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Nowicki KD, Balboni IM, Cidon MJ, Dhanrajani AD, Driest KD, Fair DC, Imundo LF, Mehta JJ, Tarvin SE, Walters HM, Woolnough LC, Edgar LC, Curran ML. Assessing Pediatric Rheumatology Fellow Competence in the Milestone Era: Past, Present, and Future. Arthritis Care Res (Hoboken) 2024; 76:600-607. [PMID: 38108087 DOI: 10.1002/acr.25276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 11/15/2023] [Accepted: 11/30/2023] [Indexed: 12/19/2023]
Abstract
Starting in 2015, pediatric rheumatology fellowship training programs were required by the Accreditation Council for Graduate Medical Education to assess fellows' academic performance within 21 subcompetencies falling under six competency domains. Each subcompetency had four or five milestone levels describing developmental progression of knowledge and skill acquisition. Milestones were standardized across all pediatric subspecialties. As part of the Milestones 2.0 revision project, the Accreditation Council for Graduate Medical Education convened a workgroup in 2022 to write pediatric rheumatology-specific milestones. Using adult rheumatology's Milestones 2.0 as a starting point, the workgroup revised the patient care and medical knowledge subcompetencies and milestones to reflect requirements and nuances of pediatric rheumatology care. Milestones within four remaining competency domains (professionalism, interpersonal and communication skills, practice-based learning and improvement, and systems-based practice) were standardized across all pediatric subspecialties, and therefore not revised. The workgroup created a supplemental guide with explanations of the intent of each subcompetency, 25 in total, and examples for each milestone level. The new milestones are an important step forward for competency-based medical education in pediatric rheumatology. However, challenges remain. Milestone level assignment is meant to be informed by results of multiple assessment methods. The lack of pediatric rheumatology-specific assessment tools typically result in clinical competency committees determining trainee milestone levels without such collated results as the foundation of their assessments. Although further advances in pediatric rheumatology fellowship competency-based medical education are needed, Milestones 2.0 importantly establishes the first pediatric-specific rheumatology Milestones to assess fellow performance during training and help measure readiness for independent practice.
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Affiliation(s)
- Katherine D Nowicki
- University of Colorado, Denver, and Children's Hospital Colorado, Aurora, Colorado
| | | | - Michal J Cidon
- Children's Hospital Los Angeles, Los Angeles, California
| | - Anita D Dhanrajani
- The University of Mississippi Medical Center, Jackson, Mississippi, Tulane University School of Medicine, New Orleans, and Children's Hospital of New Orleans, New Orleans, Louisiana
| | - Kyla D Driest
- Nationwide Children's Hospital and The Ohio State University, Columbus
| | | | - Lisa F Imundo
- Columbia University Medical Center, New York City, New York
| | - Jay J Mehta
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Stacey E Tarvin
- Riley Hospital for Children at Indiana University, Indianapolis
| | - Heather M Walters
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hamptstead, New York, and Cohen Children's Medical Center of New York, New Hyde Park
| | | | - Laura C Edgar
- Accreditation Council for Graduate Medical Education, Chicago, Illinois
| | - Megan L Curran
- University of Colorado, Denver, and Children's Hospital Colorado, Aurora, Colorado
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Manojlovich M, Bettencourt AP, Mangus CW, Parker SJ, Skurla SE, Walters HM, Mahajan P. Refining a Framework to Enhance Communication in the Emergency Department During the Diagnostic Process: An eDelphi Approach. Jt Comm J Qual Patient Saf 2024; 50:348-356. [PMID: 38423950 DOI: 10.1016/j.jcjq.2024.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 01/23/2024] [Accepted: 01/24/2024] [Indexed: 03/02/2024]
Abstract
BACKGROUND Emergency departments (EDs) are susceptible to diagnostic error. Suboptimal communication between the patient and the interdisciplinary care team increases risk to diagnostic safety. The role of communication remains underrepresented in existing diagnostic decision-making conceptual models. METHODS The authors used eDelphi methodology, whereby data are collected electronically, to achieve consensus among an expert panel of 18 clinicians, patients, family members, and other participants on a refined ED-based diagnostic decision-making framework that integrates several potential opportunities for communication to enhance diagnostic quality. This study examined the entire diagnostic process in the ED, from prehospital to discharge or transfer to inpatient care, and identified where communication breakdowns could occur. After four iterative rounds of the eDelphi process, including a final validation round by all participants, the project's a priori consensus threshold of 80% agreement was reached. RESULTS The authors developed a final framework that positions communication more prominently in the diagnostic process in the ED and enhances the original National Academies of Sciences, Engineering, and Medicine (NASEM) and ED-adapted NASEM frameworks. Specific points in the ED journey were identified where more attention to communication might be helpful. Two specific types of communication-information exchange and shared understanding-were identified as high priority for optimal outcomes. Ideas for communication-focused interventions to prevent diagnostic error in the ED fell into three categories: patient-facing, clinician-facing, and system-facing interventions. CONCLUSION This project's refinement of the NASEM framework adapted to the ED can be used to develop communications-focused interventions to reduce diagnostic error in this highly complex and error-prone setting.
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Sripada RK, Walters HM. "I wish people could come together like we have," patient and provider perspectives on VA residential PTSD treatment. Psychol Serv 2023; 20:809-819. [PMID: 36136833 PMCID: PMC10249047 DOI: 10.1037/ser0000713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Although most posttraumatic stress disorder (PTSD) care in the Veterans health administration (VHA) is provided on an outpatient basis, the VHA has 40 residential rehabilitation treatment programs (RRTPs) designed to treat Veterans who require more intensive and closely monitored care. Unfortunately, the clinical outcomes of these programs are modest, and previous attempts to identify key drivers of outcomes have uncovered few modifiable factors. The present study, informed by the model of resources, life events and changes in psychological state, was designed to identify factors associated with treatment response among RRTP patients and providers. Semistructured interviews were conducted with 24 patients and 12 providers at three regional RRTPs, using interview guides based on the theoretical model. Data were analyzed using rapid analysis. Results showed that patients and providers agreed on several factors critical to RRTP success. These factors included the provision of evidence-based psychotherapy (EBP), support and understanding from fellow patients, and skill and support from providers. Patients and providers also noted the importance of psychological flexibility, openness, and willingness to change. Patients who experienced less symptom improvement over the course of treatment were more likely to report poor therapeutic alliance. These findings underscore the importance of continued emphasis on EBP delivery but also suggest that RRTPs might find additional ways to capitalize on the residential milieu to encourage engagement in treatment and a focus on therapeutic change. (PsycInfo Database Record (c) 2023 APA, all rights reserved).
