Living With Toxic Wounds: The Voices and Visual Self-Representations of Gulf War Veterans

Operations Desert Shield and Storm occurred over 30 years ago, yet many of those who were deployed continue to experience chronic and debilitating symptoms, now recognized as Gulf War Illness (GWI). While efforts have been made to explore clinical treatments for GWI, misperceptions and skepticism about its complex nature and a lack of consensus on its etiology impede progress in this area. A critical necessity remains to better understand the experiences, needs, and concerns of veterans with GWI. In this qualitative research study, 40 Gulf War veterans were interviewed about their perceptions regarding symptoms of physical health, cognitive functioning, quality of life, and the quality of care received. In addition, they depicted their experiences through an artistic elicitation collage. Through a grounded theory method, key findings indicated that there are remaining hurdles, such as challenging symptoms, persisting unknowns about the illness, and variations in treatment quality. Veterans have mostly managed and coped with GWI, but they voice the need for acknowledgment and support. The main implication from this study is the significance of both clinical and institutional validation and recognition of the GWI experience as well as the need for specific support systems.

A pilot of a veteran suicide prevention learning collaborative among community organizations: Initial results and outcomes

INTRODUCTION

Veteran suicide remains an ongoing public health concern in need of fresh, community-based initiatives. The Department of Veterans Affairs (VA) has built an enterprise-wide integrated behavioral health system that has pioneered numerous suicide prevention methods. However, most Veterans receive healthcare outside the VA, from organizations that may not be equipped to address Veteran suicide risk. One solution is implementing a VA/community suicide prevention learning collaborative to support organizations in implementing suicide prevention best practices for Veterans. Although learning collaboratives have a history of supporting improved patient safety in healthcare systems, to our knowledge, none have focused on Veteran suicide prevention.

METHOD

The current quality improvement project sought to pilot a VA/community suicide prevention learning collaborative in the broader Denver and Colorado Springs areas with 13 organizations that served, interacted with, or employed Veterans.

RESULTS

The collaborative had a large footprint in the region, with organizations interacting with over 24,000 community members and over 5000 Veterans. Organizations implemented 92 Veteran suicide prevention program components within a 16-month period. Overall, the learning collaborative made significant strides in Veteran suicide prevention.

CONCLUSION

Findings suggest that this method facilitates rapid implementation of Veteran suicide prevention practices and may be promising for accelerating uptake within communities.

Associations between nonfatal firearm injuries and risk of subsequent suicide among Veteran VA users: A retrospective cohort study

BACKGROUND

Suicide is a leading cause of death in the United States, particularly among Veterans. Nonfatal firearm injuries may indicate subsequent risk of suicide and, thus, provide important opportunities for prevention in emergency departments and other health care settings. We used a retrospective cohort design to analyze associations between nonfatal firearm injuries and subsequent suicide among all Veterans who used U.S. Department of Veterans Affairs (VA) health care, nationally, between 2010 and 2019.

METHODS

We linked VA health care and mortality data to identify VA users, nonfatal firearm injuries, and deaths. International Classification of Diseases (ICD)-10th Revision cause-of-death codes were used to identify suicides. Veterans' firearm injuries and their intent were categorized using cause-of-injury codes from the ICD Clinical Modification-9th and 10th Revisions systems. Using bivariable and multivariable regression, we estimated risk of subsequent suicide among Veterans with, versus without, nonfatal firearm injuries. Among Veterans with nonfatal firearm injuries, we examined characteristics associated with subsequent suicide; electronic health record (chart) reviews explored documentation about firearm access among those who died.

RESULTS

Among 9,817,020 VA-using Veterans, 11,503 experienced nonfatal firearm injuries (64.9% unintentional, 12.3% intentional self-harm, 18.5% assault). Of these, 69 (0.6%) subsequently died by suicide (42 involving firearms). The odds of subsequent suicide among Veterans with, versus without, nonfatal firearm injuries were 2.4 (95% confidence interval 1.9-3.0); odds were only slightly attenuated in multivariable modeling. Among Veterans with nonfatal firearm injuries, those with depression or substance use disorder diagnoses had twice the odds of subsequent suicide than those without. Chart reviews identified small proportions of suicide decedents who were assessed for (21.7%), and/or counseled about (15.9%), firearm access.

