIONS

Findings indicate that male veterans face unique challenges accessing mental health services and may benefit from increased VA services focused on MST and noncombat specific PTSD. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Factors associated with a lack of health care utilization among Veterans after a positive suicide screen in the emergency department

OBJECTIVES

Many Veterans at high risk for suicide are identified in Veterans Health Administration (VHA) emergency departments (ED). Little is known about what may predict care utilization in this population. To address this knowledge gap, we explored factors associated with Veterans' lack of VHA care utilization following a positive suicide risk screen in the ED.

METHODS

In a retrospective observational study, we identified all patients who were seen in a VHA ED from October 1, 2019, to September 30, 2020. We examined factors associated with not utilizing VHA mental health (MH) and all VHA care in the 6 months following a positive suicide ED screen. Predictors included comorbidity, homelessness, and MH visit and diagnosis history.

RESULTS

We identified 23,446 Veterans with a positive suicide risk screen in the ED in fiscal year 2020. Overall, 4.1% had no VHA MH visits 6 months postscreen. The probability of not utilizing MH care was significantly higher for Veterans with no comorbidity (4.7% vs. 3.4% for mild comorbidity), no MH diagnosis (10.5% vs 2.8%), no past-year MH visits (13.6% vs 2.3%), and no past-year homelessness (5.4% vs. 1.1%). A smaller proportion of the population did not receive any VHA care 6 months postscreen (0.5%). Veterans who did not experience homelessness (0.6% vs 0.2%), had no MH diagnosis (1.6% vs. 0.3%), and had no previous MH visits (1.9% vs 0.2%) were significantly more likely to not utilize VHA care.

CONCLUSIONS

Veterans who do not utilize VHA care after a positive suicide risk screen appear to have fewer documented health and housing concerns than those who do receive care. Yet, Veterans with a positive suicide risk screen who are otherwise healthy may remain at elevated risk for suicide following their ED visit. ED providers may consider enhanced follow-up care to mitigate suicide risk for these Veterans.

Evaluation of a Psychoeducational Group to Expand Mobile Application Knowledge and Use in a Veteran Residential Treatment Program

Despite the availability of free, evidence-informed mental health mobile applications (apps) to support Veterans and Service Members, interventions are needed to ensure patients are aware of the developed resources. A psychoeducational group was developed and evaluated by a quality improvement project in the context of a Department of Veterans Affairs residential treatment program. Four weekly group sessions introduced 82 Veterans to two similarly themed apps at each group and supported Veteran installation, introduction to the clinical subject matter, app orientation and demonstration, and device/app troubleshooting. Although 94% owned a smartphone, prior to the group, seven of eight apps introduced during the group had been used by fewer than 10% of participants. Following group participation, the proportion of participants agreeing that they were comfortable using mental health apps increased from 33% at baseline to 75%. Similarly, relative to 54% of participants at baseline who agreed that they were aware of available mental health mobile applications, the proportion rose to 89% after the group. Most participants rated three apps as "helpful" or "very helpful" (Breath2Relax, Mindfulness Coach, and PTSD Coach) and most participants reported they were likely to use these apps in the future. Results and qualitative feedback identified needed improvements to the group, including the replacement of some featured apps and the inclusion of automated app usage metrics. Well-designed implementation studies of dissemination strategies are needed to inform best practices for the adoption of these promising interventions.

Understanding veteran barriers to specialty outpatient PTSD clinical care

OBJECTIVE

Veterans seeking treatment for posttraumatic stress disorder (PTSD) commonly report general and veteran-specific barriers to treatment such as stigma and challenges with navigating the Veterans Health Affairs (VHA) system. This study aimed to characterize barriers endorsed by a national sample of veterans seeking care in VHA PTSD specialty outpatient clinics, as well as to examine the impact of demographics on endorsed barriers.

METHODS

This study included 17,069 veterans referred to PTSD specialty outpatient clinics in the VHA during Fiscal Year 2019. Barriers to care, demographics, clinical concerns, and PTSD symptom severity (PCL-5) were assessed at intake.

RESULTS

Veterans (mean age=47.6 years, 83.3% male) endorsed an average of 2.39 barriers. The most commonly endorsed barriers included difficulty interacting with others (37.9%), difficulty being in public (33.8%), work (30.3%), concern for finances (20%), and difficulty getting out of bed (19.5%). A significant minority of veterans (22%) endorsed no barriers. Male sex (23.1%) and White race (23.6%) were associated with a greater likelihood of reporting no barriers.

CONCLUSIONS

These findings indicate the need for a comprehensive approach to addressing multi-faceted barriers for veterans seeking treatment in PTSD specialty clinics. Findings also highlight the potential importance of tailoring strategies to reduce barriers based on demographic and clinical characteristics such as race, sex, and degree of avoidance. Future research should seek to longitudinally examine the impact of barriers on treatment engagement.

Grit but Not Help-Seeking Was Associated with Food Insecurity among Low Income, At-Risk Rural Veterans

Rural veterans have poorer health, use healthcare services less often than their urban counterparts, and have more prevalent food insecurity than average U.S. households. Food insecurity and resource use may be influenced by modifiable psychological attributes such as grit and help-seeking behaviors, which may be improved through interventions. Grit and help-seeking have not been previously evaluated among rural veterans. Thus, this cross-sectional study evaluated the hypothesis that grit and help-seeking were associated with food insecurity and the use of resources. Food security, resource use, grit, and help-seeking behavior were assessed among rural veterans (≥18 years) from five food pantries in southern Illinois counties (n = 177) from March 2021 to November 2021. Adjusted multiple regression was used to estimate the relationship between the odds of food insecurity and the use of resources with grit and help-seeking scores. Higher grit scores were significantly associated with lower odds of food insecurity (OR = 0.5, p = 0.009). No other associations were detected. The results provided evidence to inform the content of future educational interventions to improve food insecurity and address health disparities among rural veterans by addressing grit. The enhancement of psychological traits such as grit is related to food security and has the potential to benefit other aspects of well-being.