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Affiliation(s)
- Rebecca K. Sripada
- VA Center for Clinical Management Research, Ann Arbor, MI
- VA Ann Arbor Healthcare System, Ann Arbor, MI
- Department of Psychiatry, University of Michigan, Ann Arbor, MI
| | - Heather M. Walters
- VA Center for Clinical Management Research, Ann Arbor, MI
- VA Ann Arbor Healthcare System, Ann Arbor, MI
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Sripada RK, Peterson CL, Dziak JJ, Nahum-Shani I, Roberge EM, Martinson AA, Porter K, Grau P, Curtis D, McElroy S, Bryant S, Gracy I, Pryor C, Walters HM, Austin K, Ehlinger C, Sayer N, Wiltsey-Stirman S, Chard K. Using the multiphase optimization strategy to adapt cognitive processing therapy (CPT MOST): study protocol for a randomized controlled factorial experiment. Trials 2023; 24:676. [PMID: 37858262 PMCID: PMC10588087 DOI: 10.1186/s13063-023-07669-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 09/25/2023] [Indexed: 10/21/2023] Open
Abstract
BACKGROUND Approximately ten percent of US military veterans suffer from posttraumatic stress disorder (PTSD). Cognitive processing therapy (CPT) is a highly effective, evidence-based, first-line treatment for PTSD that has been widely adopted by the Department of Veterans Affairs (VA). CPT consists of discrete therapeutic components delivered across 12 sessions, but most veterans (up to 70%) never reach completion, and those who discontinue therapy receive only four sessions on average. Unfortunately, veterans who drop out prematurely may never receive the most effective components of CPT. Thus, there is an urgent need to use empirical approaches to identify the most effective components of CPT so CPT can be adapted into a briefer format. METHODS The multiphase optimization strategy (MOST) is an innovative, engineering-inspired framework that uses an optimization trial to assess the performance of individual intervention components within a multicomponent intervention such as CPT. Here we use a fractional factorial optimization trial to identify and retain the most effective intervention components to form a refined, abbreviated CPT intervention package. Specifically, we used a 16-condition fractional factorial experiment with 270 veterans (N = 270) at three VA Medical Centers to test the effectiveness of each of the five CPT components and each two-way interaction between components. This factorial design will identify which CPT components contribute meaningfully to a reduction in PTSD symptoms, as measured by PTSD symptom reduction on the Clinician-Administered PTSD Scale for DSM-5, across 6 months of follow-up. It will also identify mediators and moderators of component effectiveness. DISCUSSION There is an urgent need to adapt CPT into a briefer format using empirical approaches to identify its most effective components. A brief format of CPT may reduce attrition and improve efficiency, enabling providers to treat more patients with PTSD. The refined intervention package will be evaluated in a future large-scale, fully-powered effectiveness trial. Pending demonstration of effectiveness, the refined intervention can be disseminated through the VA CPT training program. TRIAL REGISTRATION ClinicalTrials.gov NCT05220137. Registration date: January 21, 2022.
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Affiliation(s)
- Rebecca K Sripada
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Department of Psychiatry, University of Michigan, Ann Arbor, USA.
| | - Cassaundra L Peterson
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, USA
| | - John J Dziak
- Institute for Health Research and Policy, University of Illinois Chicago, Chicago, USA
| | - Inbal Nahum-Shani
- University of Michigan Institute for Social Research, Ann Arbor, USA
| | - Erika M Roberge
- VA Salt Lake City Health Care System, University of Utah School of Medicine, Salt Lake City, USA
| | | | | | - Peter Grau
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Department of Psychiatry, University of Michigan, Ann Arbor, USA
| | - Diana Curtis
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, USA
| | | | - Sarah Bryant
- VA Salt Lake City Health Care System, Salt Lake City, USA
| | - Isabel Gracy
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, USA
| | - Cosette Pryor
- VA Salt Lake City Health Care System, Salt Lake City, USA
| | - Heather M Walters
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, USA
| | - Karen Austin
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, USA
| | | | - Nina Sayer
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, USA
| | | | - Kathleen Chard
- Cincinnati VA Medical Center, University of Cincinnati, Cincinnati, USA
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Myers MG, Ganoczy D, Walters HM, Pfeiffer PN, Ilgen MA, Bohnert KM. Assessing the diagnostic utility of the Cannabis Use Disorder Identification Test - Revised (CUDIT-R) among veterans with medical and non-medical cannabis use. Drug Alcohol Depend 2023; 247:109876. [PMID: 37130467 DOI: 10.1016/j.drugalcdep.2023.109876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 04/05/2023] [Accepted: 04/10/2023] [Indexed: 05/04/2023]
Abstract
BACKGROUND Few studies examine the utility of the Cannabis Use Disorder Identification Test - Revised (CUDIT-R) in relation to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (DSM-5) criteria for cannabis use disorder (CUD). This study assesses the performance of the CUDIT-R among a sample of Veterans with and without medical cannabis use. METHODS We approached and consented primary care patients presenting to one of three Department of Veterans Affairs (VA) Medical Centers. Veterans with at least monthly cannabis use and complete CUD data at baseline were included in this analysis (n=234). CUDIT-R scores were compared against Alcohol Use Disorder and Associated Disabilities Interview Schedule-5 (DSM-5) CUD as the standard to calculate measures of validity (sensitivity, specificity), identify optimal CUDIT-R cutoff values, and assess the diagnostic proficiency of the CUDIT-R using receiver operating characteristic (ROC) curves. We further stratified analyses by active medical cannabis card holder status and DSM-5 CUD severity (any, moderate, and severe). RESULTS Among the entire sample, 38.9% qualified for any DSM-5 CUD, with 10.7% and 3.0% meeting criteria for moderate and severe CUD, respectively. We identified optimal CUDIT-R scores at 10 for any DSM-5 CUD (sensitivity=0.58; specificity=0.80), at 12 for moderate CUD (sensitivity=0.72; specificity=0.82), and at 14 for severe CUD (sensitivity=0.71; specificity=0.87). ROC curves showed higher CUDIT-R validity among non-card holders compared with medical cannabis card holders. CONCLUSION The present study identified optimal CUDIT-R cutoff scores for Veterans who use cannabis. Varying DSM-5 validity measures inform the need for population-specific CUDIT-R cutoff values.
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Affiliation(s)
- Matthew G Myers
- Department of Epidemiology and Biostatistics, College of Human Medicine, Michigan State University, East Lansing, MI 48824, United States
| | - Dara Ganoczy
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI 48105, United States
| | - Heather M Walters
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI 48105, United States
| | - Paul N Pfeiffer
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI 48105, United States; Department of Psychiatry, Michigan Medicine, University of Michigan, Ann Arbor, MI 48109, United States
| | - Mark A Ilgen
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI 48105, United States; Department of Psychiatry, Michigan Medicine, University of Michigan, Ann Arbor, MI 48109, United States
| | - Kipling M Bohnert
- Department of Epidemiology and Biostatistics, College of Human Medicine, Michigan State University, East Lansing, MI 48824, United States; VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI 48105, United States.