CONCLUSIONS

Findings suggest that Veterans' nonfatal firearm injuries, regardless of injury intent, may be important but underutilized opportunities for suicide prevention. Future work should explore mechanisms to reduce risk among these patients.

A common language for Gulf War Illness (GWI) research studies: GWI common data elements

AIMS

The Gulf War Illness programs (GWI) of the United States Department of Veteran Affairs and the Department of Defense Congressionally Directed Medical Research Program collaborated with experts to develop Common Data Elements (CDEs) to standardize and systematically collect, analyze, and share data across the (GWI) research community.

MAIN METHODS

A collective working group of GWI advocates, Veterans, clinicians, and researchers convened to provide consensus on instruments, case report forms, and guidelines for GWI research. A similar initiative, supported by the National Institute of Neurologic Disorders and Stroke (NINDS) was completed for a comparative illness, Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS), and provided the foundation for this undertaking. The GWI working group divided into two sub-groups (symptoms and systems assessment). Both groups reviewed the applicability of instruments and forms recommended by the NINDS ME/CFS CDE to GWI research within specific domains and selected assessments of deployment exposures. The GWI CDE recommendations were finalized in March 2018 after soliciting public comments.

KEY FINDINGS

GWI CDE recommendations are organized in 12 domains that include instruments, case report forms, and guidelines. Recommendations were categorized as core (essential), supplemental-highly recommended (essential for specified conditions, study types, or designs), supplemental (commonly collected, but not required), and exploratory (reasonable to use, but require further validation). Recommendations will continually be updated as GWI research progresses.

SIGNIFICANCE

The GWI CDEs reflect the consensus recommendations of GWI research community stakeholders and will allow studies to standardize data collection, enhance data quality, and facilitate data sharing.

Collage-based graphic elicitation method for capturing the lived experiences of veterans with Gulf War illness

AIMS

Graphic elicitation is an emergent data gathering approach in qualitative research. An overview of the development and application of a collage based graphic elicitation method in gaining greater understanding about the experience of Gulf War Illness (GWI) is presented in this paper. The unique contributions of this method are also discussed.

MAIN METHODS

Fourteen veterans with GWI were interviewed and then invited to represent their experiences in a visual format through a collage graphic elicitation task. Interviews and collage artworks were coded and compared to both verbal and art responses during the graphic elicitation process.

KEY FINDINGS

Comparison of the content in the interview responses and collage artwork indicates that the graphic elicitation process resulted in three distinct responses: (1) Synthesis and confirmation of content articulated in the interviews, (2) focus on salient aspects of living with GWI, and (3) revealing previously unarticulated experiences.

SIGNIFICANCE

This work demonstrates the unique contributions of collage graphic elicitation, including allowing for spontaneity, metaphorical thinking, enriching verbal explication, and uncovering lived experiences and new affective responses. The sample size was too small to make any generalizations, and more research is needed to further validate these initial findings.

The Veterans Affairs Patient Safety Center of Inquiry-Suicide Prevention Collaborative: Creating Novel Approaches to Suicide Prevention Among Veterans Receiving Community Services

Background

While the US Department of Veterans Affairs has made significant strides to prevent veteran suicide, efforts have largely targeted veterans actively engaged in and eligible for Veterans Health Administration (VHA) care, which is consistent with the VHA mission. The majority of veterans are not enrolled in VHA care, and many are ineligible for services. Veterans not connected to VHA have experienced an increase in suicides in recent years.