Differential Impact of COVID-19 on the Use of Tele-mental Health Among Veterans Living in Urban or Rural Areas

OBJECTIVE

The authors examined the use of Veterans Affairs Video Connect (VVC) for mental health care by rural and urban veterans and the impact of the COVID-19 pandemic on patterns of VVC use.

METHODS

Data from 557,668 rural and 1,384,093 urban veterans (collected July 2019-October 2020) from the Veterans Health Administration Corporate Data Warehouse were examined with interrupted time-series models to determine rural versus urban VVC use before and during the initial 7 months of the pandemic.

RESULTS

Before COVID-19, rates of VVC use as percentages of all mental health care were higher among rural veterans. After implementation of pandemic restrictions, rural veteran VVC use continued to increase, but this increase was surpassed by that of urban veterans.

CONCLUSIONS

These findings highlight the need to monitor emerging disparities in telehealth use and to encourage and support use of VVC and access to mental health care for all veterans, particularly those experiencing barriers to care.

Association of Adequacy of Broadband Internet Service With Access to Primary Care in the Veterans Health Administration Before and During the COVID-19 Pandemic

IMPORTANCE

Although telemedicine expanded rapidly during the COVID-19 pandemic and is widely available for primary care, required broadband internet speeds may limit access.

OBJECTIVE

To identify disparities in primary care access in the Veterans Health Administration based on the association between broadband availability and primary care visit modality.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study used administrative data on veterans enrolled in Veterans Health Administration primary care to identify visits at 937 primary care clinics providing telemedicine and in-person clinical visits before the COVID-19 pandemic (October 1, 2016, to February 28, 2020) and after the onset of the pandemic (March 1, 2020, to June 30, 2021).

EXPOSURES

Federal Communications Commission-reported broadband availability was classified as inadequate (download speed, ≤25 MB/s; upload speed, ≤3 MB/s), adequate (download speed, ≥25 <100 MB/s; upload speed, ≥5 and <100 MB/s), or optimal (download and upload speeds, ≥100 MB/s) based on data reported at the census block by internet providers and was spatially merged to the latitude and longitude of each veteran's home address using US Census Bureau shapefiles.

MAIN OUTCOMES AND MEASURES

All visits were coded as in-person or virtual (ie, telephone or video) and counted for each patient, quarterly by visit modality. Poisson models with Huber-White robust errors clustered at the census block estimated the association between a patient's broadband availability category and the quarterly primary care visit count by visit type, adjusted for covariates.

RESULTS

In primary care, 6 995 545 veterans (91.8% men; mean [SD] age, 63.9 [17.2] years; 71.9% White; and 63.0% residing in an urban area) were seen. Adjusted regression analyses estimated the change after the onset of the pandemic vs before the pandemic in patients' quarterly primary care visit count; patients living in census blocks with optimal vs inadequate broadband had increased video visit use (incidence rate ratio [IRR], 1.33; 95% CI, 1.21-1.46; P < .001) and decreased in-person visits (IRR, 0.84; 95% CI, 0.84-0.84; P < .001). The increase in the rate of video visits before vs after the onset of the pandemic was greatest among patients in the lowest Area Deprivation Index category (indicating least social disadvantage) with availability of optimal vs inadequate broadband (IRR, 1.73; 95% CI, 1.42-2.09).

CONCLUSIONS AND RELEVANCE

This cohort study found that patients with optimal vs inadequate broadband availability had more video-based primary care visits and fewer in-person primary care visits after the onset of the COVID-19 pandemic, suggesting that broadband availability was associated with video-based telemedicine use. Future work should assess the association of telemedicine access with clinical outcomes.

Evidence-based posttraumatic stress disorder treatment in a community sample: Military-affiliated versus civilian patient outcomes

Posttraumatic stress disorder (PTSD) is a significant mental health issue among military service members and veterans. Although the U.S. Department of Veterans Affairs (VA) provides crucial resources for behavioral health care, many veterans seek mental health services through community clinics. Previous research illustrates that military and veteran patients benefit less from evidence-based treatments (EBTs) for PTSD than civilians. However, most PTSD treatment outcome research on military and veteran populations is conducted in VA or military settings. Little is known about outcomes among military-affiliated patients in community settings. The primary aim of this study was to directly compare civilian versus military-affiliated patient outcomes on PTSD and depression symptoms using the PTSD Checklist for DSM-5 (PCL-5) and the nine-item Patient Health Questionnaire (PHQ-9) in a community setting. Participants (N = 502) included military-affiliated (veteran, Guard/Reservist, active duty) and civilian patients who engaged in cognitive processing therapy (CPT) or prolonged exposure (PE) for PTSD in community clinics. Both groups demonstrated significant reductions on the PCL-5, military-affiliated: d = -0.91, civilian: d = -1.18; and PHQ-9, military-affiliated: d = -0.65, civilian: d = -0.88, following treatment. However, military-affiliated patients demonstrated smaller posttreatment reductions on the PCL-5, M_diff = 5.75, p = .003, and PHQ-9, M_diff = 1.71, p = .011, compared to civilians. Results demonstrate that military-affiliated patients benefit from EBTs for PTSD, albeit to a lesser degree than civilians, even in community settings. These findings also highlight the importance of future research on improving EBTs for military personnel with PTSD.