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Sripada RK, Smith K, Walters HM, Ganoczy D, Kim HM, Grau PP, Nahum-Shani I, Possemato K, Kuhn E, Zivin K, Pfeiffer PN, Bohnert KM, Cigrang JA, Avallone KM, Rauch SAM. Testing adaptive interventions to improve PTSD treatment outcomes in Federally Qualified Health Centers: Protocol for a randomized clinical trial. Contemp Clin Trials 2023; 129:107182. [PMID: 37044157 PMCID: PMC10349653 DOI: 10.1016/j.cct.2023.107182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 04/02/2023] [Accepted: 04/08/2023] [Indexed: 04/14/2023]
Abstract
BACKGROUND Posttraumatic stress disorder (PTSD) disproportionately affects low-income individuals and is untreated in 70% of those affected. One third of low-income Americans are treated in Federally Qualified Health Centers (FQHCs), which do not have the capacity to provide all patients with first-line treatments such as Prolonged Exposure (PE). To address this problem, FQHCs could use low-intensity interventions (e.g., Clinician-Supported PTSD Coach: CS PTSD Coach) and medium-intensity interventions (e.g., PE for Primary Care: PE-PC) to treat PTSD with fewer resources. However, some patients will still require high-intensity treatments (e.g., full-length PE) for sustained clinical benefit. Thus, there is a critical need to develop stepped-care models for PTSD in FQHCs. METHOD We are conducting a Sequential, Multiple Assignment, Randomized Trial (SMART) with 430 adults with PTSD in FQHCs. Participants are initially randomized to CS PTSD Coach or PE-PC. After four sessions, early responders step down to lower frequency interaction within their assigned initial treatment strategy. Slow responders are re-randomized to either continue their initial treatment strategy or step up to Full PE for an additional eight weeks. The specific aims are to test the effectiveness of initiating treatment with PE-PC versus CS PTSD Coach in reducing PTSD symptoms and to test the effectiveness of second-stage strategies (continue versus step-up to Full PE) for slow responders. CONCLUSIONS This project will provide critical evidence to inform the development of an effective stepped-care model for PTSD. Testing scalable, sustainable sequences of PTSD treatments delivered in low-resource community health centers will improve clinical practice for PTSD.
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Affiliation(s)
- Rebecca K Sripada
- Department of Psychiatry, Michigan Medicine, Ann Arbor, MI, United States of America; Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, United States of America.
| | - Kayla Smith
- Department of Psychiatry, Michigan Medicine, Ann Arbor, MI, United States of America
| | - Heather M Walters
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, United States of America
| | - Dara Ganoczy
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, United States of America
| | - H Myra Kim
- Department of Psychiatry, Michigan Medicine, Ann Arbor, MI, United States of America; Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, United States of America; Consulting for Statistics, Computing and Analytics Research, University of Michigan, Ann Arbor, MI, United States of America
| | - Peter P Grau
- Department of Psychiatry, Michigan Medicine, Ann Arbor, MI, United States of America; Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, United States of America
| | - Inbal Nahum-Shani
- Data-Science for Dynamic Decision-making Center, Institute for Social Research, University of Michigan, Ann Arbor, MI, United States of America
| | - Kyle Possemato
- VA Center for Integrated Healthcare, Syracuse, NY, United States of America
| | - Eric Kuhn
- National Center for PTSD, Dissemination and Training Division, VA Palo Alto Health Care System, Palo Alto, CA, United States of America; Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, United States of America
| | - Kara Zivin
- Department of Psychiatry, Michigan Medicine, Ann Arbor, MI, United States of America; Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, United States of America
| | - Paul N Pfeiffer
- Department of Psychiatry, Michigan Medicine, Ann Arbor, MI, United States of America; Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, United States of America
| | - Kipling M Bohnert
- Department of Epidemiology and Biostatistics, College of Human Medicine, Michigan State University, East Lansing, MI, United States of America
| | - Jeffrey A Cigrang
- School of Professional Psychology, College of Health Education and Human Services, Wright State University, Fairborn, OH, United States of America
| | - Kimberly M Avallone
- Department of Psychiatry, Michigan Medicine, Ann Arbor, MI, United States of America
| | - Sheila A M Rauch
- VA Atlanta Healthcare System, Decatur, GA, United States of America; Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, United States of America
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Sahn B, Lu Y, Hui-Yuen JS, Fishbein J, Gottlieb BS, Eberhard BA, Walters HM. The safety of COVID-19 vaccination in immunocompromised children and young adults with immune-mediated inflammatory disease. Acta Paediatr 2023; 112:794-801. [PMID: 36583590 PMCID: PMC9880735 DOI: 10.1111/apa.16652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 12/17/2022] [Accepted: 12/29/2022] [Indexed: 12/31/2022]
Abstract
AIM To assess safety of COVID-19 vaccination in paediatric patients with immune-mediated inflammatory disease (IMID). METHODS Subjects of 5-21 years of age with IMID who received at least one COVID-19 vaccine completed electronic surveys after each vaccine to assess side effects within 1 week of vaccination, current medications and COVID-19 testing after vaccination. Charts were reviewed for COVID-19 polymerase chain reaction and IgG response to SARS-CoV-2 spike protein results and for disease flare during the study period. RESULTS Among 190 enrolled subjects, 71% were female, with median age 17 (range 6-21) years. The most common diagnosis was juvenile idiopathic arthritis/rheumatoid arthritis (55%). 78% of subjects were taking immunosuppressive medication. At least one side effect was reported in 65% of subjects after any dose of the vaccine; with side effects in 38%, 53% and 55% of subjects after the first, second and third vaccine doses, respectively. The most common side effects were injection site pain (59%), fatigue (54%) and headache (39%). No anaphylaxis or myocarditis was reported. Three subjects (2%) experienced disease flare. CONCLUSION In our cohort of paediatric patients with IMID, observed side effects were found to be mild and disease flare rates were found to be low following COVID-19 vaccination.
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Affiliation(s)
- Benjamin Sahn
- Department of Pediatrics, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, New York, USA.,Division of Pediatric Gastroenterology, Liver Disease, and Nutrition, Cohen Children's Medical Center of NY, New Hyde Park, New York, USA
| | - Ying Lu
- Department of Pediatrics, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, New York, USA.,Division of Pediatric Gastroenterology, Liver Disease, and Nutrition, Cohen Children's Medical Center of NY, New Hyde Park, New York, USA
| | - Joyce S Hui-Yuen
- Department of Pediatrics, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, New York, USA.,Division of Pediatric Rheumatology, Cohen Children's Medical Center of NY, New Hyde Park, New York, USA
| | - Joanna Fishbein
- Biostatistics Unit, Office of Academic Affairs, Northwell Health, New Hyde Park, New York, USA
| | - Beth S Gottlieb
- Department of Pediatrics, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, New York, USA.,Division of Pediatric Rheumatology, Cohen Children's Medical Center of NY, New Hyde Park, New York, USA
| | - Barbara A Eberhard
- Department of Pediatrics, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, New York, USA.,Division of Pediatric Rheumatology, Cohen Children's Medical Center of NY, New Hyde Park, New York, USA
| | - Heather M Walters
- Department of Pediatrics, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, New York, USA.,Division of Pediatric Rheumatology, Cohen Children's Medical Center of NY, New Hyde Park, New York, USA
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Sripada RK, Rodriguez JL, Wright TP, Hyland JA, Walters HM, Ganoczy D, Haft SM, Smith ER, Porter KE, Driesenga SA, DeJong TM, Rauch SAM. Feasibility and Acceptability of Group-Facilitated Prolonged Exposure Therapy for PTSD in VA Residential Rehabilitation Treatment Programs. Behav Ther 2022; 53:714-724. [PMID: 35697433 DOI: 10.1016/j.beth.2022.02.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 02/11/2022] [Accepted: 02/15/2022] [Indexed: 11/02/2022]
Abstract
Prolonged Exposure therapy (PE) is a first-line treatment for posttraumatic stress disorder (PTSD); however, few VA patients receive this treatment. One of the barriers to PE receipt is that it is only available in an individual (one-on-one) format, whereas many VA mental health clinics provide the majority of their psychotherapy services in group format. In particular, PTSD residential rehabilitation treatment programs (RRTPs) offer most programming in group format. Consequently, strategies are needed to improve the scalability of PE by adapting it to fit the delivery setting. The current study was designed to pilot test a group-facilitated format of PE in RRTPs. Thirty-nine Veterans who were engaged in care in the PTSD RRTP at a Midwestern VA were recruited to participate in a Group-facilitated PE protocol. Participants engaged in twelve 90-minute sessions of Group PE over the course of 6 weeks, plus six 60-minute individual sessions for imaginal exposure. Group treatment followed the PE model and consisted of psychoeducation, treatment rationale, and in vivo exposure to reduce trauma-related avoidance and thereby improve PTSD symptoms. PTSD symptoms were measured via the PTSD Checklist for DSM-5 (PCL-5) and depression symptoms were measured via the Patient Health Questionnaire (PHQ-9) at baseline, endpoint (6 weeks), and at 2-month follow-up. Thirty-nine individuals initiated Group-facilitated PE and 34 completed treatment. The average number of group sessions attended was 11 out of 12. Acceptability ratings were high. Mean change (improvement) in the intent-to-treat sample at 2-month follow-up was 20.0 points on the PCL-5 (CI 18.1, 21.9; Cohen's d = 1.1) and 4.8 points on the PHQ-9 (CI 4.1, 5.5, d = .8). These results suggest that adapted evidence-based interventions for PTSD can improve treatment access and efficiency for the RRTP setting. A group-based approach has the potential to improve the scalability of PTSD treatment by reducing required resources. A fully powered trial is now needed to test the effectiveness of Group-facilitated PE in the RRTP setting.
