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Dodge J, Stern K, Smith T, Magness CS, Garlick J, Garland S, Pfeiffer PN, Foster CE. A qualitative study of supporters of adults following a suicide-related psychiatric emergency. Fam Syst Health 2024:2024-70293-001. [PMID: 38573682 DOI: 10.1037/fsh0000875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/05/2024]
Abstract
INTRODUCTION Family, friends, and romantic partners (i.e., supporters) play a key role in the implementation of safety and support measures for loved ones with elevated risk for suicide; yet despite the link between interpersonal factors and suicide risk, few supporter-focused interventions exist. METHOD This qualitative study to inform intervention development was conducted from September 2021 to March 2022 and explored (a) the feasibility and acceptability of a single-session phone call to a support person (n = 30, 67% female, 88% White non-Hispanic, Mage = 40.3 [SD = 17.1]) nominated during an emergency department (ED) visit for suicide risk and (b) the needs of supporters during and after a loved one's suicide crisis. RESULTS Of the 30 supporters nominated, 27 were eligible to participate and were contacted. Eighteen completed an interview (66%). Seven core themes with 26 subthemes were identified characterizing the supporter's experience prior to, during, and following their loved one's suicide crisis. We found moderate acceptability and feasibility of a single-session supportive phone call to a support person following an ED visit for suicide risk. DISCUSSION Supporters reported a period of stress prior to and during the ED visit as well as adaptive coping with continued barriers and challenges. Brief interventions aimed at improving communication between the supporter, patient, and their care team; defining roles; and enhancing practical and emotional support are likely to be acceptable and feasible. Further study is needed to determine whether brief interventions to improve supporter self-efficacy can benefit both supporter and patient. (PsycInfo Database Record (c) 2024 APA, all rights reserved).
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Affiliation(s)
- Jessica Dodge
- Health Services Research and Development, Ann Arbor Veterans Affairs Hospital
| | - Karlin Stern
- Department of Psychiatry, University of Michigan
| | - Tayla Smith
- Department of Psychiatry, University of Michigan
| | | | - James Garlick
- Health Services Research and Development, Ann Arbor Veterans Affairs Hospital
| | - Sean Garland
- Department of Psychology, University of Michigan
| | - Paul N Pfeiffer
- Health Services Research and Development, Ann Arbor Veterans Affairs Hospital
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Panaite V, Cohen NJ, Luther SL, Finch DK, Alman A, Schultz SK, Haun J, Miles SR, Belanger HG, Kozel FA, Rottenberg J, Pfeiffer PN. Mental health treatment utilization patterns among 108,457 Afghanistan and Iraq veterans with depression. Psychol Serv 2024:2024-48650-001. [PMID: 38300588 DOI: 10.1037/ser0000819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2024]
Abstract
People with depression often underutilize mental health care. This study was conceived as a first step toward a clinical decision support tool that helps identify patients who are at higher risk of underutilizing care. The primary goals were to (a) describe treatment utilization patterns, early termination, and return to care; (b) identify factors associated with early termination of treatment; and (c) evaluate the accuracy of regression models to predict early termination. These goals were evaluated in a retrospective cohort analysis of 108,457 U.S. veterans who received care from the Veterans Health Administration between 2001 and 2021. Our final sample was 16.5% female with an average age of 34.5. Veterans were included if they had a depression diagnosis, a positive depression screen, and received general health care services at least a year before and after their depression diagnosis. Using treatment quality guidelines, the threshold for treatment underutilization was defined as receiving fewer than four psychotherapy sessions or less than 84 days of antidepressants. Over one fifth of veterans (21.6%) received less than the minimally recommended care for depression. The odds of underutilizing treatment increased with lack of Veterans Administration benefits, male gender, racial/ethnic minority status, and having received mental health treatment in the past (adjusted OR > 1.1). Posttraumatic stress disorder comorbidity correlated with increased depression treatment utilization (adjusted OR < .9). Models with demographic and clinical information from medical records performed modestly in classifying patients who underutilized depression treatment (area under the curve = 0.595, 95% CI [0.588, 0.603]). Most veterans in this cohort received at least the minimum recommended treatment for depression. To improve the prediction of underutilization, patient factors associated with treatment underutilization likely need to be supplemented by additional clinical information. (PsycInfo Database Record (c) 2024 APA, all rights reserved).
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Affiliation(s)
- Vanessa Panaite
- Research and Development Service, James A. Haley Veterans' Hospital
| | - Nathan J Cohen
- Department of Environmental Medicine and Public Health, Icahn School of Medicine at Mount Sinai
| | - Stephen L Luther
- Research and Development Service, James A. Haley Veterans' Hospital
| | - Dezon K Finch
- Research and Development Service, James A. Haley Veterans' Hospital
| | - Amy Alman
- College of Public Health, University of South Florida
| | - Susan K Schultz
- Department of Psychiatry and Behavioral Neurosciences, University of South Florida
| | - Jolie Haun
- Research and Development Service, James A. Haley Veterans' Hospital
| | - Shannon R Miles
- Department of Psychiatry and Behavioral Neurosciences, University of South Florida
| | - Heather G Belanger
- Department of Psychiatry and Behavioral Neurosciences, University of South Florida
| | - F Andrew Kozel
- Department of Behavioral Sciences and Social Medicine, Florida State University
| | | | - Paul N Pfeiffer
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System
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3
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Pfeiffer PN, Geller J, Ganoczy D, Jagusch J, Carty J, Festin FED, Gilmer WS, Martis B, Ranganathan M, Wiechers IR, Hosanagar A. Clinical Outcomes of Intravenous Ketamine Treatment for Depression in the VA Health System. J Clin Psychiatry 2024; 85:23m14984. [PMID: 38206011 DOI: 10.4088/jcp.23m14984] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2024]
Abstract
Objective/Background: Intravenous (IV) ketamine is effective for reducing symptoms of major depressive disorder in short-term clinical trials; this study characterized clinical outcomes of repeated infusions in routine clinical practice and the frequency and number of infusions used to sustain symptom improvement. Methods: Records of IV ketamine infusions for depression and associated Patient Health Questionnaire-9 (PHQ-9) scores were identified from Veterans Health Administration (VA) electronic medical records for patients treated in Fiscal Year 2020 and up to 12 months following the date of their first infusion. Results: Sample patients (n = 215) had a mean baseline PHQ-9 score of 18.6 and a mean of 2.1 antidepressant medication trials in the past year and 6.1 antidepressant trials in the 20 years prior to their first ketamine infusion. Frequency of infusions decreased from every 5 days to every 3-4 weeks over the first 5 months of infusions, with a mean of 18 total infusions over 12 months. After 6 weeks of treatment, 26% had a 50% improvement in PHQ-9 score (response) and 15% had PHQ-9 score ≤ 5 (remission). These improvements were similar at 12 and 26 weeks. No demographic characteristics or comorbid diagnoses were associated with 6-week PHQ-9 scores. Conclusions: While only a minority of patients treated with IV ketamine for depression experienced response or remission, symptom improvements achieved within the first 6 weeks were sustained over at least 6 months with decreasing infusion frequency. Further study is needed to determine optimal infusion frequency and potential for adverse effects with repeated ketamine infusions for depression.
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Affiliation(s)
- Paul N Pfeiffer
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
- Department of Psychiatry, University of Michigan Medical School, Ann Arbor, Michigan
- Corresponding author: Paul N. Pfeiffer, MD; VA Center for Clinical Management Research, 2800 Plymouth Road, Building 16, Ann Arbor, MI 48109
| | - Jamarie Geller
- Department of Psychiatry, University of Michigan Medical School, Ann Arbor, Michigan
| | - Dara Ganoczy
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Jennifer Jagusch
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - John Carty
- Albuquerque VA Medical Center, Albuquerque, New Mexico
- University of New Mexico School of Medicine Albuquerque, New Mexico
| | - Fe Erlita D Festin
- VA Boston Healthcare System, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Boston University School of Medicine, Boston, Massachusetts
| | - William S Gilmer
- Edward Hines Jr VA Hospital, Hines, Illinois
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Brian Martis
- VA San Diego Healthcare System, San Diego, California
- University of San Diego School of Medicine, San Diego, California
| | - Mohini Ranganathan
- VA Connecticut Healthcare System, West Haven, Connecticut
- Yale School of Medicine, New Haven
| | - Ilse R Wiechers
- Yale School of Medicine, New Haven
- VA Office of Mental Health and Suicide Prevention, Washington, DC
- University of California San Francisco School of Medicine, San Francisco, California
| | - Avinash Hosanagar
- Department of Psychiatry, University of Michigan Medical School, Ann Arbor, Michigan
- Mental Health Service, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
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Dodge J, Sullivan K, Grau PP, Chen C, Sripada R, Pfeiffer PN. Retention in Individual Trauma-Focused Treatment Following Family-Based Treatment Among US Veterans. JAMA Netw Open 2023; 6:e2349098. [PMID: 38127345 PMCID: PMC10739069 DOI: 10.1001/jamanetworkopen.2023.49098] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 11/09/2023] [Indexed: 12/23/2023] Open
Abstract
Importance Despite the availability of several empirically supported trauma-focused interventions, retention in posttraumatic stress disorder (PTSD) psychotherapy is poor. Preliminary efficacy data shows that brief, family-based interventions may improve treatment retention in a veteran's individual PTSD treatment, although whether this occurs in routine clinical practice is not established. Objective To characterize receipt of family therapy among veterans diagnosed with PTSD and evaluate whether participation in family therapy is associated with an increased likelihood of completing individual trauma-focused treatment. Design, Setting, and Participants This retrospective cohort study used the Veterans Health Administration (VHA) Informatics and Computing Infrastructure to extract electronic health record data of participants. All participants were US veterans diagnosed with PTSD between October 1, 2015, and December 31, 2019, who attended at least 1 individual trauma-focused treatment session. Statistical analysis was performed from May to August 2023. Exposures Receipt of any family psychotherapy and subtype of family-based psychotherapy. Main Outcomes and Measures Minimally adequate individual trauma-focused treatment completion (ie, 8 or more sessions of trauma-focused treatment in a 6-month period). Results Among a total of 1 516 887 US veterans with VHA patient data included in the study, 58 653 (3.9%) received any family therapy; 334 645 (23.5%) were Black, 1 006 168 (70.5%) were White, and 86 176 (6.0%) were other race; 1 322 592 (87.2%) were male; 1 201 902 (79.9%) lived in urban areas; and the mean (SD) age at first individual psychotherapy appointment was 52.7 (15.9) years. Among the 58 653 veterans (3.9%) who received any family therapy, 36 913 (62.9%) received undefined family therapy only, 15 528 (26.5%) received trauma-informed cognitive-behavioral conjoint therapy (CBCT) only, 5210 (8.9%) received integrative behavioral couples therapy (IBCT) only, and 282 (0.5%) received behavioral family therapy (BFT) only. Compared with receiving no family therapy, the odds of completing individual PTSD treatment were 7% higher for veterans who also received CBCT (OR, 1.07 [95% CI, 1.01-1.13]) and 68% higher for veterans received undefined family therapy (OR, 1.68 [95% CI, 1.63-1.74]). However, compared with receiving no family therapy care, veterans had 26% lower odds of completing individual PTSD treatment if they were also receiving IBCT (OR, 0.74 [95% CI, 0.66-0.82]). Conclusions and Relevance In this cohort study of US veterans, family-based psychotherapies were found to differ substantially in their associations with individual PTSD psychotherapy retention. These findings highlight potential benefits of concurrently providing family-based therapy with individual PTSD treatment but also the need for careful clinical attention to the balance between family-based therapies and individual PTSD treatment.