Pathways to program entry: Factors promoting entry and participation in veteran peer-support programs

Given the documented underutilization of community-based services by veterans, this study aims to identify factors promoting engagement in programs. Qualitative data from interviews with 154 veterans in peer support programs were analyzed to identify factors promoting program entry and participation. Findings confirm the importance of both internal and external factors for program engagement. Internal factors included feeling a sense of disconnection, dissatisfaction with other programs, emotional needs, concrete needs, and a desire to serve others. External factors included encouragement from others, program culture, and program climate. Implications for program development and evaluation are discussed. While much of the current literature on veterans focuses on individual characteristics promoting or impeding service use, this study provides insight into programmatic features such as culture and climate which foster participation and meaningful engagement. Ultimately, programs serving veterans need input and influence by veterans, and should emphasize peer support and other opportunities for social connection.

Older Veterans' Treatment Preferences: Psychotherapy and Self-Management Treatment Modalities

OBJECTIVES

Self-management may help older Veterans with mental health challenges and can overcome barriers to traditional psychotherapy. However, the reasons underlying older Veterans' treatment preferences remain unknown. The current study investigated older Veterans' perspectives on psychotherapy and self-management.

METHODS

Seventy-four Veterans ≥ 60 years old were included in this mixed methods study. Participants provided rationale(s) after ranking their preferences for psychotherapy and four self-management modalities. Logistic regressions examined whether depressive and anxiety symptom severity contributes to preferences. Qualitative analyses were conducted to investigate reasoning for preferences.

RESULTS

Most participants preferred psychotherapy (64.9%) over self-management (35.1%). Logistic regressions showed that depressive and anxiety symptom severity was not significantly associated with preferences. Qualitative analyses revealed that past experience and access-related barriers were underlying the preferences. Themes unique to psychotherapy included the availability of emotional support and the process of information sharing. In contrast, ease of access was associated with self-management.

CONCLUSIONS

Older Veterans preferred psychotherapy to receive support and to develop trust in meeting their goals.

CLINICAL IMPLICATIONS

Older Veterans' needs point to the importance of providers' consideration of a person-centered approach and treatment collaboration. Notably, Veterans' preference for psychotherapy highlights the importance and need for human support in addition to self-management tools.

Engaging Stakeholders in Identifying Access Research Priorities for the Department of Veterans Affairs

BACKGROUND

The Veterans Access Research Consortium (VARC), a Department of Veterans Affairs (VA) Consortium of Research focused on access to healthcare, has been funded by VA's Health Services Research and Development Service (HSR&D) to develop a research roadmap for healthcare access. The goal of the roadmap is to identify operationally aligned research questions that are most likely to lead to meaningful improvements in Veterans' healthcare access.

OBJECTIVES

To describe the process of soliciting diverse stakeholder perspectives about key priorities on which VA's HSR&D access agenda should focus and identify the results of that process.

METHODS

We used a modified Delphi approach to engage researchers and VA operational partners in a process to develop recommendations regarding the access-related research questions VA should prioritize. We then collaborated with three Veteran Engagement Groups (VEGs) across the country to solicit Veterans' reactions to the Delphi results and their perspectives about access-related issues affecting access to VA health care.

RESULTS

The Delphi panel consisted of 22 research and operational experts, both internal and external to VA. The Delphi process resulted in five research questions identified by the panelists as highest priority for VA to pursue, each representing one of the following domains: (1) measurement of access, (2) barriers to access, (3) equity and subpopulations, (4) effective interventions to improve access, and (5) consequences of poor/better access. Veterans' perspectives focused primarily on the barriers to access domain. Veterans indicated several barriers that might be addressed through research or operational initiatives, including poor communication about services, weak connections to and partnerships with local community care facilities, and poor provision of telehealth resources and education.

CONCLUSIONS

Engaging multiple methods to solicit stakeholder perspectives enables more nuanced understanding of access-related priorities for VA. Future research should consider utilizing such an approach to identify additional research and/or operational priorities.

A Pilot Study Comparing Two Measures of Perceived Health Services Access Among Military Veterans With Musculoskeletal Injuries and Mental Health Conditions

INTRODUCTION

Service members endure a number of musculoskeletal injuries (MSIs) during service (e.g., ankle sprains and chronic back pain). Musculoskeletal injuries can reduce engagement in physical activity after military service and contribute to a sedentary lifestyle that diminishes physical health and elevates the risk for psychological distress including suicide-related behaviors. Yet, little is known about barriers and facilitators to accessing care in veterans with co-occurring MSI and mental health conditions. The purpose of this study was to pilot two brief measures of barriers and facilitators to rehabilitation and mental health services in military veterans with musculoskeletal and mental health conditions. Self-report tools vary in their response formats in ways that can impact usability, data quality, and completeness. We examine two response styles (i.e., checklist vs. thermometer) for two health services (mental health and rehabilitation) to determine usability, patterns in item endorsement, and veteran preference.

MATERIALS AND METHODS

Barriers and facilitators informed by the Fortney Veterans Healthcare Access model were assessed by veterans (n = 31) on the newly developed 22-item, paper-and-pencil scale with separate ratings for mental health and rehabilitation services. All participants completed scales with both response styles and the order of administration was randomized (i.e., either the checklist first or the thermometer-style response first). Data also included self-reported demographics, musculoskeletal and mental health diagnoses, health-related quality of life, physical activity levels, mental health symptoms, suicide risk, and coronavirus disease of 2019 pandemic-related stress.

RESULTS

Veterans reported no differences in ease of use across response formats; however, 83.9% (n = 26) preferred the checklist style, with only 3.22% (n = 1) preferring the thermometer format. Checklist items also resulted in less missing data (i.e., range 0.00%-6.45%) than the thermometer-style option (i.e., range 6.45%-61.30%). On the checklist, total number of perceived barriers was low for mental health and rehabilitation services (i.e., M = 1.58 and M = 1.61, respectively). Distance to care and problems related to symptoms were the most frequently identified barriers for both services. Facilitators outnumbered barriers for mental and rehabilitation services, and nearness of the clinic/hospital was the top-rated facilitator for both. On the thermometer, the perceived strength of each mental health (M = 39.37) and rehabilitation (M = 39.81) service barrier was moderate (0-100 scale), while the average perceived strength of each mental health (M = 61.66) and rehabilitation service (M = 61.84) facilitator was higher. Associations between barrier and facilitator scores with mental and physical health indicators were small with exceptions. For instance, suicide attempt likelihood was positively correlated with rehabilitation services barriers; mental health burden was positively associated with both barriers and facilitators.