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Affiliation(s)
- Rebecca K Sripada
- Veterans Affairs Center for Clinical Management Research, Ann Arbor; Veterans Affairs Ann Arbor Health Care System; University of Michigan.
| | | | | | | | | | - Dara Ganoczy
- Veterans Affairs Center for Clinical Management Research, Ann Arbor
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Sripada RK, Walters HM, Ganoczy D, Avallone KM, Cigrang JA, Rauch SAM. Feasibility and Acceptability of Prolonged Exposure in Primary Care (PE-PC) for Posttraumatic Stress Disorder in Federally Qualified Health Centers: A Pilot Study. Adm Policy Ment Health 2022; 49:722-734. [PMID: 35445362 PMCID: PMC9020756 DOI: 10.1007/s10488-022-01195-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/23/2022] [Indexed: 12/05/2022]
Abstract
Posttraumatic stress disorder (PTSD) is a debilitating psychiatric disorder that affects 6% of U.S. adults, yet is treated in only 30% of affected individuals and even fewer low-income individuals. One third of the nation’s low-income individuals are treated in Federally Qualified Health Centers (FQHCs). Most of these facilities lack capacity to provide their patients with first-line, evidence-based treatments for PTSD such as Prolonged Exposure (PE). To address this problem, PE has been adapted for use in a primary care setting and demonstrated efficacy in a brief model for military service members (PE in Primary Care: PE-PC). The effectiveness of this treatment in civilian, low-resource settings such as FQHCs is unknown. This pilot study tested the feasibility and acceptability of PE-PC in 30 Michigan FQHC patients. High rates of therapy participation suggest that the intervention was feasible and acceptable. Semi-structured interview data from 10 patients and 5 FQHC providers indicated that the intervention was helpful and filled a critical need for effective PTSD treatment in the FQHC setting. Interviews also elucidated barriers such as transportation, provider training, and time commitment for patients and providers. These findings set the stage for a full-scale randomized controlled trial to test the effectiveness of PE-PC on PTSD symptoms in this low-resource, high-need setting. Trial registry ClinicalTrials.gov Identifier: NCT03711266. October 18, 2018.
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Affiliation(s)
- Rebecca K Sripada
- Veterans Affairs Center for Clinical Management Research, Veterans Affairs Ann Arbor Health Care System, Ann Arbor, MI, USA. .,Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA.
| | - Heather M Walters
- Veterans Affairs Center for Clinical Management Research, Veterans Affairs Ann Arbor Health Care System, Ann Arbor, MI, USA
| | - Dara Ganoczy
- Veterans Affairs Center for Clinical Management Research, Veterans Affairs Ann Arbor Health Care System, Ann Arbor, MI, USA
| | | | | | - Sheila A M Rauch
- Department of Psychiatry and Behavioral Sciences, Emory University, Atlanta, GA, USA.,Atlanta VA Medical Center, Atlanta, GA, USA
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Valenstein M, Clive R, Ganoczy D, Garlick J, Walters HM, West BT, Kim HM, Eisenberg D, Bohnert KM, DesJardins SL, Zivin K, Lepkowski J, Pfeiffer PN. A nationally representative sample of veteran and matched non-veteran college students: Mental health symptoms, suicidal ideation, and mental health treatment. J Am Coll Health 2022; 70:436-445. [PMID: 32529930 DOI: 10.1080/07448481.2020.1753751] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 02/04/2020] [Accepted: 03/29/2020] [Indexed: 06/11/2023]
Abstract
Objective To assess mental health symptoms, suicidal ideation/behaviors, and treatment among a nationally representative probability sample of student veterans. Participants: Student veterans enrolled in post-secondary educational institutions and matched comparison students. Methods: Sampled participants completed an online survey (n = 1,838). Analyses accounted for the complex sample design and non-response. Results: Substantial percentages of student veterans screened positive for: depression (36.9%, 95% CI: 31.1-42.7), PTSD (35.7%, 95% CI 29.9-41.5), anxiety (29.5%, 95% CI 26.8-32.2), and suicidal ideation (14.6%, 95% CI 12.1-17.1), with student veterans having odds ratios between 1.7 to 2.4 for positive screens compared to non-veteran students. Only 41.5% (95% CI 33.0-50.0) of student veterans with positive screens received treatment, although they had 50% higher odds of receiving treatment than non-veteran students. Conclusions: Student veterans have high rates of mental health symptoms and low rates of treatment. However, they are more likely to receive treatment than comparison students.