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Affiliation(s)
- Jessica Dodge
- Health Services Research and Development/Center for Clinical Management Research, Ann Arbor Veterans Affairs Hospital (152), Ann Arbor, Michigan
| | | | - Peter P. Grau
- Health Services Research and Development/Center for Clinical Management Research, Ann Arbor Veterans Affairs Hospital (152), Ann Arbor, Michigan
- Department of Psychiatry, University of Michigan Medical School, Ann Arbor
| | - Charity Chen
- Health Services Research and Development/Center for Clinical Management Research, Ann Arbor Veterans Affairs Hospital (152), Ann Arbor, Michigan
| | - Rebecca Sripada
- Health Services Research and Development/Center for Clinical Management Research, Ann Arbor Veterans Affairs Hospital (152), Ann Arbor, Michigan
- Department of Psychiatry, University of Michigan Medical School, Ann Arbor
| | - Paul N. Pfeiffer
- Health Services Research and Development/Center for Clinical Management Research, Ann Arbor Veterans Affairs Hospital (152), Ann Arbor, Michigan
- Department of Psychiatry, University of Michigan Medical School, Ann Arbor
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5
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Pfeiffer PN, Ganoczy D, Zivin K, Gerlach L, Damschroder L, Ulmer CS. Guideline-concordant use of cognitive behavioral therapy for insomnia in the Veterans Health Administration. Sleep Health 2023; 9:893-896. [PMID: 37704561 DOI: 10.1016/j.sleh.2023.07.002] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 07/03/2023] [Accepted: 07/08/2023] [Indexed: 09/15/2023]
Abstract
OBJECTIVE To characterize guideline-concordant use of cognitive behavioral therapy for insomnia vs. sleep medications among Veterans Health Administration patients. METHODS Cognitive behavioral therapy for insomnia was identified from the text of psychotherapy notes within the Veterans Health Administration's electronic medical record. Patients that received first-line cognitive behavioral therapy for insomnia (ie, no prior insomnia treatment) were compared to those who first received a sleep medication in fiscal year 2021. RESULTS Among 5,519,016 patients, first-line cognitive behavioral therapy for insomnia was received by 9313 (0.2%) whereas 225,618 (4.1%) were newly prescribed a sleep medication without prior cognitive behavioral therapy for insomnia. Patients over 60 years old and those with substance use disorders were less likely to receive first-line cognitive behavioral therapy for insomnia compared to other patients. CONCLUSIONS Adherence to practice guidelines to provide cognitive behavioral therapy for insomnia as first-line treatment for insomnia disorder remains a challenge, highlighting the need to better integrate effective implementation strategies within therapist training programs. Targeted strategies may be needed for older patients or those with substance use disorders.
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Affiliation(s)
- Paul N Pfeiffer
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA; Department of Psychiatry, University of Michigan, Ann Arbor, Michigan, USA.
| | - Dara Ganoczy
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
| | - Kara Zivin
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA; Department of Psychiatry, University of Michigan, Ann Arbor, Michigan, USA
| | - Lauren Gerlach
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA; Department of Psychiatry, University of Michigan, Ann Arbor, Michigan, USA
| | - Laura Damschroder
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
| | - Christi S Ulmer
- Durham VA Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham, North Carolina, USA; Department of Psychiatry and Behavioral Sciences, Duke University, Durham, North Carolina, USA
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6
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Saulnier KG, Panaite V, Ganoczy D, Kim HM, Zivin K, Hofer T, Piette JD, Pfeiffer PN. Depression symptom outcomes and re-engagement among VA patients who discontinue care while symptomatic. Gen Hosp Psychiatry 2023; 85:87-94. [PMID: 37862961 DOI: 10.1016/j.genhosppsych.2023.10.008] [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: 03/02/2023] [Revised: 10/12/2023] [Accepted: 10/12/2023] [Indexed: 10/22/2023]
Abstract
OBJECTIVE Evaluate outcomes of Veterans who discontinued treatment with at least moderate ongoing depressive symptoms. METHOD Veterans with elevated depression symptoms from 29 Department of Veterans Affairs facilities completed baseline surveys and follow-up assessments for one year. Analyses examined rates and predictors of treatment discontinuation, treatment re-engagement, and subsequent symptoms among patients who remained out of care. RESULTS A total of 242 (17.8%; n = 1359) participants discontinued treatment while symptomatic, with Black participants, participants with less severe depression, and participants receiving only psychotherapy (versus combined psychotherapy and antidepressant medications) discontinuing at higher rates. Among all participants who discontinued treatment (n = 445), 45.8% re-engaged within the following six months with participants receiving combined treatment re-engaging at higher rates. Of participants who discontinued while symptomatic within the first 6 months of the study and did not return to care (n = 112), 68.8% remained symptomatic at 12 months. Lower baseline treatment expectancy and greater depression symptom severity were associated with remaining symptomatic while untreated. CONCLUSIONS Black race, lower symptom severity, and treatment modality may help identify patients at higher risk for discontinuing care while symptomatic, whereas patients with lower treatment expectations may be at greater risk for remaining out of care despite continuing symptoms.
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Affiliation(s)
- K G Saulnier
- VA Serious Mental Illness Treatment Resource and Evaluation Center, Ann Arbor, MI, USA; VA Ann Arbor Healthcare System, Ann Arbor, MI, USA; University of Michigan Medical School, Ann Arbor, MI, USA.
| | - V Panaite
- James A. Haley Veterans' Hospital, Tampa, FL, USA
| | - D Ganoczy
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - H M Kim
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA; University of Michigan Consulting for Statistics, Computing, and Analytics Research, Ann Arbor, MI, USA
| | - K Zivin
- University of Michigan Medical School, Ann Arbor, MI, USA; VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA; School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - T Hofer
- University of Michigan Medical School, Ann Arbor, MI, USA; VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - J D Piette
- University of Michigan Medical School, Ann Arbor, MI, USA; VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA; School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - P N Pfeiffer
- VA Ann Arbor Healthcare System, Ann Arbor, MI, USA; University of Michigan Medical School, Ann Arbor, MI, USA; VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
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7
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Zivin K, Van T, Osatuke K, Boden M, Pfeiffer PN, Sripada RK, Abraham KM, Burgess J, Kim HM. Behavioral Health Provider Burnout and Mental Health Care in the Veterans Health Administration. J Gen Intern Med 2023; 38:2254-2261. [PMID: 37227659 PMCID: PMC10211276 DOI: 10.1007/s11606-023-08235-y] [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: 09/13/2022] [Accepted: 05/09/2023] [Indexed: 05/26/2023]
Abstract
BACKGROUND Although many studies assess predictors of provider burnout, few analyses provide high-quality, consistent evidence on the impact of provider burnout on patient outcomes exist, particularly among behavioral health providers (BHPs). OBJECTIVE To assess the impact of burnout among psychiatrists, psychologists, and social workers on access-related quality measures in the Veterans Health Administration (VHA). DESIGN This study used burnout in VA All Employee Survey (AES) and Mental Health Provider Survey (MHPS) data to predict metrics assessed by the Strategic Analytics for Improvement and Learning Value, Mental Health Domain (MH-SAIL), VHA's quality monitoring system. The study used prior year (2014-2018) facility-level burnout proportion among BHPs to predict subsequent year (2015-2019) facility-level MH-SAIL domain scores. Analyses used multiple regression models, adjusting for facility characteristics, including BHP staffing and productivity. PARTICIPANTS Psychologists, psychiatrists, and social workers who responded to the AES and MHPS at 127 VHA facilities. MAIN MEASURES Four compositive outcomes included two objective measures (population coverage, continuity of care), one subjective measure (experience of care), and one composite measure of the former three measures (mental health domain quality). KEY RESULTS Adjusted analyses showed prior year burnout generally had no impact on population coverage, continuity of care, and patient experiences of care but had a negative impact on provider experiences of care consistently across 5 years (p < 0.001). Pooled across years, a 5% higher facility-level burnout in AES and MHPS had a 0.05 and 0.09 standard deviation worse facility experiences of care from the prior year, respectively. CONCLUSIONS Burnout had a significant negative impact on provider-reported experiential outcome measures. This analysis showed that burnout had a negative effect on subjective but not on objective quality measures of Veteran access to care, which could inform future policies and interventions regarding provider burnout.
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Affiliation(s)
- Kara Zivin
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA.
- Department of Psychiatry, Michigan Medicine, Ann Arbor, MI, USA.
| | - Tony Van
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Katerine Osatuke
- VHA National Center for Organization Development, Cincinnati, OH, USA
| | - Matt Boden
- Program Evaluation and Resource Center and VA Office of Mental Health Operations, VA Palo Alto Health Care System, Palo Alto, CA, USA
| | - Paul N Pfeiffer
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
- Department of Psychiatry, Michigan Medicine, Ann Arbor, MI, USA
| | - Rebecca K Sripada
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
- Department of Psychiatry, Michigan Medicine, Ann Arbor, MI, USA
| | - Kristen M Abraham
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
- Department of Psychology, University of Detroit Mercy, Detroit, MI, USA
| | - Jennifer Burgess
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
- Department of Psychiatry, Michigan Medicine, Ann Arbor, MI, USA
| | - Hyungjin Myra Kim
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
- Consulting for Statistics, Computing and Analytics Research, University of Michigan, Ann Arbor, MI, USA
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8
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Stroumsa D, Moniz MH, Crissman H, Dalton VK, Tilea A, Pfeiffer PN, Marsh EE. Pregnancy Outcomes in a US Cohort of Transgender People. JAMA 2023; 329:1879-1881. [PMID: 37166818 PMCID: PMC10176175 DOI: 10.1001/jama.2023.7688] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 04/20/2023] [Indexed: 05/12/2023]
Abstract
This study assesses severe parental morbidity, cesarean deliveries, and preterm births among commercially and publicly insured trans people compared with cisgender people.
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Affiliation(s)
- Daphna Stroumsa
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor
| | - Michelle H. Moniz
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor
| | - Halley Crissman
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor
| | - Vanessa K. Dalton
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor
| | - Anca Tilea
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor
| | | | - Erica E. Marsh
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor
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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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10
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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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11
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Schmutte T, Krishnamurti LS, Davidson L, Klee A, Bullock J, Panas RM, Pfeiffer PN, Chinman M. Implementing Peer Specialists in Suicide Prevention Efforts in the Veterans Health Administration. Psychiatr Q 2023; 94:311-319. [PMID: 37278930 PMCID: PMC10424796 DOI: 10.1007/s11126-023-10034-x] [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] [Accepted: 05/29/2023] [Indexed: 06/07/2023]
Abstract
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.