CONCLUSIONS

Results of this pilot comparing two measurement approaches identified actionable next steps. Brief barriers and facilitators checklists were viable for veteran ratings across type of health. The thermometer-based tool captured the perceived strength of barriers and facilitators but yielded problematic rates of missing data in its current form and was not preferred by veterans.

Evaluation of a Veterans Health Administration Whole Health for Mental Health Course for Clinicians

Objectives: Veterans experience mental health disorders at higher rates than their civilian counterparts and also experience multiple barriers to mental health services. The Veterans Health Administration (VA) has implemented a Whole Health approach to make health care more person-focused and oriented toward promotion of health-sustaining behavior. We conducted an evaluation to investigate the effects of a Whole Health for Mental Health (WHMH) course for clinicians that focuses on shifting the perspective to a system of care in which mental health is incorporated as a core part of whole-person care. Design: We collected surveys before the course, immediately after the course, and at a 2-month follow-up. Settings/Location: The course was implemented in non-clinical settings in two VA medical centers (one in the Northeast and one in the Mountain West). Subjects: Our sample consisted of VA staff who enrolled in WHMH and completed a pre- and post-survey (n = 100) and follow-up survey (n = 99). Intervention: The WHMH is a 2-day face-to-face course that covers multiple aspects of mental health through a Whole Health lens. The course includes evidence-based practices within each aspect of mental health. The course also emphasizes implementation of Whole Health in clinicians' lives, their practice, and the health care system. Outcome measures: Attitudes were measured at pre-, post-, and follow-up assessments. The WHMH behaviors were measured at pre- and follow-up assessments. Results: There were statistically significant, large changes toward improvement from pre-test to post-test for all attitudes examined. These changes remained significant at follow-up, and the magnitude of change remained at least medium to large. Statistically significant, medium magnitude or larger improvements were found at follow-up for four of the five WHMH behavior outcomes examined. Conclusions: Our results suggest that clinicians can increase their attitudes and use of Whole Health concepts and both conventional and complementary approaches related to mental health issues.

Antipsychotic initiation and new diagnoses excluded from quality-measure reporting among Veterans in community nursing homes contracted by the Veterans Health Administration in the United States

OBJECTIVES

To assess whether prevailing antipsychotic use rates in community nursing homes (CNH) influence new initiation of antipsychotics and diagnosis with antipsychotic indications among Veterans.

METHODS

We used linked 2013-2016 Veterans Administration (VA) data, Medicare claims, Nursing Home Compare, and Minimum Data Set (MDS) assessments. The exposure was the proportion (in quintiles) of all CNH residents prescribed antipsychotics in the quarter preceding a Veteran's admission date. Using adjusted logistic regression, we analyzed two outcomes measured using MDS: antipsychotic initiation, and new diagnosis of an antipsychotic quality-measure exclusionary condition (i.e., schizophrenia, Tourette's syndrome, or Huntington's disease).

RESULTS

Among 8201 Veterans without an indication for antipsychotics at baseline, 21.1% initiated antipsychotics and 3.5% were newly diagnosed with any exclusionary diagnosis after CNH admission. Schizophrenia accounted for almost all (96.8%) the new diagnoses. Antipsychotic initiation increased with higher CNH antipsychotic use rates: OR = 2.55, 95% CI: 2.08--3.12, quintile 5 versus 1. CNHs with the highest prevalent use of antipsychotics were associated with increased odds of Veterans acquiring an exclusionary diagnosis (OR = 2.09, 95% CI: 1.32-3.32, quintile 5 vs. 1).

CONCLUSIONS

Incident antipsychotic use is common among Veterans admitted to CNHs. CNH antipsychotic prescribing practices are associated with Veterans being newly diagnosed with antipsychotic prescription indications, primarily schizophrenia.

Care Outcomes for Chiropractic Outpatient Veterans (COCOV): a qualitative study with veteran stakeholders from a pilot trial of multimodal chiropractic care

BACKGROUND

Low back pain (LBP) is common among military veterans seeking treatment in Department of Veterans Affairs (VA) healthcare facilities. As chiropractic services within VA expand, well-designed pragmatic trials and implementation studies are needed to assess clinical effectiveness and program uptake. This study evaluated veteran stakeholder perceptions of the feasibility and acceptability of care delivery and research processes in a pilot trial of multimodal chiropractic care for chronic LBP.

METHODS

The qualitative study was completed within a mixed-method, single-arm, pragmatic, pilot clinical trial of chiropractic care for LBP conducted in VA chiropractic clinics. Study coordinators completed semi-structured, in person or telephone interviews with veterans near the end of the 10-week trial. Interviews were audiorecorded and transcribed verbatim. Qualitative content analysis using a directed approach explored salient themes related to trial implementation and delivery of chiropractic services.