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Affiliation(s)
- Marcia Valenstein
- Department of Veterans Affairs, Ann Arbor Center for Clinical Management Research, HSR&D, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
| | - Rebecca Clive
- Department of Veterans Affairs, Ann Arbor Center for Clinical Management Research, HSR&D, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Dara Ganoczy
- Department of Veterans Affairs, Ann Arbor Center for Clinical Management Research, HSR&D, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - James Garlick
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
| | - Heather M Walters
- Department of Veterans Affairs, Ann Arbor Center for Clinical Management Research, HSR&D, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Brady T West
- Institute for Social Research, Survey Research Center, University of Michigan, Ann Arbor, MI, USA
| | - Hyungjin M Kim
- Department of Veterans Affairs, Ann Arbor Center for Clinical Management Research, HSR&D, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
- Computing and Analytics Research (CSCAR), University of Michigan Consulting for Statistics, Ann Arbor, MI, USA
| | - Daniel Eisenberg
- Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - Kipling M Bohnert
- Department of Veterans Affairs, Ann Arbor Center for Clinical Management Research, HSR&D, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
| | | | - Kara Zivin
- Department of Veterans Affairs, Ann Arbor Center for Clinical Management Research, HSR&D, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
- Institute for Social Research, Survey Research Center, University of Michigan, Ann Arbor, MI, USA
- Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - James Lepkowski
- Institute for Social Research, Survey Research Center, University of Michigan, Ann Arbor, MI, USA
| | - Paul N Pfeiffer
- Department of Veterans Affairs, Ann Arbor Center for Clinical Management Research, HSR&D, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
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11
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Walters HM, Mian Z, Thomas L, Cerise J, Eberhard BA, Pagano E, Gottlieb BS, Steigerwald K, Hui-Yuen JS. Seroprevalence and Clinical Outcomes of SARS-CoV-2 in Paediatric Patients with Rheumatic Disease. Rheumatology (Oxford) 2021; 61:SI112-SI119. [PMID: 34599820 DOI: 10.1093/rheumatology/keab730] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 09/22/2021] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES Immunosuppressed paediatric patients with rheumatic disease (RD) may be at risk for severe or critical disease related to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Data remain scarce on COVID-19 outcomes in paediatric RD patients. The aim of this study is to determine the seroprevalence of SARS-CoV-2 IgG and to describe COVID-19 outcomes in immunosuppressed paediatric RD patients. METHODS Patients diagnosed with RD before age 18 and treated with at least one immunosuppressive medication for at least three months were enrolled from a tertiary paediatric rheumatology practice in New York, and also underwent routine SARS-CoV-2 IgG testing from May to November 2020. Five hundred and seventy-one patients were screened and 262 were enrolled. SARS-CoV-2 IgG+ subjects were assessed for symptoms of COVID-19 infection. SARS-CoV-2 PCR results were recorded where available. Demographic, diagnostic, medication, and outcome data were collected. RESULTS Of 262 subjects (186 female), 35 (13%) were SARS-CoV-2 IgG+; 17 (49%) had symptoms suggestive of COVID-19. Of 17 patients who had SARS-CoV-2 PCR testing, 11 (65%) were PCR+; seven of whom were IgG+. Most SARS-CoV-2 IgG+ subjects were not PCR tested. The most common symptoms in IgG+ and/or PCR+ subjects were fever, fatigue, and cough. No SARS-CoV-2 IgG+ or PCR+ subject developed severe or critical COVID-19 or required hospitalisation. CONCLUSIONS This is the first report of clinical outcomes of SARS-CoV-2 infection and seroprevalence of SARS-CoV-2 IgG in a large cohort of paediatric RD patients. Most SARS-CoV-2 IgG+ subjects had no symptoms of COVID-19 infection. Symptomatic subjects all had mild COVID-19 symptoms, suggesting that risk of severe or critical COVID-19 in immunosuppressed paediatric RD patients is minimal.
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Affiliation(s)
- Heather M Walters
- Division of Pediatric Rheumatology, Cohen Children's Medical Center, New Hyde Park, NY, USA.,Department of Pediatrics, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Zanab Mian
- Division of Pediatric Rheumatology, Cohen Children's Medical Center, New Hyde Park, NY, USA.,Department of Pediatrics, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Lydia Thomas
- Division of Pediatric Rheumatology, Cohen Children's Medical Center, New Hyde Park, NY, USA.,Department of Pediatrics, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Jane Cerise
- Department of Pediatrics, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA.,Biostatistics Unit, Feinstein Institutes for Medical Research, Manhasset, NY, USA
| | - B Anne Eberhard
- Division of Pediatric Rheumatology, Cohen Children's Medical Center, New Hyde Park, NY, USA.,Department of Pediatrics, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Eileen Pagano
- Division of Pediatric Rheumatology, Cohen Children's Medical Center, New Hyde Park, NY, USA.,Department of Pediatrics, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Beth S Gottlieb
- Division of Pediatric Rheumatology, Cohen Children's Medical Center, New Hyde Park, NY, USA.,Department of Pediatrics, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Katherine Steigerwald
- Division of Pediatric Rheumatology, Cohen Children's Medical Center, New Hyde Park, NY, USA.,Department of Pediatrics, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Joyce S Hui-Yuen
- Division of Pediatric Rheumatology, Cohen Children's Medical Center, New Hyde Park, NY, USA.,Department of Pediatrics, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA.,Center for Autoimmune, Musculoskeletal, and Hematopoietic Diseases Research, Feinstein Institutes for Medical Research, Manhasset, NY, USA
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12
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Walters HM, Pan N, Lehman TJA, Adams A, Kalliolias GD, Zhu YS, Santiago F, Nguyen J, Sitaras L, Cunningham-Rundles S, Walsh TJ, Toussi SS. The impact of disease activity and tumour necrosis factor-α inhibitor therapy on cytokine levels in juvenile idiopathic arthritis. Clin Exp Immunol 2016; 184:308-17. [PMID: 26934060 DOI: 10.1111/cei.12782] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/25/2016] [Indexed: 12/31/2022] Open
Abstract
The aim of this study was to evaluate prospectively cytokine levels and disease activity in juvenile idiopathic arthritis (JIA) patients treated with and without tumour necrosis factor (TNF)-α inhibitors. TNF-α inhibitor-naive JIA subjects were followed prospectively for 6 months. Cytokine levels of TNF-α, interleukin (IL)-1β, IL-6, IL-8, IL-10 and IL-17 were measured at baseline for JIA subjects and healthy controls (HCs). Cytokine levels were then measured at four time-points after initiation of TNF-α inhibition for anti-TNF-α-treated (anti-TNF) JIA subjects, and at two subsequent time-points for other JIA (non-TNF) subjects. JIA disease activity by Childhood Health Assessment Questionnaire (CHAQ) disability index/pain score and physician joint count/global assessment was recorded. Sixteen anti-TNF, 31 non-TNF and 16 HCs were analysed. Among JIA subjects, those with higher baseline disease activity (subsequent anti-TNFs) had higher baseline TNF-α, IL-6 and IL-8 than those with lower disease activity (non-TNFs) (P < 0·05). TNF-α and IL-10 increased, and IL-6 and IL-8 no longer remained significantly higher after TNF-α inhibitor initiation in anti-TNF subjects. Subgroup analysis of etanercept versus adalimumab-treated subjects showed that TNF-α and IL-17 increased significantly in etanercept but not adalimumab-treated subjects, despite clinical improvement in both groups of subjects. JIA subjects with increased disease activity at baseline had higher serum proinflammatory cytokines. TNF-α inhibition resulted in suppression of IL-6 and IL-8 in parallel with clinical improvement in all anti-TNF-treated subjects, but was also associated with elevated TNF-α and IL-17 in etanercept-treated subjects.