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Affiliation(s)
- Timothy Schmutte
- Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut, USA.
| | - Lauren S Krishnamurti
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Larry Davidson
- Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Anne Klee
- Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut, USA
- Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Joshua Bullock
- Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut, USA
- Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Raymond M Panas
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Paul N Pfeiffer
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
- Department of Psychiatry, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Matthew Chinman
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- RAND Corporation, Pittsburgh, PA, USA
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12
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Grau PP, Sripada RK, Ganoczy D, Weinstein JH, Pfeiffer PN. Outcomes of Acceptance and Commitment Therapy for depression and predictors of treatment response in Veterans Health Administration patients. J Affect Disord 2023; 323:826-833. [PMID: 36529407 DOI: 10.1016/j.jad.2022.12.025] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 12/06/2022] [Accepted: 12/07/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND Acceptance and Commitment Therapy for depression (ACT-D) is a promising depression treatment which has not been evaluated on a large scale within VA. This study aimed to evaluate ACT-D's effectiveness in a national, treatment-seeking sample of Veterans. METHODS The sample comprised 831 Veterans who received a primary depression diagnosis and received at least two sessions of ACT-D during fiscal years 2015-2020. We used GLM to measure predictors of symptom change, treatment response (50 % reduction in PHQ-9 and AAQ-II scores), subthreshold depression symptoms (PHQ-9 < 10; AAQ-II < 27), and treatment completion. RESULTS Veterans experienced an average reduction of 3.39 points on the PHQ-9 (Cohen's d = 0.56) and 3.76 points on the AAQ-II (Cohen's d = 0.43). On the PHQ-9, 40 % achieved subthreshold depression symptoms. On the AAQ-II, 36 % of Veterans achieved subthreshold psychological inflexibility scores. Service-connected disability rating for depression and higher levels of medical comorbidity were both related to lower levels of overall depression symptom change and treatment response. Substance use disorder and bipolar/psychosis diagnoses were associated with greater reductions in psychological inflexibility. LIMITATIONS This is an observational study without a control group, so we were unable to compare the effectiveness of ACT-D to other usual care for depression. We were also unable to assess variables that can influence treatment success, such as therapist fidelity and patient engagement. CONCLUSIONS ACT-D achieved similar improvements in depression as reported in controlled trials. Adaptations to ACT-D may be needed to improve outcomes for Veterans with depression and comorbid PTSD.
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Affiliation(s)
- Peter P Grau
- VA Serious Mental Illness Treatment Resource and Evaluation Center (SMITREC), 2800 Plymouth Road, Bldg 16, Ann Arbor, MI 48109, United States; VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI 48105, United States; Department of Psychiatry, University of Michigan Medical School, United States; Veterans Affairs Center for Clinical Management Research, Health Services Research and Development, Ann Arbor, MI, United States.
| | - Rebecca K Sripada
- VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI 48105, United States; Department of Psychiatry, University of Michigan Medical School, United States; Veterans Affairs Center for Clinical Management Research, Health Services Research and Development, Ann Arbor, MI, United States
| | - Dara Ganoczy
- Veterans Affairs Center for Clinical Management Research, Health Services Research and Development, Ann Arbor, MI, United States
| | - Jonathan H Weinstein
- VA Northport Medical Center, 79 Middleville Road, Northport, NY 11768, United States
| | - Paul N Pfeiffer
- VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI 48105, United States; Department of Psychiatry, University of Michigan Medical School, United States; Veterans Affairs Center for Clinical Management Research, Health Services Research and Development, Ann Arbor, MI, United States
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13
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Lapidos A, Franks MB, Werner P, Pfeiffer PN. Implementing a State-Funded Peer-Run Mental Health Warmline During the COVID-19 Pandemic. J Health Care Poor Underserved 2023. [DOI: 10.1353/hpu.2023.0033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
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14
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Pfeiffer PN, Zivin K, Hosanagar A, Panaite V, Ganoczy D, Kim HM, Hofer T, Piette JD. Assessment of Outcome-Based Measures of Depression Care Quality in Veterans Health Administration Facilities. J Behav Health Serv Res 2023; 50:49-67. [PMID: 36207569 PMCID: PMC9542458 DOI: 10.1007/s11414-022-09813-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/27/2022] [Indexed: 02/01/2023]
Abstract
To inform the potential use of patient-reported depression symptom outcomes as measures of care quality, this study collected and analyzed longitudinal Patient Health Questionnaire (PHQ9) scores among 1,638 patients who screened positive for major depression according to a PHQ9 ≥ 10 across 29 Department of Veterans Affairs facilities. The study found baseline PHQ9, prior mental health visits, physical functioning, and treatment expectancy were consistently associated with subsequent PHQ9 outcomes. No facilities outperformed any others on PHQ9 scores at the 6-month primary endpoint, and the corresponding intra-class coefficient was ≤ .01 for the entire sample (n = 1,214) and 0.03 for the subgroup of patients with new depression episodes (n = 629). Measures of antidepressant receipt, psychotherapy, or treatment intensification were not associated with 6-month PHQ9 scores. PHQ9 outcomes are therefore unlikely to be useful as quality indicators for VA healthcare facilities due to low inter-facility variation, and new care process measures are needed to inform care for patients with chronic depression prevalent in this sample.
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Affiliation(s)
- Paul N. Pfeiffer
- grid.413800.e0000 0004 0419 7525VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI USA ,grid.413800.e0000 0004 0419 7525Mental Health Service, VA Ann Arbor Healthcare System, Ann Arbor, MI USA ,grid.214458.e0000000086837370University of Michigan Medical School, Ann Arbor, MI USA
| | - Kara Zivin
- grid.413800.e0000 0004 0419 7525VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI USA ,grid.214458.e0000000086837370University of Michigan Medical School, Ann Arbor, MI USA ,grid.214458.e0000000086837370School of Public Health, University of Michigan, Ann Arbor, MI USA
| | - Avinash Hosanagar
- grid.413800.e0000 0004 0419 7525Mental Health Service, VA Ann Arbor Healthcare System, Ann Arbor, MI USA ,grid.214458.e0000000086837370University of Michigan Medical School, Ann Arbor, MI USA
| | - Vanessa Panaite
- grid.281075.90000 0001 0624 9286James A. Haley Veterans’ Hospital, Tampa, FL USA
| | - Dara Ganoczy
- grid.413800.e0000 0004 0419 7525VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI USA
| | - H. Myra Kim
- grid.413800.e0000 0004 0419 7525VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI USA ,grid.214458.e0000000086837370University of Michigan Consulting for Statistics, Computing, and Analytics Research, Ann Arbor, MI USA
| | - Timothy Hofer
- grid.413800.e0000 0004 0419 7525VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI USA ,grid.214458.e0000000086837370University of Michigan Medical School, Ann Arbor, MI USA
| | - John D. Piette
- grid.413800.e0000 0004 0419 7525VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI USA ,grid.214458.e0000000086837370University of Michigan Medical School, Ann Arbor, MI USA ,grid.214458.e0000000086837370School of Public Health, University of Michigan, Ann Arbor, MI USA
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15
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Severe J, Pfeiffer PN, Palm-Cruz K, Hoeft T, Sripada R, Hawrilenko M, Chen S, Fortney J. Clinical Predictors of Engagement in Teleintegrated Care and Telereferral Care for Complex Psychiatric Disorders in Primary Care: a Randomized Trial. J Gen Intern Med 2022; 37:3361-3367. [PMID: 35106719 PMCID: PMC9550945 DOI: 10.1007/s11606-021-07343-x] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 12/15/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Telepsychiatry Collaborative Care (TCC) and Telepsychiatry/Telepsychology Enhanced Referral (TER) expand the reach of specialty mental health services to underserved populations. OBJECTIVE Assess clinical predictors of treatment engagement for complex psychiatric conditions in TCC-in which remote specialists consult with primary care teams via an onsite care manager who also provides brief psychotherapy-and TER, in which remote specialists provide direct telehealth treatment. DESIGN A randomized pragmatic trial from twenty-four primary care clinics without onsite psychiatrists or psychologists. PARTICIPANTS A total of 1,004 adult patients screened positive for posttraumatic stress disorder (PTSD)and/or bipolar disorder were randomized to receive TCC or TER for 1 year. MAIN MEASURES Psychotherapy engagement was measured by the number of sessions completed, and pharmacotherapy engagement by the medication adherence item from the Schizophrenia Care and Assessment Program Health Questionnaire (SCAP-HQ). KEY RESULTS Engagement in TCC psychotherapy visits was greater compared to TER. There was no association between the PTSD symptom severity and treatment engagement. The internal state scale (ISS) activation subscale, an indicator of mania, was associated with reduced odds of initiating psychotherapy (odds ratio [OR] = 0.70; 95% CI, 0.59 to 0.84) but not the number of sessions attended once psychotherapy started. The Drug Abuse Screening Test-10(DAST-10) score was associated with receipt of fewer psychotherapy sessions (incidence ratio rate [IRR] = 0.88; 95% CI, 0.81 to 0.95). The number of physical health comorbidities was associated with greater engagement in psychotherapy (IRR = 1.11, 95% CI, 1.03 to 1.19) and pharmacotherapy (OR = 1.54; 95% CI, 1.27 to 1.87). None of the findings varied by intervention group. CONCLUSIONS Both teleintegrated and telereferral care offer an opportunity to treat patients with complex psychiatric conditions. While there was no difference in clinical characteristics predicting engagement, onsite care managers engaged patients in more psychotherapy sessions than remote therapists. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02738944.