RESULTS

Of 40 participants, 24 completed interviews (60% response; 67% male gender; mean age 51.7 years). Overall, participants considered the trial protocol and procedures feasible and reported that the chiropractic care and recruitment methods were acceptable. Findings were organized into 4 domains, 10 themes, and 21 subthemes. Chiropractic service delivery domain encompassed 3 themes/8 subthemes: scheduling process (limited clinic hours, scheduling future appointments, attendance barriers); treatment frequency (treatment sufficient for LBP complaint, more/less frequent treatments); and chiropractic clinic considerations (hire more chiropractors, including female chiropractors; chiropractic clinic environment; patient-centered treatment visits). Outcome measures domain comprised 3 themes/4 subthemes: questionnaire burden (low burden vs. time-consuming or repetitive); relevance (items relevant for LBP study); and timing and individualization of measures (questionnaire timing relative to symptoms, personalized approach to outcomes measures). The online data collection domain included 2 themes/4 subthemes: user concerns (little difficulty vs. form challenges, required computer skills); and technology issues (computer/internet access, junk mail). Clinical trial planning domain included 2 themes/5 subthemes: participant recruitment (altruistic service by veterans, awareness of chiropractic availability, financial compensation); and communication methods (preferences, potential barriers).

CONCLUSIONS

This qualitative study highlighted veteran stakeholders' perceptions of VA-based chiropractic services and offered important suggestions for conducting a full-scale, veteran-focused, randomized trial of multimodal chiropractic care for chronic LBP in this clinical setting.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03254719.

Historical Trends in Veteran Community Substance Use Treatment: 2000-2019

Background: Substance use is a significant health crisis for the Veteran population. Prior research has thoroughly examined Veteran substance use within Veterans Health Administration (VHA) settings. However, such data tends to be outdated, and there is minimal research on substance use services delivered outside of VHA systems. This study examines historical patterns of Veteran substance use using a large sample of community-based substance-use treatment admissions. Methods: Data were drawn from the Substance Abuse and Mental Health Data Archive Treatment Episode Data Set-Admissions. Of the 39,425,886 total admissions between 2000 and 2019, 1,361,339 were of Veterans. Analyses compared Veteran versus non-Veteran admissions on demographics and historical trends in nature of substance-use admissions. Results: Relative to non-Veterans, Veteran admissions were more likely to be prompted by alcohol use. Over time, heterogeneity in substances prompting admissions has increased dramatically for both Veterans and non-Veterans, with particularly notable increases in opiate and stimulant use. Conclusion: Results suggest Veterans admitted to community substance-use treatment are unique relative to their non-Veteran peers. Development and implementation of treatments to target a range of substances while also considering the environmental challenges (e.g., homelessness) commonly faced by this population appear essential to best servicing community-based Veterans.

Evaluation of neighborhood resources and mental health in American military Veterans using geographic information systems

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Four meaningful neighborhood resource groups were identified by clustering.

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Living in alcohol-permissive/tobacco-restrictive neighborhoods had negative impacts.

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Place of residence and distance to the closest VA care facility were not significant.

Neighborhood-level social determinants are increasingly recognized as factors shaping mental health in adults. Data-driven informatics methods and geographic information systems (GIS) offer innovative approaches for quantifying neighborhood attributes and studying their influence on mental health. Guided by a modification of Andersen’s Behavioral Model of Health Service Use framework, this cross-sectional study examined associations of neighborhood resource groups with psychological distress and depressive symptoms in 1,528 U.S. Veterans. Data came from the Veteran Affairs (VA) Health Services Research and Development Proactive Mental Health trial and publicly available sources. Hierarchical clustering based on the proportions of neighborhood resources within walkable distance was used to identify neighborhood resource groups and generalized estimating equations analyzed the association of identified neighborhood resource groups with mental health outcomes. Few resources were found in walkable areas except alcohol and/or tobacco outlets. In clustering analysis, four meaningful neighborhood groups were identified characterized by alcohol and tobacco outlets. Living in an alcohol-permissive and tobacco-restrictive neighborhood was associated with increased psychological distress but not depressive symptoms. Living in urban or rural areas and access to VA care facilities were not associated with either outcome. These findings can be used in developing community-based mental health-promoting interventions and public health policies such as zoning policies to regulate alcohol outlets in neighborhoods. Augmenting community-based services with Veteran-specialized services in neighborhoods where Veterans live provides opportunities for improving their mental health.

Associations between symptoms of posttraumatic stress disorder, pain, and alcohol use disorder among OEF/OIF/OND veterans

BACKGROUND

Alcohol use disorder (AUD) is prevalent among Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn (OEF/OIF/OND) veterans. Pain and posttraumatic stress disorder (PTSD) are highly comorbid and increase risk of AUD. Prior studies linking pain or PTSD to AUD have not explored interactions between pain and PTSD symptoms.

METHODS

OEF/OIF/OND veterans (N = 1230) were recruited from social media websites for a cross-sectional study of health behavior. Pain was assessed using the Pain Outcomes Questionnaire. PTSD symptoms and PTSD symptom clusters were assessed using the Posttraumatic Stress Disorder Checklist for DSM-5. AUD symptoms were assessed with the AUD Identification Test. Linear regression models were used to test for main and interaction effects in the full sample and separately by sex.

RESULTS

Both pain and PTSD symptoms were associated with increased AUD symptomology, though the relationship between pain and AUD was heighted at relatively low PTSD symptoms. With respect to PTSD symptom clusters, re-experiencing and negative cognitions and mood were associated with increased AUD symptomology. Interactions between pain and re-experiencing as well as pain and avoidance were revealed. Results for men mirrored the full sample, while an interaction between pain and negative cognitions and mood was associated with AUD in women.

CONCLUSIONS

Results highlight associations between AUD, PTSD symptoms, and pain among veterans. While the relationship between pain and AUD appeared stronger in the context of low PTSD symptoms, both pain and PTSD symptoms were associated with increased AUD. Clinicians treating veterans with AUD should address the range of potential comorbidities.

"There's a huge benefit just to know that someone cares:" a qualitative examination of rural veterans' experiences with TelePain

BACKGROUND

Veterans in the United States are at an increased risk of chronic pain and have higher reported pain prevalence and severity than nonveterans. This qualitative study aims to examine veterans' perspectives on the acceptability of receiving pain care through TelePain, a telehealth program implemented by the Veterans Health Administration (VA) that offers specialty pain care to rural veterans in their homes or in a video conferencing room at a nearby outpatient clinic.