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Affiliation(s)
- H M Walters
- Department of Pediatric Rheumatology, Cohen Children's Medical Center, North-Shore-Long Island Jewish Health System, Lake Success, NY
| | - N Pan
- Department of Rheumatology, Hospital for Special Surgery, New York, NY, USA
| | - T J A Lehman
- Department of Rheumatology, Hospital for Special Surgery, New York, NY, USA
| | - A Adams
- Department of Rheumatology, Hospital for Special Surgery, New York, NY, USA
| | - G D Kalliolias
- Department of Rheumatology, Hospital for Special Surgery, New York, NY, USA.,Arthritis and Tissue Degeneration Program, Hospital for Special Surgery, New York, NY, USA.,Department of Medicine, New York, NY, USA
| | - Y S Zhu
- Clinical and Translational Science Center, Weill Cornell Medical College, New York, NY, USA
| | - F Santiago
- Clinical and Translational Science Center, Weill Cornell Medical College, New York, NY, USA
| | - J Nguyen
- Department of Epidemiology and Biostatistics, Hospital for Special Surgery, New York, NY, USA
| | - L Sitaras
- Department of Pediatrics, New York, NY, USA
| | | | - T J Walsh
- Department of Pediatrics, New York, NY, USA.,Department of Medicine, Weill Cornell Medical College/New York Presbyterian Hospital, New York, NY, USA
| | - S S Toussi
- Department of Pediatrics, New York, NY, USA
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13
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Gorman LA, Sripada RK, Ganoczy D, Walters HM, Bohnert KM, Dalack GW, Valenstein M. Determinants of National Guard Mental Health Service Utilization in VA versus Non-VA Settings. Health Serv Res 2016; 51:1814-37. [PMID: 26840993 DOI: 10.1111/1475-6773.12446] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To determine associations between need, enabling, and predisposing factors with mental health service use among National Guard soldiers in the first year following a combat deployment to Iraq or Afghanistan. DATA SOURCES/STUDY SETTING Primary data were collected between 2011 and 2013 from 1,426 Guard soldiers representing 36 units. STUDY DESIGN Associations between Guard soldier factors and any mental health service use were assessed using multivariable logistic regression models in a cross-sectional study. Further analysis among service users (N = 405) assessed VA treatment versus treatment in other settings. PRINCIPAL FINDINGS Fifty-six percent of Guard soldiers meeting cutoffs on symptom scales received mental health services with 81 percent of those reporting care from the VA. Mental health service use was associated with need (mental health screens and physical health) and residing in micropolitan communities. Among service users, predisposing factors (middle age range and female gender) and enabling factors (employment, income above $50,000, and private insurance) were associated with greater non-VA services use. CONCLUSION Overall service use was strongly associated with need, whereas sector of use (non-VA vs. VA) was insignificantly associated with need but strongly associated with enabling factors. These findings have implications for the recent extension of veteran health coverage to non-VA providers.
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Affiliation(s)
| | - Rebecca K Sripada
- Department of Psychiatry, University of Michigan, Ann Arbor, MI.,VA Center for Clinical Management Research, Ann Arbor Health Care System, Ann Arbor, MI
| | - Dara Ganoczy
- VA Center for Clinical Management Research, Ann Arbor Health Care System, Ann Arbor, MI
| | - Heather M Walters
- VA Center for Clinical Management Research, Ann Arbor Health Care System, Ann Arbor, MI
| | - Kipling M Bohnert
- Department of Psychiatry, University of Michigan, Ann Arbor, MI.,VA Center for Clinical Management Research, Ann Arbor Health Care System, Ann Arbor, MI
| | - Gregory W Dalack
- Department of Psychiatry, University of Michigan, Ann Arbor, MI.,VA Center for Clinical Management Research, Ann Arbor Health Care System, Ann Arbor, MI
| | - Marcia Valenstein
- Department of Psychiatry, University of Michigan, Ann Arbor, MI.,VA Center for Clinical Management Research, Ann Arbor Health Care System, Ann Arbor, MI
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14
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Sripada RK, Richards SKH, Rauch SAM, Walters HM, Ganoczy D, Bohnert KM, Gorman LA, Kees M, Blow AJ, Valenstein M. Socioeconomic Status and Mental Health Service Use Among National Guard Soldiers. Psychiatr Serv 2015; 66:992-5. [PMID: 25930042 DOI: 10.1176/appi.ps.201400346] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVE Convergent evidence suggests that low socioeconomic status (SES) may be related to reduced mental health service use. However, this relationship has not been tested in the National Guard (NG) population, in which the prevalence of mental health symptoms is high. METHODS Surveys were completed by 1,262 NG soldiers. SES was measured by education and income. Adjusted multivariable regression models assessed associations between SES, overall service use, and use of specific types of services. RESULTS SES was not associated with overall use but was associated with use of certain types of services. Higher SES was associated with lower likelihood of psychotropic medication use (odds ratio=.83, 95% confidence interval=.72-.96), and higher SES strengthened the positive relationship between PTSD and use of individual therapy. CONCLUSIONS Higher SES may increase the use of individual therapy among soldiers with PTSD. Barriers to care among individuals with low SES merit continued attention and outreach efforts.
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Affiliation(s)
- Rebecca K Sripada
- Dr. Sripada, Ms. Walters, Ms. Ganoczy, Dr. Bohnert, and Dr. Valenstein are with the Serious Mental Illness Treatment Resource and Evaluation Center, Center for Clinical Management Research, and Ms. Richards and Dr. Rauch are with the Mental Health Service, all at the U.S. Department of Veterans Affairs Ann Arbor Health Care System, Ann Arbor, Michigan. Dr. Sripada, Ms. Walters, Dr. Bohnert, Dr. Kees, and Dr. Valenstein are also with the Department of Psychiatry, University of Michigan Medical School, Ann Arbor (e-mail: ). Dr. Gorman is with the Michigan Public Health Institute, Okemos. Dr. Blow is with the Department of Family and Child Ecology, Michigan State University, East Lansing
| | - Sarah K H Richards
- Dr. Sripada, Ms. Walters, Ms. Ganoczy, Dr. Bohnert, and Dr. Valenstein are with the Serious Mental Illness Treatment Resource and Evaluation Center, Center for Clinical Management Research, and Ms. Richards and Dr. Rauch are with the Mental Health Service, all at the U.S. Department of Veterans Affairs Ann Arbor Health Care System, Ann Arbor, Michigan. Dr. Sripada, Ms. Walters, Dr. Bohnert, Dr. Kees, and Dr. Valenstein are also with the Department of Psychiatry, University of Michigan Medical School, Ann Arbor (e-mail: ). Dr. Gorman is with the Michigan Public Health Institute, Okemos. Dr. Blow is with the Department of Family and Child Ecology, Michigan State University, East Lansing
| | - Sheila A M Rauch