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Affiliation(s)
- Jennifer Severe
- Department of Psychiatry, University of Michigan Medical School, 4250 Plymouth Rd, Ann Arbor, MI, 48109, USA.
| | - Paul N Pfeiffer
- Department of Psychiatry, University of Michigan Medical School, 4250 Plymouth Rd, Ann Arbor, MI, 48109, USA
- Department of Veterans Affairs, Ann Arbor Veterans Affairs Center for Clinical Management Research, Ann Arbor, MI, USA
| | - Katherine Palm-Cruz
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, WA, USA
| | - Theresa Hoeft
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, WA, USA
| | - Rebecca Sripada
- Department of Psychiatry, University of Michigan Medical School, 4250 Plymouth Rd, Ann Arbor, MI, 48109, USA
- Department of Veterans Affairs, Ann Arbor Veterans Affairs Center for Clinical Management Research, Ann Arbor, MI, USA
| | - Matthew Hawrilenko
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, WA, USA
| | - Shiyu Chen
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, WA, USA
| | - John Fortney
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, WA, USA
- Department of Veterans Affairs, Health Services Research and Development, Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, WA, USA
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16
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Ilgen MA, Price AM, Coughlin LN, Pfeiffer PN, Stewart HJ, Pope E, Britton PC. Encouraging the use of the Veterans Crisis Line among high-risk Veterans: A randomized trial of a Crisis Line Facilitation intervention. J Psychiatr Res 2022; 154:159-166. [PMID: 35940001 DOI: 10.1016/j.jpsychires.2022.07.047] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 07/11/2022] [Accepted: 07/20/2022] [Indexed: 11/29/2022]
Abstract
The Veterans Crisis Line (VCL) is a core component of VA's suicide prevention strategy. Despite the availability and utility of the VCL, many Veterans do not utilize this resource during times of crisis. A brief, psychoeducational behavioral intervention (termed Crisis Line Facilitation [CLF]) was developed to increase utilization of the VCL and reduce suicidal behaviors in high-risk Veterans. The therapist-led session includes educational information regarding the VCL, as well as a chance to discuss the participant's perceptions of contacting the VCL during periods of crisis. The final component of the session is a practice call placed to the VCL by both the therapist and the participant. The CLF intervention was compared to Enhanced Usual Care (EUC) during a multi-site randomized clinical trial for 307 Veteran participants recently hospitalized for a suicidal crisis who reported no contact with the VCL in the prior 12 months. Initial analyses indicated that participants randomized to the CLF intervention were less likely to report suicidal behaviors, including suicide attempts compared to participants randomized to receive EUC over 12-months of follow-up (χ2 = 18.48/p < 0.0001), however this effect was not sustained when analyses were conducted on an individual level. No significant differences were found between conditions on VCL utilization. Initial evidence suggests a brief CLF intervention has an impact on preventing suicidal behaviors in Veterans treated in inpatient mental health programs; however, it may not change use of the VCL. This brief intervention could be easily adapted into clinical settings to be delivered by standard clinical staff.
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Affiliation(s)
- Mark A Ilgen
- VA Center for Clinical Management Research (CCMR), Department of Veterans Affairs Healthcare System, Ann Arbor, MI, USA; Department of Psychiatry, University of Michigan Medical School, Ann Arbor, MI, USA.
| | - Amanda M Price
- VA Center for Clinical Management Research (CCMR), Department of Veterans Affairs Healthcare System, Ann Arbor, MI, USA; Department of Psychiatry, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Lara N Coughlin
- VA Center for Clinical Management Research (CCMR), Department of Veterans Affairs Healthcare System, Ann Arbor, MI, USA; Department of Psychiatry, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Paul N Pfeiffer
- VA Center for Clinical Management Research (CCMR), Department of Veterans Affairs Healthcare System, Ann Arbor, MI, USA; Department of Psychiatry, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Haylie J Stewart
- VA Center for Clinical Management Research (CCMR), Department of Veterans Affairs Healthcare System, Ann Arbor, MI, USA; Department of Psychiatry, University of Michigan Medical School, Ann Arbor, MI, USA
| | | | - Peter C Britton
- VA Center of Excellence for Suicide Prevention, VA Finger Lakes Health Care System, USA; Department of Psychiatry, University of Rochester Medical Center, Rochester, NY, USA
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17
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Weaver A, Landry C, Zhang A, McQuown L, Hahn J, Harrington M, Tucker KM, Holzworth J, Buys T, Smith FN, Grogan-Kaylor A, Pfeiffer PN, Kilbourne AM, Himle JA. Study protocol: A randomized controlled trial of Raising Our Spirits Together, an entertaining, group-based technology-assisted cognitive behavioral therapy for depression, tailored for rural adults and delivery by clergy. Contemp Clin Trials Commun 2022; 29:100952. [PMID: 35865278 PMCID: PMC9294258 DOI: 10.1016/j.conctc.2022.100952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 03/27/2022] [Accepted: 06/23/2022] [Indexed: 11/25/2022] Open
Abstract
This paper presents a methodological description of a randomized controlled trial (RCT) testing the effect of Raising Our Spirits Together (ROST), a technology-assisted cognitive behavioral therapy (T-CBT) for depression, tailored for the rural context and for delivery by clergy, compared to an enhanced control condition. Depression is among the most common mental health conditions; yet the majority of adults with depression do not receive needed treatment due to limited access to mental health professionals, treatment-associated costs, distance to care, and stigma. These barriers are particularly salient in rural areas of the United States. T-CBT with human support is an accessible and effective treatment for depression; however, currently available T-CBTs have poor completion rates due to the lack of tailoring and other features to support engagement. ROST is a T-CBT specifically tailored for the rural setting and delivery by clergy, who are preferred, informal providers. ROST also presents core CBT content in a simple, jargon-free manner that supports multiple learning preferences. ROST is delivered virtually in a small group format across 8 weekly sessions via videoconferencing software consistent with other clergy-based programs, such as Bible studies or self-help groups. In this study, adults with depressive symptoms recruited from two rural Michigan counties will be randomized to receive ROST versus an enhanced control condition (N = 84). Depressive symptoms post-treatment and at 3 months follow-up according to the Patient Health Questionnaire (PHQ-9) will be the primary outcome. Findings will determine whether ROST is effective for improving depression symptoms in underserved, under resourced rural communities.
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18
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Damschroder LJ, Sussman JB, Pfeiffer PN, Kurlander JE, Freitag MB, Robinson CH, Spoutz P, Christopher MLD, Battar S, Dickerson K, Sedgwick C, Wallace-Lacey AG, Barnes GD, Linsky AM, Ulmer CS, Lowery JC. Maintaining Implementation through Dynamic Adaptations (MIDAS): protocol for a cluster-randomized trial of implementation strategies to optimize and sustain use of evidence-based practices in Veteran Health Administration (VHA) patients. Implement Sci Commun 2022; 3:53. [PMID: 35568903 PMCID: PMC9107220 DOI: 10.1186/s43058-022-00297-z] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 04/05/2022] [Indexed: 11/18/2022] Open
Abstract
Background The adoption and sustainment of evidence-based practices (EBPs) is a challenge within many healthcare systems, especially in settings that have already strived but failed to achieve longer-term goals. The Veterans Affairs (VA) Maintaining Implementation through Dynamic Adaptations (MIDAS) Quality Enhancement Research Initiative (QUERI) program was funded as a series of trials to test multi-component implementation strategies to sustain optimal use of three EBPs: (1) a deprescribing approach intended to reduce potentially inappropriate polypharmacy; (2) appropriate dosing and drug selection of direct oral anticoagulants (DOACs); and (3) use of cognitive behavioral therapy as first-line treatment for insomnia before pharmacologic treatment. We describe the design and methods for a harmonized series of cluster-randomized control trials comparing two implementation strategies. Methods For each trial, we will recruit 8–12 clinics (24–36 total). All will have access to relevant clinical data to identify patients who may benefit from the target EBP at that clinic and provider. For each trial, clinics will be randomized to one of two implementation strategies to improve the use of the EBPs: (1) individual-level academic detailing (AD) or (2) AD plus the team-based Learn. Engage. Act. Process. (LEAP) quality improvement (QI) learning program. The primary outcomes will be operationalized across the three trials as a patient-level dichotomous response (yes/no) indicating patients with potentially inappropriate medications (PIMs) among those who may benefit from the EBP. This outcome will be computed using month-by-month administrative data. Primary comparison between the two implementation strategies will be analyzed using generalized estimating equations (GEE) with clinic-level monthly (13 to 36 months) percent of PIMs as the dependent variable. Primary comparative endpoint will be at 18 months post-baseline. Each trial will also be analyzed independently. Discussion MIDAS QUERI trials will focus on fostering sustained use of EBPs that previously had targeted but incomplete implementation. Our implementation approaches are designed to engage frontline clinicians in a dynamic optimization process that integrates the use of actional clinical data and making incremental changes, designed to be feasible within busy clinical settings. Trial registration ClinicalTrials.gov: NCT05065502. Registered October 4, 2021—retrospectively registered. Supplementary Information The online version contains supplementary material available at 10.1186/s43058-022-00297-z.
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Affiliation(s)
- Laura J Damschroder
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI, 48105, USA.