METHODS

The VA electronic health record was used to identify patients who were referred to TelePain from rural clinics located in Washington, Oregon, and Alaska between 12/01/2019 and 03/31/2020. The study team completed 16 semi-structured interviews with rural veterans about their experiences with TelePain. After interview transcripts were recorded digitally and transcribed, Atlas.ti was used to organize data and facilitate qualitative coding. Interview transcripts were analyzed using thematic analysis.

RESULTS

Veterans reported general satisfaction with receiving pain care through telehealth and valued having supportive, knowledgeable providers who provided useful information and resources. In addition, veterans appreciated the convenience of telehealth. Barriers to care included problems with program follow-up, negative perceptions of mental health care for pain, and preference for in-person care. Although some patients suggested that telehealth audio and video could be improved, most patients did not have any significant problems with telehealth technology.

CONCLUSIONS

In this sample of rural veterans who used TelePain, many reported satisfaction with the program and positive experiences with providers. Targets for quality improvement include streamlining the program's referral and scheduling process and improving patient motivation to engage in psychological pain treatments. Results indicate that delivering pain services over telehealth is an acceptable modality for this patient population.

Psychoeducation as Precision Health in Military-Related Mild Traumatic Brain Injury

A significant proportion of Service Members and Veterans (SMVs) experience at least 1 mild traumatic brain injury during military activities (mil-mTBI), which can result in enduring cognitive symptoms. Although multiple cognitive rehabilitation (CR) interventions have been developed for this population, patient psychoeducation focusing on biopsychosocial relationships and health behaviors is often cited as the first line of defense for mil-mTBI sequelae. However, theoretical and conceptual foundations of these psychoeducational techniques are not well articulated. This raises questions about the potency of attempts to boost health literacy in affected SMVs, who represent a highly heterogeneous patient population within a special cultural milieu. To elucidate the significance of this problem and identify opportunities for improvement, we view the psychoeducation of SMVs through the lens of educational principles described in serious mental illness, where "psychoeducation" was first formally defined, as well as contextual and phenomenological aspects of mil-mTBI that may complicate treatment efforts. To advance psychoeducation research and practice in mil-mTBI, we discuss how treatment theory, which seeks to link active treatment ingredients with specific therapeutic targets, and an associated conceptual framework for medical rehabilitation-the Rehabilitation Treatment Specification System-can be leveraged to personalize educational content, integrate it into multicomponent CR interventions, and evaluate its effectiveness.

Health Service Access Among Homeless Veterans: Health Access Challenges Faced by Homeless African American Veterans

Veteran homelessness is a public health crisis, especially among the disproportionate number of minority veterans in the homeless veteran population. African American homeless veterans in particular face unique challenges accessing appropriate health care services to meet their medical needs. Their needs are often underrepresented in the literature on veteran homelessness. Drawing together over 80 studies and government reports from the last two decades, this review provides a timely synopsis of homeless veterans' health care access, with a particular focus on the barriers faced by African American veterans. This review employs Penchansky and Thomas' Access Model to frame health access barriers faced by homeless veterans, dialing in on what is known about the experience of African American veterans, within the five dimensions of access: Availability, Accessibility, Accommodation, Affordability, and Acceptability. Actionable guidance and targeted interventions to address health access barriers for all veterans are delineated with a focus on the need to gather further data for African American homeless veterans and to consider tailoring interventions for this important and underserved group.

Veteran help-seeking behaviour for mental health issues: a systematic review

INTRODUCTION

Serving military personnel and veterans have been identified to have a high prevalence of mental health disorders. Despite this, only a significantly small number seek mental healthcare. With the UK beginning to invest further support to the armed forces community, identification of barriers and facilitators of help-seeking behaviour is needed.

METHODS

Corresponding literature search was conducted in PsycINFO, PsycArticles, Medline, Web of Science and EBSCO. Articles which discussed barriers and facilitators of seeking help for mental health concerns in the veteran population were included. Those which discussed serving personnel or physical problems were not included within this review. A total of 26 papers were analysed.

RESULTS

A number of barriers and facilitators of help-seeking for a mental health issue within the veteran population were identified. Barriers included stigma, military culture of stoicism and self-reliance, as well as deployment characteristics of combat exposure and different warzone deployments. Health service difficulties such as access and lack of understanding by civilian staff were also identified. Facilitators to help combat these barriers included a campaign to dispel the stigma, including involvement of veterans and training of military personnel, as well as more accessibility and understanding from healthcare staff.

CONCLUSIONS

While some barriers and facilitators have been identified, much of this research has been conducted within the USA and on male veterans and lacks longitudinal evidence. Further research is needed within the context of other nations and female veterans and to further indicate the facilitators of help-seeking among veterans.

Strategies for Discussing Firearms Storage Safety in Primary Care: Veteran Perspectives

BACKGROUND

Two-thirds of veteran suicides are attributable to firearm injury. Although half of veterans who die by suicide are seen in primary care settings in the month prior to death, little is known about how to promote firearm safety within primary care.

OBJECTIVE

Describe veterans' perspectives on discussing firearms storage safety (FSS) during primary care visits, and identify key strategies for primary care teams to use in discussing FSS with veterans at elevated risk for suicide.

DESIGN

Qualitative analysis of transcripts and notes from four veteran focus groups and from individual semi-structured interviews with six veterans.

PARTICIPANTS

Altogether, 68 veterans participated. Three of the groups were associated with one Veterans Health Administration facility. Groups were diverse in age, service era, and gender.