- Dr. Sripada, Ms. Walters, Ms. Ganoczy, Dr. Bohnert, and Dr. Valenstein are with the Serious Mental Illness Treatment Resource and Evaluation Center, Center for Clinical Management Research, and Ms. Richards and Dr. Rauch are with the Mental Health Service, all at the U.S. Department of Veterans Affairs Ann Arbor Health Care System, Ann Arbor, Michigan. Dr. Sripada, Ms. Walters, Dr. Bohnert, Dr. Kees, and Dr. Valenstein are also with the Department of Psychiatry, University of Michigan Medical School, Ann Arbor (e-mail: ). Dr. Gorman is with the Michigan Public Health Institute, Okemos. Dr. Blow is with the Department of Family and Child Ecology, Michigan State University, East Lansing
| | - Heather M Walters
- Dr. Sripada, Ms. Walters, Ms. Ganoczy, Dr. Bohnert, and Dr. Valenstein are with the Serious Mental Illness Treatment Resource and Evaluation Center, Center for Clinical Management Research, and Ms. Richards and Dr. Rauch are with the Mental Health Service, all at the U.S. Department of Veterans Affairs Ann Arbor Health Care System, Ann Arbor, Michigan. Dr. Sripada, Ms. Walters, Dr. Bohnert, Dr. Kees, and Dr. Valenstein are also with the Department of Psychiatry, University of Michigan Medical School, Ann Arbor (e-mail: ). Dr. Gorman is with the Michigan Public Health Institute, Okemos. Dr. Blow is with the Department of Family and Child Ecology, Michigan State University, East Lansing
| | - Dara Ganoczy
- Dr. Sripada, Ms. Walters, Ms. Ganoczy, Dr. Bohnert, and Dr. Valenstein are with the Serious Mental Illness Treatment Resource and Evaluation Center, Center for Clinical Management Research, and Ms. Richards and Dr. Rauch are with the Mental Health Service, all at the U.S. Department of Veterans Affairs Ann Arbor Health Care System, Ann Arbor, Michigan. Dr. Sripada, Ms. Walters, Dr. Bohnert, Dr. Kees, and Dr. Valenstein are also with the Department of Psychiatry, University of Michigan Medical School, Ann Arbor (e-mail: ). Dr. Gorman is with the Michigan Public Health Institute, Okemos. Dr. Blow is with the Department of Family and Child Ecology, Michigan State University, East Lansing
| | - Kipling M Bohnert
- Dr. Sripada, Ms. Walters, Ms. Ganoczy, Dr. Bohnert, and Dr. Valenstein are with the Serious Mental Illness Treatment Resource and Evaluation Center, Center for Clinical Management Research, and Ms. Richards and Dr. Rauch are with the Mental Health Service, all at the U.S. Department of Veterans Affairs Ann Arbor Health Care System, Ann Arbor, Michigan. Dr. Sripada, Ms. Walters, Dr. Bohnert, Dr. Kees, and Dr. Valenstein are also with the Department of Psychiatry, University of Michigan Medical School, Ann Arbor (e-mail: ). Dr. Gorman is with the Michigan Public Health Institute, Okemos. Dr. Blow is with the Department of Family and Child Ecology, Michigan State University, East Lansing
| | - Lisa A Gorman
- Dr. Sripada, Ms. Walters, Ms. Ganoczy, Dr. Bohnert, and Dr. Valenstein are with the Serious Mental Illness Treatment Resource and Evaluation Center, Center for Clinical Management Research, and Ms. Richards and Dr. Rauch are with the Mental Health Service, all at the U.S. Department of Veterans Affairs Ann Arbor Health Care System, Ann Arbor, Michigan. Dr. Sripada, Ms. Walters, Dr. Bohnert, Dr. Kees, and Dr. Valenstein are also with the Department of Psychiatry, University of Michigan Medical School, Ann Arbor (e-mail: ). Dr. Gorman is with the Michigan Public Health Institute, Okemos. Dr. Blow is with the Department of Family and Child Ecology, Michigan State University, East Lansing
| | - Michelle Kees
- Dr. Sripada, Ms. Walters, Ms. Ganoczy, Dr. Bohnert, and Dr. Valenstein are with the Serious Mental Illness Treatment Resource and Evaluation Center, Center for Clinical Management Research, and Ms. Richards and Dr. Rauch are with the Mental Health Service, all at the U.S. Department of Veterans Affairs Ann Arbor Health Care System, Ann Arbor, Michigan. Dr. Sripada, Ms. Walters, Dr. Bohnert, Dr. Kees, and Dr. Valenstein are also with the Department of Psychiatry, University of Michigan Medical School, Ann Arbor (e-mail: ). Dr. Gorman is with the Michigan Public Health Institute, Okemos. Dr. Blow is with the Department of Family and Child Ecology, Michigan State University, East Lansing
| | - Adrian J Blow
- Dr. Sripada, Ms. Walters, Ms. Ganoczy, Dr. Bohnert, and Dr. Valenstein are with the Serious Mental Illness Treatment Resource and Evaluation Center, Center for Clinical Management Research, and Ms. Richards and Dr. Rauch are with the Mental Health Service, all at the U.S. Department of Veterans Affairs Ann Arbor Health Care System, Ann Arbor, Michigan. Dr. Sripada, Ms. Walters, Dr. Bohnert, Dr. Kees, and Dr. Valenstein are also with the Department of Psychiatry, University of Michigan Medical School, Ann Arbor (e-mail: ). Dr. Gorman is with the Michigan Public Health Institute, Okemos. Dr. Blow is with the Department of Family and Child Ecology, Michigan State University, East Lansing
| | - Marcia Valenstein
- Dr. Sripada, Ms. Walters, Ms. Ganoczy, Dr. Bohnert, and Dr. Valenstein are with the Serious Mental Illness Treatment Resource and Evaluation Center, Center for Clinical Management Research, and Ms. Richards and Dr. Rauch are with the Mental Health Service, all at the U.S. Department of Veterans Affairs Ann Arbor Health Care System, Ann Arbor, Michigan. Dr. Sripada, Ms. Walters, Dr. Bohnert, Dr. Kees, and Dr. Valenstein are also with the Department of Psychiatry, University of Michigan Medical School, Ann Arbor (e-mail: ). Dr. Gorman is with the Michigan Public Health Institute, Okemos. Dr. Blow is with the Department of Family and Child Ecology, Michigan State University, East Lansing
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15
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Bonar EE, Bohnert KM, Walters HM, Ganoczy D, Valenstein M. Student and Nonstudent National Guard Service Members/Veterans and Their Use of Services for Mental Health Symptoms. J Am Coll Health 2015; 63:437-46. [PMID: 25337770 PMCID: PMC4776315 DOI: 10.1080/07448481.2014.975718] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Abstract
OBJECTIVE To compare mental health symptoms and service utilization among returning student and nonstudent service members/veterans (SM/Vs). PARTICIPANTS SM/Vs (N = 1,439) were predominately white (83%) men (92%), half were over age 30 (48%), and 24% were students. METHODS SM/Vs completed surveys 6 months post deployment (October 2011-July 2013). RESULTS Students and nonstudent SM/Vs did not differ in positive screens for depression, anxiety, hazardous drinking, or posttraumatic stress disorder. Students (n = 81) and nonstudents (n = 265) with mental health symptoms had low levels of mental health service use (eg, Department of Veterans Affairs [VA], civilian, or military facilities), at 47% and 57%. respectively. Fewer students used VA mental health services. Common barriers to treatment seeking included not wanting treatment on military records and embarrassment. CONCLUSIONS Like other returning SM/Vs, student SM/Vs have unmet mental health needs. The discrepancy between potential need and treatment seeking suggests that colleges might be helpful in further facilitating mental health service use for student SM/Vs.