| | - Jeremy B Sussman
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI, 48105, USA.,Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA.,Institute for Healthcare Policy and Innovation, Ann Arbor, MI, USA
| | - Paul N Pfeiffer
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI, 48105, USA.,Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
| | - Jacob E Kurlander
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI, 48105, USA.,Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA.,Institute for Healthcare Policy and Innovation, Ann Arbor, MI, USA
| | - Michelle B Freitag
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI, 48105, USA
| | - Claire H Robinson
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI, 48105, USA
| | - Patrick Spoutz
- Veterans Health Affairs VISN 20 Pharmacy Benefits Management, Vancouver, WA, USA
| | - Melissa L D Christopher
- Pharmacy Benefits Management Services, Veterans Health Administration, 810 Vermont Ave NW, Washington DC, 20420, USA
| | - Saraswathy Battar
- Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA.,Baylor College of Medicine, Houston, TX, USA
| | | | - Christopher Sedgwick
- Department of Veterans Affairs, VA Heartland Network (VISN 15), Kansas City, MO, USA
| | | | - Geoffrey D Barnes
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA.,Institute for Healthcare Policy and Innovation, Ann Arbor, MI, USA.,Frankel Cardiovascular Center, University of Michigan, Ann Arbor, MI, USA
| | - Amy M Linsky
- Section of General Medicine, VA Boston Healthcare System, Boston, MA, USA.,Center for Health Organizations and Implementation Research, VA Boston Healthcare System, Boston, MA, USA.,Section of General Internal Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Christi S Ulmer
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT) Durham Veterans Affairs Health Care System, Durham, NC, USA.,Department of Psychiatry and Behavioral Sciences, Duke University, Durham, NC, USA
| | - Julie C Lowery
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI, 48105, USA
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19
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Helminski D, Kurlander JE, Renji AD, Sussman JB, Pfeiffer PN, Conte ML, Gadabu OJ, Kokaly AN, Goldberg R, Ranusch A, Damschroder LJ, Landis-Lewis Z. Dashboards in Health Care Settings: Protocol for a Scoping Review. JMIR Res Protoc 2022; 11:e34894. [PMID: 35234650 PMCID: PMC8928055 DOI: 10.2196/34894] [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] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 01/11/2022] [Accepted: 01/11/2022] [Indexed: 12/18/2022] Open
Abstract
Background Health care organizations increasingly depend on business intelligence tools, including “dashboards,” to capture, analyze, and present data on performance metrics. Ideally, dashboards allow users to quickly visualize actionable data to inform and optimize clinical and organizational performance. In reality, dashboards are typically embedded in complex health care organizations with massive data streams and end users with distinct needs. Thus, designing effective dashboards is a challenging task and theoretical underpinnings of health care dashboards are poorly characterized; even the concept of the dashboard remains ill-defined. Researchers, informaticists, clinical managers, and health care administrators will benefit from a clearer understanding of how dashboards have been developed, implemented, and evaluated, and how the design, end user, and context influence their uptake and effectiveness. Objective This scoping review first aims to survey the vast published literature of “dashboards” to describe where, why, and for whom they are used in health care settings, as well as how they are developed, implemented, and evaluated. Further, we will examine how dashboard design and content is informed by intended purpose and end users. Methods In July 2020, we searched MEDLINE, Embase, Web of Science, and the Cochrane Library for peer-reviewed literature using a targeted strategy developed with a research librarian and retrieved 5188 results. Following deduplication, 3306 studies were screened in duplicate for title and abstract. Any abstracts mentioning a health care dashboard were retrieved in full text and are undergoing duplicate review for eligibility. Articles will be included for data extraction and analysis if they describe the development, implementation, or evaluation of a dashboard that was successfully used in routine workflow. Articles will be excluded if they were published before 2015, the full text is unavailable, they are in a non-English language, or they describe dashboards used for public health tracking, in settings where direct patient care is not provided, or in undergraduate medical education. Any discrepancies in eligibility determination will be adjudicated by a third reviewer. We chose to focus on articles published after 2015 and those that describe dashboards that were successfully used in routine practice to identify the most recent and relevant literature to support future dashboard development in the rapidly evolving field of health care informatics. Results All articles have undergone dual review for title and abstract, with a total of 2019 articles mentioning use of a health care dashboard retrieved in full text for further review. We are currently reviewing all full-text articles in duplicate. We aim to publish findings by mid-2022. Findings will be reported following guidance from the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) checklist. Conclusions This scoping review will provide stakeholders with an overview of existing dashboard tools, highlighting the ways in which dashboards have been developed, implemented, and evaluated in different settings and for different end user groups, and identify potential research gaps. Findings will guide efforts to design and use dashboards in the health care sector more effectively. International Registered Report Identifier (IRRID) DERR1-10.2196/34894
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Affiliation(s)
- Danielle Helminski
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Jacob E Kurlander
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, United States.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, United States.,Veterans Affairs Ann Arbor Center for Clinical Management Research, Ann Arbor, MI, United States
| | - Anjana Deep Renji
- Department of Learning Health Sciences, University of Michigan, Ann Arbor, MI, United States
| | - Jeremy B Sussman
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, United States.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, United States.,Veterans Affairs Ann Arbor Center for Clinical Management Research, Ann Arbor, MI, United States
| | - Paul N Pfeiffer
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, United States.,Veterans Affairs Ann Arbor Center for Clinical Management Research, Ann Arbor, MI, United States.,Department of Psychiatry, University of Michigan, Ann Arbor, MI, United States
| | - Marisa L Conte
- Department of Learning Health Sciences, University of Michigan, Ann Arbor, MI, United States.,Taubman Health Sciences Library, University of Michigan, Ann Arbor, MI, United States
| | - Oliver J Gadabu
- Department of Learning Health Sciences, University of Michigan, Ann Arbor, MI, United States
| | - Alex N Kokaly
- Department of Medicine, UCLA Health, Los Angeles, CA, United States
| | - Rebecca Goldberg
- University of Michigan Medical School, Ann Arbor, MI, United States
| | - Allison Ranusch
- Veterans Affairs Ann Arbor Center for Clinical Management Research, Ann Arbor, MI, United States
| | - Laura J Damschroder
- Veterans Affairs Ann Arbor Center for Clinical Management Research, Ann Arbor, MI, United States
| | - Zach Landis-Lewis
- Department of Learning Health Sciences, University of Michigan, Ann Arbor, MI, United States
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20
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Zivin K, Chang MUM, Van T, Osatuke K, Boden M, Sripada RK, Abraham KM, Pfeiffer PN, Kim HM. Relationships between work-environment characteristics and behavioral health provider burnout in the Veterans Health Administration. Health Serv Res 2022; 57 Suppl 1:83-94. [PMID: 35230714 PMCID: PMC9108225 DOI: 10.1111/1475-6773.13964] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [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] [Received: 07/19/2021] [Revised: 02/03/2022] [Accepted: 02/04/2022] [Indexed: 11/28/2022] Open
Abstract
Objective To identify work–environment characteristics associated with Veterans Health Administration (VHA) behavioral health provider (BHP) burnout among psychiatrists, psychologists, and social workers. Data Sources The 2015–2018 data from Annual All Employee Survey (AES); Mental Health Provider Survey (MHPS); N = 57,397 respondents; facility‐level Mental Health Onboard Clinical (MHOC) staffing and productivity data, N = 140 facilities. Study Design For AES and MHPS separately, we used mixed‐effects logistic regression to predict BHP burnout using surveys from year pairs (2015–2016, 2016–2017, 2017–2018; six models). Within each year‐pair, we used the earlier year of data to train models and tested the model in the later year, with burnout (emotional exhaustion and/or depersonalization) as the outcome for each survey. We used potentially modifiable work–environment characteristics as predictors, controlling for employee demographic characteristics as covariates, and employment facility as random intercepts. Data Collection/Extraction Methods We included work–environment predictors that appeared in all 4 years (11 in AES; 17 in MHPS). Principal Findings In 2015–2018, 31.0%–38.0% of BHPs reported burnout in AES or MHPS. Work characteristics consistently associated with significantly lower burnout were included for AES: reasonable workload; having appropriate resources to perform a job well; supervisors address concerns; given an opportunity to improve skills. For MHPS, characteristics included: reasonable workload; work improves veterans' lives; mental health care provided is well‐coordinated; and three reverse‐coded items: staffing vacancies; daily work that clerical/support staff could complete; and collateral duties reduce availability for patient care. Facility‐level staffing ratios and productivity did not significantly predict individual‐level burnout. Workload represented the strongest predictor of burnout in both surveys. Conclusions This study demonstrated substantial, ongoing impacts that having appropriate resources including staff, workload, and supervisor support had on VHA BHP burnout. VHA may consider investing in approaches to mitigate the impact of BHP burnout on employees and their patients through providing staff supports, managing workload, and goal setting.
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Affiliation(s)
- Kara Zivin
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, United States.,Department of Psychiatry, Michigan Medicine, Ann Arbor, Michigan, United States
| | - Ming-Un Myron Chang
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, United States
| | - Tony Van
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, United States
| | - Katerine Osatuke
- VHA National Center for Organization Development, Cincinnati, Ohio, United States
| | - Matthew Boden
- Program Evaluation and Resource Center and VA Office of Mental Health Operations, VA Palo Alto Health Care System, Palo Alto, California
| | - Rebecca K Sripada
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, United States.,Department of Psychiatry, Michigan Medicine, Ann Arbor, Michigan, United States
| | - Kristen M Abraham
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, United States.,Department of Psychology, University of Detroit Mercy, Detroit, Michigan, United States
| | - Paul N Pfeiffer
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, United States.,Department of Psychiatry, Michigan Medicine, Ann Arbor, Michigan, United States
| | - Hyungjin Myra Kim
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, United States.,Consulting for Statistics, Computing and Analytics Research, University of Michigan, Ann Arbor, Michigan, United States
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21
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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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22
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Klim C, Vitous CA, Keller-Cohen D, Vega E, Forman J, Lapidos A, Abraham KM, Pfeiffer PN. Characterizing suicide-related self-disclosure by peer specialists: a qualitative analysis of audio-recorded sessions. Adv Ment Health 2022; 20:170-180. [PMID: 35756076 PMCID: PMC9231833 DOI: 10.1080/18387357.2021.2010585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 01/03/2023]
Abstract
Objective We characterized peer support specialists' self-disclosures related to suicide and recipient responses to inform services for high-risk individuals that may include peer support. Method We used an inductive approach and thematic analysis to identify themes from audio recordings of initial sessions between peer support specialists trained in suicide-related self-disclosure and 10 study participants who were admitted to inpatient psychiatry units with suicidal ideation or a suicide attempt. Results The first theme, "I've been suicidal, but those details are not important", reflects that peers mentioned suicide-related aspects of their histories briefly, often as part of introductions, without participants responding specifically to those aspects. The second theme, "Being suicidal is one of the challenges I've faced", reflects that in more detailed disclosures by peer specialists and in participant responses, suicide is a part of the mental health challenges and life stressors discussed, not the focus. The third theme "Let's focus on my recovery and what I've learned" reflects that peers steered their self-disclosures away from suicide and towards what was helpful in their recovery. Conclusions Suicide-related self-disclosures embedded within peer specialists' introduction or overall recovery narrative convey a shared experience while focusing conversation on mental health challenges other than suicide.
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Affiliation(s)
- Casimir Klim
- Department of Psychiatry and Psychology, Mayo Clinic Center for Graduate Medical Education
| | - C. Ann Vitous
- Department of Surgery, University of Michigan Medical School
| | | | | | - Jane Forman
- VA Health Services Research and Development Center for Clinical Management Research, VA Ann Arbor Healthcare System
| | | | | | - Paul N. Pfeiffer
- VA Health Services Research and Development Center for Clinical Management Research, VA Ann Arbor Healthcare System,Department of Psychiatry, University of Michigan Medical School
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23
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Vance MC, Chang MM, Sussman JB, Zivin K, Pfeiffer PN. Predicting clinically significant response to primary care treatment for depression from electronic health records of veterans. J Affect Disord 2021; 294:337-345. [PMID: 34311334 DOI: 10.1016/j.jad.2021.07.017] [Citation(s) in RCA: 1] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 06/30/2021] [Accepted: 07/12/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To reduce delays in referral to specialty mental health care, we evaluated clinical prediction models estimating the likelihood of response to primary care treatment of depression in the VA healthcare system. METHODS We included patients with a primary care depression diagnosis between October 1, 2015 and December 31, 2017, an initial PHQ-9 score ≥ 10 within 30 days, a follow-up PHQ-9 score within 2-8 months, and no specialty mental health care within three months prior to depression diagnosis. We evaluated eight ordinary least squares regression models, each with a different procedure for selecting predictors of percentage change in PHQ-9 score from baseline to follow-up. Predictors included patient characteristics from electronic health records and neighborhood characteristics from US census data. We repeated each modeling procedure 1,000 times, using different training and validation sets of patients. We used R2, RMSE, and MAE to evaluate model performance. RESULTS The final cohort included 3,464 patients. The two best performing models included multiple iterations of backwards stepwise variable selection with R2 of 0.07, RMSE of 41.45, MAE of 33.30; and R2 of 0.07, RMSE of 41.39, MAE of 33.28. LIMITATIONS Wide follow-up interval, possibility of misclassification error due to use of EHR data. CONCLUSIONS Model performance did not suggest its use as a guide in clinical decision-making. Future research should explore whether obtaining additional risk factor data from patients (e.g., duration of symptoms) or modeling PHQ-9 scores over a narrower time interval improves performance of clinical risk prediction tools for depression.