APPROACH

The goals of the focus groups and interviews were to assess acceptance of FSS discussions during primary care visits, identify facilitators and barriers to conducting FSS discussions, and identify strategies for primary care teams to use to effectively conduct FSS discussions. Transcripts and meeting notes were analyzed using a grounded theory approach.

KEY RESULTS

There was general acceptance of having FSS discussions in primary care. Yet, most veterans did not support direct questioning about firearm ownership, which may trigger fears of having firearms taken away or limit access to firearms. Participants recommended primary care teams provide rationale for FSS discussions and be prepared to provide information on legal consequences of disclosing firearm ownership. Strategies suggested for primary care staff also included using a personalized, caring, and conversational approach rather than highly scripted or checklist approach, engaging veterans in a non-judgmental manner, and conveying respect for veterans' knowledge of firearms.

CONCLUSIONS

Discussing FSS with veterans in primary care settings is a promising upstream approach that can complement other suicide prevention efforts, but must be conducted in a veteran-centric manner.

Massage for Combat Injuries in Veteran with Undisclosed PTSD: a Retrospective Case Report

INTRODUCTION

Massage has shown promise in reducing symptoms related to dissociation and anxiety that can exacerbate chronic pain and suffering. The combat wounded, veteran population is increasing and requires a multidisciplinary approach for comprehensive treatment. This case study examines massage therapy use to improve veteran combat injury rehabilitation and recovery experience through purposive, retrospective, and comprehensive SOAP note review.

METHODS

A 31-year-old White male received seven, 60-min, full body massages for combat related shoulder injury complications incurred approximately six years before presentation. The right shoulder sustained a broken humeral head and complete dislocation during a defensive maneuver in a life-threatening attack. This case study utilized data from three different assessments: goniometric measurements for shoulder range of motion, observation and documentation for environmental comfort behaviors, and client self-report for treatment goal attainment. Six weekly, full body, 60-min massages were completed sequentially. A follow-up 60-min treatment was completed at Week 8. Treatment to the injured area included focused trigger point therapy, myofascial release, and proprioceptive neuromuscular facilitation to the neck, shoulder, and chest.

RESULTS

Total percent change for active flexion, extension, abduction, adduction, internal rotation, and external rotation were 12.5, 150, 40, 167, 14.3, and 0%, respectively. Total percent change for passive flexion, extension, abduction, adduction, internal rotation, and external rotation were 63.6, 350, 66.7, 450, 133, and 77.8%, respectively. Environmental comfort behaviors were reduced. Client treatment goals were attained.

CONCLUSIONS

Massage therapy provided meaningful benefit to a combat injury for a veteran with PTSD.

Pilot trial of a transdiagnostic computerized anxiety sensitivity intervention among VA primary care patients

People in need of mental health treatment do not access care at high rates or in a timely manner, inclusive of Veterans at Department of Veteran's Affairs (VA) medical centers. Barriers to care have been identified, and one potential solution is the use of technology-based interventions within primary care. This study evaluated the Cognitive Anxiety Sensitivity Treatment (CAST), a previously developed computerized treatment that has shown efficacy in community samples for mental health symptoms including: anxiety, depression, post-traumatic stress, and suicidal ideation. VA primary care patients with elevated anxiety sensitivity (N = 25) were recruited to participate in a mixed-method open pilot to examine acceptability, usability, and preliminary effectiveness in a VA primary care setting. Participants completed an initial visit, that included the intervention, and a one-month follow-up. Veterans found CAST to be generally acceptable, with strong usability ratings. Qualitative analyses identified areas of strength and areas for improvement for use with VA primary care Veterans. Repeated measures ANCOVAs revealed significant effects for symptoms of anxiety, depression, traumatic-stress, and suicidal ideation. CAST could potentially have a large public health impact if deployed across VA medical centers as a first-step intervention for a range of mental health presenting concerns.

Improving Access to Palliative Care at a VHA Hospital

OBJECTIVE

Explore veteran-specific factors impacting the acceptance of palliative care services at a Veterans Health Administration hospital.

METHODS

Prospective, focused one-on-one interviews were conducted with 18 inpatient veterans with an initial consult to receive palliative care services. Domains impacting reception of outpatient palliative care management were evaluated including knowledge deficit, emotional barriers, physical barriers, psychosocial barriers, and physical support. Themes and trends from interview responses were analyzed using a qualitative directed content analysis approach.

RESULTS

The following themes were discovered to influence veteran participation in outpatient palliative care: Knowledge Deficit, Environmental Factors, Positive Patient Satisfaction, Openness to Technology, and Resiliency. Characteristics of veterans interviewed included an average age of 71 with an average distance from the hospital of 59 miles.

CONCLUSION

The identification of factors impacting veteran access to palliative care will be used to guide interventions and improve receipt of services. Care of seriously ill veterans may be substantially improved by facilitating access to palliative care.

Reducing veterans' risk for suicidal behaviors: a qualitative study to inform development of the RECLAIM health promotion program

Background

In an effort to reduce the high rate of suicide among post-9/11 veterans, a collaborative team within the Department of Veterans Affairs (VA) has developed a holistic community-based health promotion program designed to facilitate social and self-connectedness. The purpose of this study was to elicit veteran and stakeholder feedback to prepare the program for piloting and implementation.

Methods

Focus groups and interviews were conducted with post-9/11 veterans and veteran stakeholders (e.g., VA clinicians) to elicit feedback regarding the health promotion program. Focus groups and interviews were audio-recorded and transcribed. Qualitative thematic analysis identified key themes emerging from the focus groups and interviews.

Results

Seven focus groups (3 Veteran groups, 4 stakeholder groups) and 3 interviews (2 Veterans, 1 stakeholder) were conducted with 41 participants (14 veterans, 27 stakeholders). Overall, participants had a positive perception of the program. Thematic analysis revealed shared perspectives that provided insight into 1) enhancing program recruitment and retention, 2) the perceived ability of a health promotion program to provide more holistic, veteran-centered care, and 3) using health promotion programs to help veterans establish structure in their daily lives.