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Affiliation(s)
- Erin E. Bonar
- Department of Psychiatry, Addiction Research Center, University of Michigan, Ann Arbor, Michigan
| | - Kipling M. Bohnert
- Department of Psychiatry, Addiction Research Center, University of Michigan, Ann Arbor, Michigan
- Department of Veterans Affairs, Ann Arbor Center for Clinical Management Research, Serious Mental Illness Treatment Resource and Evaluation Center (SMITREC), Ann Arbor, Michigan
| | - Heather M. Walters
- Department of Veterans Affairs, Ann Arbor Center for Clinical Management Research, Serious Mental Illness Treatment Resource and Evaluation Center (SMITREC), Ann Arbor, Michigan
| | - Dara Ganoczy
- Department of Veterans Affairs, Ann Arbor Center for Clinical Management Research, Serious Mental Illness Treatment Resource and Evaluation Center (SMITREC), Ann Arbor, Michigan
| | - Marcia Valenstein
- Department of Psychiatry, Addiction Research Center, University of Michigan, Ann Arbor, Michigan
- Department of Veterans Affairs, Ann Arbor Center for Clinical Management Research, Serious Mental Illness Treatment Resource and Evaluation Center (SMITREC), Ann Arbor, Michigan
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16
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Walters HM, Pan N, Lehman TJA, Adams A, Huang WT, Sitaras L, Cunningham-Rundles S, Walsh TJ, Toussi SS. A prospective study comparing infection risk and disease activity in children with juvenile idiopathic arthritis treated with and without tumor necrosis factor-alpha inhibitors. Clin Rheumatol 2014; 34:457-64. [PMID: 25227771 DOI: 10.1007/s10067-014-2779-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2014] [Revised: 08/25/2014] [Accepted: 09/07/2014] [Indexed: 12/19/2022]
Abstract
Tumor necrosis factor-alpha (TNF-α) inhibitors are effective treatment for juvenile idiopathic arthritis (JIA) but may increase infection rates. However, active JIA may also render patients vulnerable to infection. In this study, we prospectively assessed infection rates in JIA patients treated with and without TNF-α inhibitors and correlated disease activity with infection risk. TNF-α inhibitor-naïve JIA subjects were followed up for 12 months. Subjects initiated on TNF-α inhibitors after enrollment were analyzed in the TNF group. Subjects treated without TNF-α inhibitors were analyzed in the non-TNF group. Questionnaires captured mild or severe infections. JIA disease activity by Childhood Health Assessment Questionnaire (CHAQ) disability index/pain score and physician joint count/global assessment was recorded. Twenty TNF and 36 non-TNF subjects were analyzed. The total infection rate ratio for TNF versus non-TNF group subjects was 1.14 (95% CI, 0.78-1.66; p = 0.51). The average rate of infections per month was 0.29 for TNF and 0.24 for non-TNF subjects. No severe infections or hospitalizations occurred in either group. Secondary infectious outcomes were also similar between groups. Controlling for study group, an increase in CHAQ pain score correlated with an increase in several infectious outcome measures. Our results suggest no difference in infection rates between JIA subjects treated with and without TNF-α inhibitors. Additionally, JIA disease activity may have contributed to infection risk in our cohort, irrespective of immunosuppressive therapy. Future analysis of the relationship between treatment regimens, disease activity, and infection rates may help to further delineate predictors of infection risk in JIA patients.
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Affiliation(s)
- Heather M Walters
- Department of Pediatric Rheumatology, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA,
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17
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Toussi SS, Pan N, Walters HM, Walsh TJ. Infections in children and adolescents with juvenile idiopathic arthritis and inflammatory bowel disease treated with tumor necrosis factor-α inhibitors: systematic review of the literature. Clin Infect Dis 2013; 57:1318-30. [PMID: 23899685 DOI: 10.1093/cid/cit489] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Tumor necrosis factor alpha (TNF-α) inhibitors are increasingly administered to children and adolescents with juvenile idiopathic arthritis (JIA) and pediatric inflammatory bowel disease (pIBD). Adult studies indicate that TNF-α inhibitors lead to an increased risk of serious infections compared to other disease-modifying antirheumatic drugs. We report herein a systematic literature review detailing the epidemiology and types of infections reported in children with JIA and pIBD treated with TNF-α inhibitors. The most frequently reported infections were mild and characterized as viral in etiology. Severe bacterial and fungal infections also occurred, but were less common and possibly associated with intrinsic risk factors and concurrent immunosuppressive therapy. Few pediatric patients developed Mycobacterium tuberculosis, likely due to effective screening. There were 8 infectious fatalities in children treated with TNF-α inhibitors. Overall, although rare, serious infections occur in immunocompromised children and adolescents with JIA and pIBD receiving TNF-α inhibitors.
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Affiliation(s)
- Sima S Toussi
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Weill Cornell Medical Center
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Walters HM, Pan N, Moorthy LN, Ward MJ, Peterson MG, Lehman TJ. Patterns and influence of familial autoimmunity in pediatric systemic lupus erythematosus. Pediatr Rheumatol Online J 2012; 10:22. [PMID: 22891746 PMCID: PMC3542590 DOI: 10.1186/1546-0096-10-22] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2012] [Accepted: 08/07/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND A high prevalence of autoimmune disease (AD) has been documented in relatives of adult patients with systemic lupus erythematosus (SLE). However, data on familial inheritance patterns in pediatric SLE patients is scarce. FINDINGS The charts of 69 patients with pediatric-onset SLE were reviewed retrospectively. The primary aim was to describe the prevalence and types of AD in relatives of children with SLE. The secondary aims were: 1) to compare severity of SLE in children with and without relatives affected by AD, and 2) to evaluate the impact of baseline demographics on severity of SLE in subjects. At diagnosis, 42% of subjects had one or more first, second, or third degree relative(s) with AD; and 32% of subjects had one or more first degree relative(s) with AD. The most common diseases in relatives of children with SLE were SLE (21%) and thyroid disease (15%). Subjects with no family history of AD were more likely to have severe SLE. SLE severity in subjects did not differ by gender. Children presenting with SLE at an earlier age were found to have more severe disease. CONCLUSIONS This study demonstrated a high prevalence of AD in families of children with SLE, although a family history of AD did not correlate with more severe SLE in subjects. Future larger studies are necessary to elucidate patterns of familial inheritance and baseline patient characteristics that may affect severity of disease in pediatric SLE.
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Affiliation(s)
- Heather M Walters
- Komansky Center for Children's Health/NY Weill Cornell Medical Center, New York, NY, USA.
| | - Nancy Pan
- Department of Pediatric Rheumatology, Hospital for Special Surgery, 535 East 70th Street, New York, 10021, NY, USA
| | - Lakshmi N Moorthy
- Department of Pediatric Rheumatology, Hospital for Special Surgery, 535 East 70th Street, New York, 10021, NY, USA,Pediatric Rheumatology, Robert Wood Johnson Medical School, University of Medicine and Dentistry of NJ, New Brunswick, NY, USA
| | - Mary J Ward
- Komansky Center for Children’s Health/NY Weill Cornell Medical Center, New York, NY, USA,Pediatrics, Weill Cornell Medical College, New York, NY, USA
| | | | - Thomas J Lehman
- Department of Pediatric Rheumatology, Hospital for Special Surgery, 535 East 70th Street, New York, 10021, NY, USA,Pediatrics, Weill Cornell Medical College, New York, NY, USA
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Vinh TK, Ahmadi M, Delgado PO, Perez SF, Walters HM, Smith HJ, Nicholls PJ, Simons C. 1-[(Benzofuran-2-yl)phenylmethyl]-triazoles and -tetrazoles - potent competitive inhibitors of aromatase. Bioorg Med Chem Lett 1999; 9:2105-8. [PMID: 10450990 DOI: 10.1016/s0960-894x(99)00328-5] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
The synthesis of a series of novel 1-[(benzofuran-2-yl)phenylmethyl]-triazoles and -tetrazoles is described. The compounds were tested for human placental aromatase inhibition in vitro, using [1beta-3H]-androstenedione as the substrate for the aromatase enzyme, the percentage inhibition and IC50 data is included.
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Affiliation(s)
- T K Vinh
- Welsh School of Pharmacy, Cardiff University, UK
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