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Affiliation(s)
- Mary C Vance
- Center for the Study of Traumatic Stress, Department of Psychiatry, Uniformed Services University, Bethesda, MD, USA.
| | - M Myron Chang
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Jeremy B Sussman
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA; Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Kara Zivin
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA; Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
| | - Paul N Pfeiffer
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA; Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
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24
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Bowersox NW, Jagusch J, Garlick J, Chen JI, Pfeiffer PN. Peer-based interventions targeting suicide prevention: A scoping review. Am J Community Psychol 2021; 68:232-248. [PMID: 33720444 PMCID: PMC9165581 DOI: 10.1002/ajcp.12510] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [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: 05/04/2023]
Abstract
Peers of individuals at risk for suicide may be able to play important roles in suicide prevention. The aim of the current study is to conduct a scoping review to characterize the breadth of peer-delivered suicide prevention services and their outcomes to inform future service delivery and research. Articles were selected based on search terms related to peers, suicide, or crisis. After reviews of identified abstracts (N = 2681), selected full-text articles (N = 286), and additional references (N = 62), a total of 84 articles were retained for the final review sample. Types of suicide prevention services delivered by peers included being a gatekeeper, on-demand crisis support, crisis support in acute care settings, and crisis or relapse prevention. Peer relationships employed in suicide prevention services included fellow laypersons; members of the same sociodemographic subgroup (e.g., racial minority), workplace, or institution (e.g., university, correctional facility); and the shared experience of having a mental condition. The majority of published studies were program descriptions or uncontrolled trials, with only three of 84 articles qualifying as randomized controlled trials. Despite a lack of methodological rigor in identified studies, peer support interventions for suicide prevention have been implemented utilizing a diverse range of peer provider types and functions. New and existing peer-delivered suicide prevention services should incorporate more rigorous evaluation methods regarding acceptability and effectiveness.
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Affiliation(s)
- Nicholas W. Bowersox
- Department of Psychiatry, University of Michigan Medical School, Ann Arbor, MI, USA
- VA Center for Clinical Management Research, Ann Arbor, MI, USA
| | - Jennifer Jagusch
- Department of Psychiatry, University of Michigan Medical School, Ann Arbor, MI, USA
- VA Center for Clinical Management Research, Ann Arbor, MI, USA
| | - James Garlick
- Department of Psychiatry, University of Michigan Medical School, Ann Arbor, MI, USA
- VA Center for Clinical Management Research, Ann Arbor, MI, USA
| | - Jason I. Chen
- VA Center to Improve Veteran Involvement in Care, Portland, OR, USA
| | - Paul N. Pfeiffer
- Department of Psychiatry, University of Michigan Medical School, Ann Arbor, MI, USA
- VA Center for Clinical Management Research, Ann Arbor, MI, USA
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25
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Lee AA, Sripada RK, Hale AC, Ganoczy D, Trivedi RB, Arnow B, Pfeiffer PN. Psychotherapy and depressive symptom trajectories among VA patients: Comparing dose-effect and good-enough level models. J Consult Clin Psychol 2021; 89:379-392. [PMID: 34124925 DOI: 10.1037/ccp0000645] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Objective: Psychotherapy for depression is effective for many veterans, but the relationship between number of treatment sessions and symptom outcomes is not well established. The Dose-Effect model predicts that greater psychotherapeutic dose (total sessions) yields greater symptom improvement with each additional session resulting in smaller session-to-session improvement. In contrast, the Good-Enough Level (GEL) model predicts that rate of symptom improvement varies by total psychotherapeutic dose with faster improvement associated with earlier termination. This study compared the dose-effect and GEL model among veterans receiving psychotherapy for depression within the Veterans Health Administration. Method: The sample included 13,647 veterans with ≥2 sessions of psychotherapy for depression with associated Patient Health Questionnaire-9 (PHQ-9) scores in primary care (n = 7,502) and specialty mental health clinics (n = 6,145) between October 2014 and September 2018. Multilevel longitudinal modeling was used to compare the Dose-Effect and GEL models within each clinic type. Results: The GEL model demonstrated greater fit for both clinic types relative to dose-effect models. In both treatment settings, veterans with fewer sessions improved faster than those with more sessions. In primary care clinics, veterans who received 4-8 total sessions achieved similar levels of symptom response. In specialty mental health clinics, increased psychotherapeutic dose was associated with greater treatment response up to 16 sessions. Veterans receiving 20 sessions demonstrated minimal treatment response. Conclusions: These findings support the GEL model and suggest a flexible approach to determining length of psychotherapy for depression may be useful for optimizing treatment response and allocation of clinical resources. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
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Affiliation(s)
- Aaron A Lee
- Department of Psychology, University of Mississippi
| | - Rebecca K Sripada
- Veterans Affairs Center for Clinical Management Research, Veterans Affairs Ann Arbor Health Care System
| | | | - Dara Ganoczy
- Veterans Affairs Center for Clinical Management Research, Veterans Affairs Ann Arbor Health Care System
| | - Ranak B Trivedi
- VA Center for Innovation to Implementation, VA Palo Alto Health Care System
| | - Bruce Arnow
- VA Center for Innovation to Implementation, VA Palo Alto Health Care System
| | - Paul N Pfeiffer
- Veterans Affairs Center for Clinical Management Research, Veterans Affairs Ann Arbor Health Care System
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26
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Ilgen MA, Stewart HJ, Lhermitte SL, Pfeiffer PN, Britton PC, Pope EB. Developing and testing Crisis Line Facilitation (CLF) to encourage help-seeking in adults receiving inpatient treatment for a suicidal crisis. Cogn Behav Pract 2021; 28. [PMID: 33679121 DOI: 10.1016/j.cbpra.2020.05.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Military Veterans are at overall greater risk of suicide than non-Veterans and have experienced increases in rates of suicide that are on par with or exceed those of the general population. The Department of Veterans Affairs has undertaken several initiatives to reduce suicide among Veterans, including the development and expansion of the Veterans Crisis Line (VCL). The VCL has the potential to reduce suicidal behaviors, but it is likely underutilized by high-risk Veterans. This paper describes the development of Crisis Line Facilitation (CLF) a brief intervention, designed to increase use of the VCL in this high-risk population. In a single session, CLF presents psychoeducational information about the VCL, discusses the participant's perceived barriers and facilitators to future use of the VCL, and culminates in the Veteran calling the VCL with the therapist to provide firsthand experiences that may counter negative impressions of the line. The intervention development process, intervention and control condition, and self-reported change indices are presented. Preliminary results (N = 301) suggest Veterans receiving CLF may experience a significant increase in comfort with, and confidence in, using the VCL during future crises compared to those in the control condition.
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Affiliation(s)
- Mark A Ilgen
- VA Center for Clinical Management Research (CCMR)
- Department of Psychiatry, University of Michigan
| | - Haylie J Stewart
- VA Center for Clinical Management Research (CCMR)
- Department of Psychiatry, University of Michigan
| | | | - Paul N Pfeiffer
- VA Center for Clinical Management Research (CCMR)
- Department of Psychiatry, University of Michigan
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27
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Pfeiffer PN, Pope B, Houck M, Benn-Burton W, Zivin K, Ganoczy D, Kim HM, Walters H, Emerson L, Nelson CB, Abraham KM, Valenstein M. Effectiveness of Peer-Supported Computer-Based CBT for Depression Among Veterans in Primary Care. Psychiatr Serv 2020; 71:256-262. [PMID: 31931686 DOI: 10.1176/appi.ps.201900283] [Citation(s) in RCA: 15] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE This study tested whether computerized cognitive-behavioral therapy for depression supported by a peer specialist with lived experience of depression (PS-cCBT) improves mental health-related outcomes for primary care patients. METHODS In the U.S. Department of Veterans Affairs, primary care patients with a new diagnosis of depression (N=330) were randomly assigned to 3 months of PS-cCBT or a usual-care control condition. Linear mixed-effects models were used to assess differences in depression symptoms, general mental health status, quality of life, and mental health recovery measured at baseline and 3 and 6 months. RESULTS In adjusted analyses, participants who received PS-cCBT experienced 1.4 points' (95% confidence interval [CI]=0.3-2.5, p=0.01) greater improvement in depression symptoms on the Quick Inventory of Depression Symptomatology-Self Report at 3 months, compared with the control group, but no significant difference was noted at 6 months. PS-cCBT recipients also had 2.6 points' (95% CI=0.5-4.8, p=0.02) greater improvement in quality of life at 3 months on the Quality of Life Enjoyment and Satisfaction Questionnaire Short Form and greater improvement in recovery on the Recovery Assessment Scale at 3 months (3.6 points; 95% CI=0.9-6.2, p=0.01) and 6 months (4.5 points; 95% CI=1.2-7.7, p=0.01). CONCLUSIONS PS-cCBT is an effective option for improving short-term depression symptoms and longer-term recovery among primary care patients newly diagnosed as having depression.