Conclusions

Findings indicated an overall acceptance of the program, and participants’ perspectives on how to reduce barriers and enhance facilitators can inform the development of a larger-scale health promotion program that can be tested through future research. While discussion questions were specifically focused on the program in this study, findings can be considered more broadly for the design and implementation of related programs to effectively improve the health and wellness of post-9/11 veterans.

Did the Affordable Care Act Decrease Veteran Enrollment in the Veterans Health Administration?

BACKGROUND

Provisions of the Affordable Care Act (ACA) provided nonelderly individuals, including Veterans, with additional health care coverage options. This may impact enrollment for health care through the Veterans Health Administration (VHA). National enrollment data was used to: (1) compare characteristics of enrollees at 3 time points in relation to the implementation of ACA insurance provisions (2012); and (2) examine enrollment trends.

METHODS

The study population included a 10% sample of Veterans under age 65 who were VHA enrollees between January 2012 and September 2015. Demographic and baseline characteristics were compared between 3 enrollment groups: pre-2012, pre-ACA (2012-2013), and post-ACA (2014-2015). Using an interrupted time series approach, we employed pooled logistic regression to assess trends in new VHA enrollment, overall, and by select enrollee characteristics.

RESULTS

A total of 429,833 enrollees were identified. Compared with pre-ACA enrollees, post-ACA enrollees were more likely to be older, have a service-connected disability, live further away from a VHA medical center, but less likely to use primary care within 6 months. The post-ACA quarterly trend in the odds of being a new enrollee was 3% lower (95% confidence interval: 0.96, 0.98) as compared with the pre-ACA trend. This decline was consistent across sex, geography, (all but 1) priority group, and state Medicaid-expansion subgroups.

CONCLUSIONS

The ACA appears to have contributed to a decline in new VHA enrollment. In addition, the profile of newer enrollees differs from that of pre-ACA enrollees. The VHA must continue to monitor trends in demand in order to continue delivering high-quality, efficient care.

Psychedelic Treatment for Trauma-Related Psychological and Cognitive Impairment Among US Special Operations Forces Veterans

BACKGROUND

U.S. Special Operations Forces Veterans are at increased risk for a variety of mental health problems and cognitive impairment associated with military service. Current treatments are lacking in effectiveness and adherence. Therefore, this study examined psychedelic treatment with ibogaine and 5-methoxy-N,N-dimethyltryptamine for trauma-related psychological and cognitive impairment among U.S. Special Operations Forces Veterans.

METHOD

We conducted a survey of Veterans who completed a specific psychedelic clinical program in Mexico between 2017 and 2019. Questions probed retrospective reports of mental health and cognitive functioning during the 30 days before and 30 days after treatment. A total of 65 people completed treatment during this time frame and were eligible for contact. Of these, 51 (78%) completed the survey and were included in data analyses (mean age = 40; male = 96%; married = 55%; Caucasian/White = 92%; Operation Enduring Freedom/Operation Iraqi Freedom Service = 96%).

RESULTS

Results indicated significant and very large reductions in retrospective report of suicidal ideation (p < .001; d = -1.9), cognitive impairment (p < .001; d = -2.8), and symptoms of posttraumatic stress disorder (p < .001; d = -3.6), depression (p < .001; d = -3.7), and anxiety (p < .001; d = -3.1). Results also showed a significant and large increase in retrospective report of psychological flexibility (p < .001; d = 2.9) from before-to-after the psychedelic treatment. Increases in the retrospective report of psychological flexibility were strongly associated with retrospective report of reductions in cognitive impairment, and symptoms of posttraumatic stress disorder, depression, and anxiety (rs range -0.61 to -0.75; p < .001). Additionally, most participants rated the psychedelic experiences as one of the top five personally meaningful (84%), spiritually significant (88%), and psychologically insightful (86%) experiences of their lives.Limitations: Several limitations should be considered including the retrospective, self-report, survey design of the study, and the lack of randomization and blinding, thus making these finding preliminary.

CONCLUSION

U.S. Special Operations Forces Veterans may have unique treatment needs because of the sequela of problems associated with repeated trauma exposure and the nature of the exposure. Psychedelic-assisted therapy with these under-researched psychedelics may hold unique promise for this population. However, controlled studies are needed to determine whether this treatment is efficacious in relieving mental health and cognitive impairment among U.S. Special Operations Forces Veterans.

Help-seeking behavior among Danish veterans with self-reported mental problems - a 22 years register-based follow-up study

Purpose: To estimate the prevalence of utilization of mental health services (MHS) among Danish veterans with self-reported deployment-related mental problems and to identify predictors for help-seeking behavior for mental problems among veterans.Materials and methods: Data on deployment characteristics was obtained from a telephone survey in 2011 among a random sample of veterans deployed during 1996-2009. Only respondents reporting sustained or less sustained mental problems were included, and data from national registers on mental health service utilization and prescribed psychotropics covering up to 22 years of follow-up was obtained. Logistic regression analysis was performed to identify predictors of help-seeking.Results: Of 434 respondents with self-reported problems, 333 (77%) received any mental health service after deployment. Of those, 48 (23%) received any help within the first 2 years after deployment start while 128 (61%) did not receive help until after 4 years. Significant predictors for MHS utilization included sustained mental problems, combat exposure characteristics (being injured in combat, watching a fellow soldier suffer injuries), and deployment-related factors (being deployed to >1 mission and being deployed to Afghanistan).Conclusion: These findings highlight the importance of time, and hereunder of a long follow-up period, when measuring the prevalence of help-seeking behavior for individuals experiencing mental problems after military deployment.