Observations

Since 2018, VHA National Center for Patient Safety has funded the Patient Safety Center of Inquiry-Suicide Prevention Collaborative (PSCI-SPC), which has worked to develop, implement, and evaluate practical solutions aimed at curbing the rising suicide rate among veterans not receiving VHA care. PSCI-SPC has 3 guiding objectives: (1) Develop and test a collaborative, organizational structure to connect VHA and community organizations, such as national, local, public, private, nonprofit, and academic partners who provide high-quality and timely health care; (2) Build and test a learning collaborative to facilitate sharing of VHA suicide prevention best practices with community partners to increase availability, consistency, and quality of mental health services for all veterans; and (3) Implement, test, and refine a novel program to provide affordable suicide prevention interventions to veterans with mental health needs, regardless of their use of, or eligibility for, VHA services. This paper details the current progress for this demonstration project. As these objectives are met, PSCI-SPC will create and disseminate products to support broad implementation of these practices to other VA medical centers and the communities they are embedded in.

Conclusions

PSCI-SPC seeks to fill an important gap in veteran health care by serving as a national clinical innovation and dissemination center for best practices in suicide prevention for veterans who receive care in their communities.

Rationale and design of an efficacy study of Group Prolonged Exposure for PTSD

INTRODUCTION

Among health problems in the Veteran population, the most common is posttraumatic stress disorder (PTSD) and its effect on the quality of life. Prolonged Exposure therapy, based on emotional processing theory, is a first-line treatment for reducing PTSD symptom severity when delivered in an individual format, and its efficacy is well established. The primary objective of this study is to establish the efficacy of prolonged exposure delivered in a small 3-person group modality. Quality of life should improve with decreases in PTSD symptoms such as sleep disturbance, irritability, and hypervigilance. Stigma is associated with hesitation in seeking treatment and treatment dropout. A secondary objective is to measure the effect of group treatment on reducing the stigma surrounding PTSD.

METHODS/DESIGN

This study is a randomized controlled trial testing the efficacy of Group Prolonged Exposure (PE) for reducing PTSD symptom severity and improving quality of life in male Afghanistan and Iraq Veterans. All participants are randomly assigned to receive Group PE or Group Present-Centered Therapy (PCT) for 10-weekly, 90-min sessions. Group PE focuses on processing trauma memories, while the goal of Group PCT is improved psychosocial functioning through management of current stressors. The primary outcome is improvement in CAPS-5 PTSD symptom severity scores and quality of life measures (WHO-QOL and SF-36) from pre-treatment to post-treatment, 3-months post-treatment, and 6-months post-treatment. A secondary outcome is reductions in perceived self-stigma of mental illness based on the Stigma Scale at baseline and follow-up points. This study is designed to expand access to this first-line treatment for PTSD by delivering PE in a small group modality while conforming to the individual PE protocol, with group treatment reducing perceived stigma of mental illness.

Treatment selection among posttraumatic stress disorder (PTSD) specialty care providers in the Veterans Health Administration: A thematic analysis

OBJECTIVE

Although efforts to implement evidence-based psychotherapies (EBPs) require understanding how providers view and initiate these interventions, little is known regarding provider treatment selection in posttraumatic stress disorder (PTSD) care. The current study examines how specialty PTSD clinic providers within the Veterans Health Administration (VHA) describe reasons for selecting specific psychotherapies in PTSD treatment planning.

METHOD

VHA psychotherapists in specialty PTSD care clinics completed a national online survey of treatment attitudes and practices, including an open-ended item inquiring about treatment selection. Thematic analysis was used to develop a framework describing factors in VHA providers' PTSD treatment selection.

RESULTS

Of 250 survey participants, 219 provided description of their treatment selection process. Providers identified four domains of factors impacting treatment planning: (1) provider factors (e.g., training), (2) perceived characteristics of the intervention (e.g., structural features), (3) patient factors (e.g., characteristics of the patient and symptom presentation), and (4) organizational context (e.g., VHA policy). Assessment of appropriate treatments for an individual patient was described as resulting from interaction across these domains, particularly perceived fit between patient needs and specific treatments.

CONCLUSIONS

Provider decision making has been understudied in implementation science. Although prior research has emphasized the role of organizational context in EBP reach, our findings suggest that other factors are salient when decisions are made at the level of the individual patient. Results suggest that increased attention to treatment selection and focused training in use of decision aids and shared decision making may have utility in increasing uptake, reach, and sustainment of EBPs among VHA PTSD specialty providers. (PsycINFO Database Record (c) 2020 APA, all rights reserved).