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Affiliation(s)
- Paul N Pfeiffer
- U.S. Department of Veterans Affairs (VA) Ann Arbor Healthcare System, Ann Arbor, Michigan (Pfeiffer, Zivin, Ganoczy, Kim, Walters, Emerson, Nelson, Abraham, Valenstein); Department of Psychiatry, University of Michigan Medical School, Ann Arbor (Pfeiffer, Zivin, Walters, Emerson, Nelson, Valenstein); Battle Creek VA Medical Center, Battle Creek, Michigan (Pope, Houck); John D. Dingell VA Medical Center, Detroit (Benn-Burton); Consulting for Statistics, Computing and Analytics Research, University of Michigan, Ann Arbor (Kim); Department of Psychology, University of Detroit Mercy, Detroit (Abraham)
| | - Brooke Pope
- U.S. Department of Veterans Affairs (VA) Ann Arbor Healthcare System, Ann Arbor, Michigan (Pfeiffer, Zivin, Ganoczy, Kim, Walters, Emerson, Nelson, Abraham, Valenstein); Department of Psychiatry, University of Michigan Medical School, Ann Arbor (Pfeiffer, Zivin, Walters, Emerson, Nelson, Valenstein); Battle Creek VA Medical Center, Battle Creek, Michigan (Pope, Houck); John D. Dingell VA Medical Center, Detroit (Benn-Burton); Consulting for Statistics, Computing and Analytics Research, University of Michigan, Ann Arbor (Kim); Department of Psychology, University of Detroit Mercy, Detroit (Abraham)
| | - Marc Houck
- U.S. Department of Veterans Affairs (VA) Ann Arbor Healthcare System, Ann Arbor, Michigan (Pfeiffer, Zivin, Ganoczy, Kim, Walters, Emerson, Nelson, Abraham, Valenstein); Department of Psychiatry, University of Michigan Medical School, Ann Arbor (Pfeiffer, Zivin, Walters, Emerson, Nelson, Valenstein); Battle Creek VA Medical Center, Battle Creek, Michigan (Pope, Houck); John D. Dingell VA Medical Center, Detroit (Benn-Burton); Consulting for Statistics, Computing and Analytics Research, University of Michigan, Ann Arbor (Kim); Department of Psychology, University of Detroit Mercy, Detroit (Abraham)
| | - Wendy Benn-Burton
- U.S. Department of Veterans Affairs (VA) Ann Arbor Healthcare System, Ann Arbor, Michigan (Pfeiffer, Zivin, Ganoczy, Kim, Walters, Emerson, Nelson, Abraham, Valenstein); Department of Psychiatry, University of Michigan Medical School, Ann Arbor (Pfeiffer, Zivin, Walters, Emerson, Nelson, Valenstein); Battle Creek VA Medical Center, Battle Creek, Michigan (Pope, Houck); John D. Dingell VA Medical Center, Detroit (Benn-Burton); Consulting for Statistics, Computing and Analytics Research, University of Michigan, Ann Arbor (Kim); Department of Psychology, University of Detroit Mercy, Detroit (Abraham)
| | - Kara Zivin
- U.S. Department of Veterans Affairs (VA) Ann Arbor Healthcare System, Ann Arbor, Michigan (Pfeiffer, Zivin, Ganoczy, Kim, Walters, Emerson, Nelson, Abraham, Valenstein); Department of Psychiatry, University of Michigan Medical School, Ann Arbor (Pfeiffer, Zivin, Walters, Emerson, Nelson, Valenstein); Battle Creek VA Medical Center, Battle Creek, Michigan (Pope, Houck); John D. Dingell VA Medical Center, Detroit (Benn-Burton); Consulting for Statistics, Computing and Analytics Research, University of Michigan, Ann Arbor (Kim); Department of Psychology, University of Detroit Mercy, Detroit (Abraham)
| | - Dara Ganoczy
- U.S. Department of Veterans Affairs (VA) Ann Arbor Healthcare System, Ann Arbor, Michigan (Pfeiffer, Zivin, Ganoczy, Kim, Walters, Emerson, Nelson, Abraham, Valenstein); Department of Psychiatry, University of Michigan Medical School, Ann Arbor (Pfeiffer, Zivin, Walters, Emerson, Nelson, Valenstein); Battle Creek VA Medical Center, Battle Creek, Michigan (Pope, Houck); John D. Dingell VA Medical Center, Detroit (Benn-Burton); Consulting for Statistics, Computing and Analytics Research, University of Michigan, Ann Arbor (Kim); Department of Psychology, University of Detroit Mercy, Detroit (Abraham)
| | - H Myra Kim
- U.S. Department of Veterans Affairs (VA) Ann Arbor Healthcare System, Ann Arbor, Michigan (Pfeiffer, Zivin, Ganoczy, Kim, Walters, Emerson, Nelson, Abraham, Valenstein); Department of Psychiatry, University of Michigan Medical School, Ann Arbor (Pfeiffer, Zivin, Walters, Emerson, Nelson, Valenstein); Battle Creek VA Medical Center, Battle Creek, Michigan (Pope, Houck); John D. Dingell VA Medical Center, Detroit (Benn-Burton); Consulting for Statistics, Computing and Analytics Research, University of Michigan, Ann Arbor (Kim); Department of Psychology, University of Detroit Mercy, Detroit (Abraham)
| | - Heather Walters
- U.S. Department of Veterans Affairs (VA) Ann Arbor Healthcare System, Ann Arbor, Michigan (Pfeiffer, Zivin, Ganoczy, Kim, Walters, Emerson, Nelson, Abraham, Valenstein); Department of Psychiatry, University of Michigan Medical School, Ann Arbor (Pfeiffer, Zivin, Walters, Emerson, Nelson, Valenstein); Battle Creek VA Medical Center, Battle Creek, Michigan (Pope, Houck); John D. Dingell VA Medical Center, Detroit (Benn-Burton); Consulting for Statistics, Computing and Analytics Research, University of Michigan, Ann Arbor (Kim); Department of Psychology, University of Detroit Mercy, Detroit (Abraham)
| | - Lauren Emerson
- U.S. Department of Veterans Affairs (VA) Ann Arbor Healthcare System, Ann Arbor, Michigan (Pfeiffer, Zivin, Ganoczy, Kim, Walters, Emerson, Nelson, Abraham, Valenstein); Department of Psychiatry, University of Michigan Medical School, Ann Arbor (Pfeiffer, Zivin, Walters, Emerson, Nelson, Valenstein); Battle Creek VA Medical Center, Battle Creek, Michigan (Pope, Houck); John D. Dingell VA Medical Center, Detroit (Benn-Burton); Consulting for Statistics, Computing and Analytics Research, University of Michigan, Ann Arbor (Kim); Department of Psychology, University of Detroit Mercy, Detroit (Abraham)
| | - C Beau Nelson
- U.S. Department of Veterans Affairs (VA) Ann Arbor Healthcare System, Ann Arbor, Michigan (Pfeiffer, Zivin, Ganoczy, Kim, Walters, Emerson, Nelson, Abraham, Valenstein); Department of Psychiatry, University of Michigan Medical School, Ann Arbor (Pfeiffer, Zivin, Walters, Emerson, Nelson, Valenstein); Battle Creek VA Medical Center, Battle Creek, Michigan (Pope, Houck); John D. Dingell VA Medical Center, Detroit (Benn-Burton); Consulting for Statistics, Computing and Analytics Research, University of Michigan, Ann Arbor (Kim); Department of Psychology, University of Detroit Mercy, Detroit (Abraham)
| | - Kristen M Abraham
- U.S. Department of Veterans Affairs (VA) Ann Arbor Healthcare System, Ann Arbor, Michigan (Pfeiffer, Zivin, Ganoczy, Kim, Walters, Emerson, Nelson, Abraham, Valenstein); Department of Psychiatry, University of Michigan Medical School, Ann Arbor (Pfeiffer, Zivin, Walters, Emerson, Nelson, Valenstein); Battle Creek VA Medical Center, Battle Creek, Michigan (Pope, Houck); John D. Dingell VA Medical Center, Detroit (Benn-Burton); Consulting for Statistics, Computing and Analytics Research, University of Michigan, Ann Arbor (Kim); Department of Psychology, University of Detroit Mercy, Detroit (Abraham)
| | - Marcia Valenstein
- U.S. Department of Veterans Affairs (VA) Ann Arbor Healthcare System, Ann Arbor, Michigan (Pfeiffer, Zivin, Ganoczy, Kim, Walters, Emerson, Nelson, Abraham, Valenstein); Department of Psychiatry, University of Michigan Medical School, Ann Arbor (Pfeiffer, Zivin, Walters, Emerson, Nelson, Valenstein); Battle Creek VA Medical Center, Battle Creek, Michigan (Pope, Houck); John D. Dingell VA Medical Center, Detroit (Benn-Burton); Consulting for Statistics, Computing and Analytics Research, University of Michigan, Ann Arbor (Kim); Department of Psychology, University of Detroit Mercy, Detroit (Abraham)
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Fortney JC, Heagerty PJ, Bauer AM, Cerimele JM, Kaysen D, Pfeiffer PN, Zielinski MJ, Pyne JM, Bowen D, Russo J, Ferro L, Moore D, Nolan JP, Fee FC, Heral T, Freyholtz-London J, McDonald B, Mullins J, Hafer E, Solberg L, Unützer J. Study to promote innovation in rural integrated telepsychiatry (SPIRIT): Rationale and design of a randomized comparative effectiveness trial of managing complex psychiatric disorders in rural primary care clinics. Contemp Clin Trials 2020; 90:105873. [PMID: 31678410 DOI: 10.1016/j.cct.2019.105873] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 10/23/2019] [Accepted: 10/24/2019] [Indexed: 01/17/2023]
Abstract
OBJECTIVE Managing complex psychiatric disorders like PTSD and bipolar disorder is challenging in Federally Qualified Health Centers (FQHCs) delivering care to U.S residents living in underserved rural areas. This protocol paper describes SPIRIT, a pragmatic comparative effectiveness trial designed to compare two approaches to managing PTSD and bipolar disorder in FQHCs. INTERVENTIONS Treatment comparators are: 1) Telepsychiatry Collaborative Care, which integrates consulting telepsychiatrists into primary care teams, and 2) Telepsychiatry Enhanced Referral, where telepsychiatrists and telepsychologists treat patients directly. METHODS Because Telepsychiatry Enhanced Referral is an adaptive intervention, a Sequential, Multiple Assignment, Randomized Trial design is used. Twenty-four FQHC clinics without on-site psychiatrists or psychologists are participating in the trial. The sample is patients screening positive for PTSD and/or bipolar disorder who are not already engaged in pharmacotherapy with a mental health specialist. Intervention fidelity is measured but not controlled. Patient treatment engagement is measured but not required, and intent-to-treat analysis will be used. Survey questions measure treatment engagement and effectiveness. The Short-Form 12 Mental Health Component Summary (SF-12 MCS) is the primary outcome. RESULTS A third (34%) of those enrolled (n = 1004) are racial/ethnic minorities, 81% are not fully employed, 68% are Medicaid enrollees, 7% are uninsured, and 62% live in poverty. Mental health related quality of life (SF-12 MCS) is 2.5 standard deviations below the national mean. DISCUSSION We hypothesize that patients randomized to Telepsychiatry Collaborative Care will have better outcomes than those randomized to Telepsychiatry Enhanced Referral because a higher proportion will engage in evidence-based treatment.
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Affiliation(s)
- John C Fortney
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, WA, USA; Department of Veterans Affairs, Health Services Research and Development, Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, WA, USA.
| | - Patrick J Heagerty
- Department of Biostatistics, School of Public Health, University of Washington, Seattle, WA, USA
| | - Amy M Bauer
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, WA, USA
| | - Joseph M Cerimele
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, WA, USA
| | - Debra Kaysen
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, WA, USA
| | - Paul N Pfeiffer
- University of Michigan Medical School, Ann Arbor, MI, USA; Department of Veterans Affairs, Health Services Research and Development, Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Melissa J Zielinski
- Department of Psychiatry, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Jeffrey M Pyne
- Department of Psychiatry, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA; Department of Veterans Affairs, Health Services Research and Development, Center for Mental Healthcare and Outcomes Research, Little Rock, AR, USA
| | - Deb Bowen
- Department of Bioethics and Humanities, University of Washington, Seattle, WA, USA
| | - Joan Russo
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, WA, USA
| | - Lori Ferro
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, WA, USA
| | - Danna Moore
- Social and Economic Sciences Research Center at Washington State University, Pullman, WA, USA
| | | | - Florence C Fee
- NHMH - No Health without Mental Health, San Francisco, CA, Arlington, VA, USA
| | | | | | - Bernadette McDonald
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, WA, USA
| | - Jeremey Mullins
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, WA, USA
| | - Erin Hafer
- Community Health Plan of Washington, Seattle, WA, USA
| | | | - Jürgen Unützer
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, WA, USA
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29
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Hale AC, Bohnert KM, Spencer RJ, Ganoczy D, Pfeiffer PN. The Prevalence and Incidence of Attention-deficit/Hyperactivity Disorder in the Veterans Health Administration From 2009 to 2016. Med Care 2020; 58:273-279. [PMID: 32049948 DOI: 10.1097/mlr.0000000000001287] [Citation(s) in RCA: 1] [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] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The prevalence and incidence of attention-deficit/hyperactivity disorder (ADHD) have increased substantially among children and adolescents over the past decade; however, little is known regarding trends in adult populations. OBJECTIVE The objective of this study was to explore trends in the prevalence, incidence, and correlates of adult ADHD in a national sample of veterans receiving care at Veteran Affairs (VA) hospitals and clinics. RESEARCH DESIGN A retrospective design was used to examine ADHD diagnosed in all VA primary care (PC) and mental health clinics (MHCs) from fiscal years (FYs) 2009 to 2016. Age-adjusted prevalence and incidence were calculated using direct standardization, and Poisson regressions modeled differences in trends between demographic groups. SUBJECTS All veterans with VA PC or MHC visits during the observation period. MEASURES ADHD incidence and prevalence, psychiatric comorbidity, neuropsychological evaluation. RESULTS An annual average of 5.09 million (range: 4.63-5.42 million) VA patients attended a PC or MHC appointment between FY09 and FY16. During this period, age-adjusted annual prevalence increased 258% from 0.23% to 0.84% and incidence increased 240% from 0.14% to 0.48%. Black veterans and older veterans had the lowest prevalence and incidence across all years. Increases in prevalence and incidence occurred across all demographic subgroups. The proportion of patients who had a neuropsychological evaluation within 6 months before or after a new ADHD diagnosis decreased from 12.6% to 10.8% [χ(1)=16.59, P<0.001]. CONCLUSION Overall increases and demographic differences in adult veterans diagnosed with ADHD suggest a growing need to establish the reliability of diagnostic practices to ensure appropriate and equitable care.
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Affiliation(s)
- Andrew C Hale
- VA Center for Clinical Management Research.,VA Ann Arbor Healthcare System.,Department of Psychiatry, University of Michigan Medical School, Ann Arbor, MI
| | - Kipling M Bohnert
- VA Center for Clinical Management Research.,Department of Psychiatry, University of Michigan Medical School, Ann Arbor, MI
| | - Robert J Spencer
- VA Ann Arbor Healthcare System.,Department of Psychiatry, University of Michigan Medical School, Ann Arbor, MI
| | - Dara Ganoczy
- VA Center for Clinical Management Research.,Department of Psychiatry, University of Michigan Medical School, Ann Arbor, MI
| | - Paul N Pfeiffer
- VA Center for Clinical Management Research.,VA Ann Arbor Healthcare System.,Department of Psychiatry, University of Michigan Medical School, Ann Arbor, MI
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30
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Klim C, Ganoczy D, Pfeiffer PN. Associations Between the NIH Toolbox Adult Social Relationship Scales and Suicidal Ideation. Community Ment Health J 2020; 56:186-192. [PMID: 31571088 PMCID: PMC6942615 DOI: 10.1007/s10597-019-00483-9] [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: 01/22/2019] [Accepted: 09/25/2019] [Indexed: 10/25/2022]
Abstract
Various measures of social support have been associated with suicidal ideation (SI). However, a brief, consistent, multidimensional approach to social support assessment has not been established. We assessed the NIH Toolbox Adult Social Relationship (ASR) scales and their associations with the Beck Scale for Suicidal Ideation (BSI). Five ASR scales (emotional support, instrumental support, friendship, loneliness, perceived rejection) were used to predict BSI scores among psychiatric inpatients at baseline (N = 79) and at 3-months follow-up (N = 63). Mean BSI scores were 22.2 (SD 8.6) at baseline and 5.7 (SD 6.7) at follow-up. The ASR scales had high internal consistency (Cronbach's α = 0.93-0.96). Emotional support was associated with SI at baseline and 3-month follow-up. Instrumental support, loneliness and perceived rejection were associated with SI at baseline. Friendship was not associated with SI at either time-point. The ASR scales appear promising in differentiating aspects of social support most relevant to SI.
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Affiliation(s)
- Casimir Klim
- University of Michigan Medical School, Ann Arbor, MI, USA.
| | - Dara Ganoczy
- VA Center for Clinical Management Research, Ann Arbor, MI, USA
| | - Paul N Pfeiffer
- Department of Psychiatry, University of Michigan Medical School, Ann Arbor, MI, USA
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31
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Lapidos A, Abraham KM, Jagusch J, Garlick J, Walters H, Kim HM, Vega E, Damschroder L, Forman J, Ahmedani B, King CA, Pfeiffer PN. Peer mentorship to reduce suicide attempts among high-risk adults (PREVAIL): Rationale and design of a randomized controlled effectiveness-implementation trial. Contemp Clin Trials 2019; 87:105850. [PMID: 31525489 PMCID: PMC7035877 DOI: 10.1016/j.cct.2019.105850] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [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: 04/24/2019] [Revised: 09/03/2019] [Accepted: 09/11/2019] [Indexed: 11/21/2022]
Abstract
RATIONALE Novel approaches to suicide prevention are needed to address increasing rates of suicide deaths. Research suggests that interventions led by certified Peer Specialists may improve suicide protective factors such as hope and connectedness; however, the effectiveness of a Peer Specialist intervention for reducing suicidal thoughts or behaviors has not previously been tested empirically. DESIGN We describe the methodology of a randomized controlled hybrid effectiveness-implementation trial of a peer specialist intervention known as PREVAIL (Peers for Valued Living). The primary effectiveness aim is to determine whether the 3-month peer mentorship intervention compared to a minimally enhanced usual care condition reduces suicide attempts and suicidal ideation among adults at high risk for suicide who have been psychiatrically hospitalized. Secondary effectiveness outcomes include medically serious suicide attempts according to chart review and self-reported self-efficacy to avoid suicide. We also describe suicide risk management, supervision, and fidelity monitoring in the context of Peer Specialist providers and our methods for assessing implementation barriers and facilitators. CONCLUSION The PREVAIL trial will demonstrate novel methods for incorporating peer providers into a suicide prevention effectiveness trial with high-risk study participants. PREVAIL's hybrid effectiveness-implementation design aims to maximize the likelihood of rapid implementation in the community if shown to be effective.
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Affiliation(s)
- Adrienne Lapidos
- University of Michigan Medical School, Department of Psychiatry, Ann Arbor, MI, United States.
| | - Kristen M Abraham
- VA Center for Clinical Management Research, Ann Arbor, MI, United States; University of Detroit Mercy, Department of Psychology, Detroit, MI, United States
| | - Jennifer Jagusch
- University of Michigan Medical School, Department of Psychiatry, Ann Arbor, MI, United States; VA Center for Clinical Management Research, Ann Arbor, MI, United States
| | - James Garlick
- University of Michigan Medical School, Department of Psychiatry, Ann Arbor, MI, United States; VA Center for Clinical Management Research, Ann Arbor, MI, United States
| | - Heather Walters
- University of Michigan Medical School, Department of Psychiatry, Ann Arbor, MI, United States; VA Center for Clinical Management Research, Ann Arbor, MI, United States
| | - H Myra Kim
- VA Center for Clinical Management Research, Ann Arbor, MI, United States; Consulting for Statistics, Computing & Analytics Research, University of Michigan, Ann Arbor, MI, United States
| | | | - Laura Damschroder
- VA Center for Clinical Management Research, Ann Arbor, MI, United States
| | - Jane Forman
- VA Center for Clinical Management Research, Ann Arbor, MI, United States
| | | | - Cheryl A King
- University of Michigan Medical School, Department of Psychiatry, Ann Arbor, MI, United States
| | - Paul N Pfeiffer
- University of Michigan Medical School, Department of Psychiatry, Ann Arbor, MI, United States; VA Center for Clinical Management Research, Ann Arbor, MI, United States
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32
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Fortney JC, Veith RC, Bauer AM, Pfeiffer PN, Valenstein M, Pyne JM, Dalack GW, Kramer TL, Ferro LJ, Metzger K, Shore JH, Carlo AD, Coates S, Ward‐Jones S, Larkins E, Hafer E, Shushan S, Weaver DL, Unützer J. Developing Telemental Health Partnerships Between State Medical Schools and Federally Qualified Health Centers: Navigating the Regulatory Landscape and Policy Recommendations. J Rural Health 2019; 35:287-297. [PMID: 30288797 PMCID: PMC7379613 DOI: 10.1111/jrh.12323] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND Federally Qualified Health Centers (FQHCs) deliver care to 26 million Americans living in underserved areas, but few offer telemental health (TMH) services. The social missions of FQHCs and publicly funded state medical schools create a compelling argument for the development of TMH partnerships. In this paper, we share our experience and recommendations from launching TMH partnerships between 12 rural FQHCs and 3 state medical schools. EXPERIENCE There was consensus that medical school TMH providers should practice as part of the FQHC team to promote integration, enhance quality and safety, and ensure financial sustainability. For TMH providers to practice and bill as FQHC providers, the following issues must be addressed: (1) credentialing and privileging the TMH providers at the FQHC, (2) expanding FQHC Scope of Project to include telepsychiatry, (3) remote access to medical records, (4) insurance credentialing/paneling, billing, and supplemental payments, (5) contracting with the medical school, and (6) indemnity coverage for TMH. RECOMMENDATIONS We make recommendations to both state medical schools and FQHCs about how to overcome existing barriers to TMH partnerships. We also make recommendations about changes to policy that would mitigate the impact of these barriers. Specifically, we make recommendations to the Centers for Medicare and Medicaid about insurance credentialing, facility fees, eligibility of TMH encounters for supplemental payments, and Medicare eligibility rules for TMH billing by FQHCs. We also make recommendations to the Health Resources and Services Administration about restrictions on adding telepsychiatry to the FQHCs' Scope of Project and the eligibility of TMH providers for indemnity coverage under the Federal Tort Claims Act.
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Affiliation(s)
- John C. Fortney
- Department of Psychiatry and Behavioral Sciences, School of MedicineUniversity of WashingtonSeattleWashington
- Department of Veterans Affairs, Health Services Research and DevelopmentCenter of Innovation for Veteran‐Centered and Value‐Driven CareSeattleWashington
| | - Richard C. Veith
- Department of Psychiatry and Behavioral Sciences, School of MedicineUniversity of WashingtonSeattleWashington
| | - Amy M. Bauer
- Department of Psychiatry and Behavioral Sciences, School of MedicineUniversity of WashingtonSeattleWashington
| | - Paul N. Pfeiffer
- Department of PsychiatryUniversity of Michigan Medical SchoolAnn ArborMichigan
- VA Center for Clinical Management ResearchVA Ann Arbor Healthcare SystemAnn ArborMichigan
| | - Marcia Valenstein
- Department of PsychiatryUniversity of Michigan Medical SchoolAnn ArborMichigan
- VA Center for Clinical Management ResearchVA Ann Arbor Healthcare SystemAnn ArborMichigan
| | - Jeffrey M. Pyne
- Department of Psychiatry, College of MedicineUniversity of Arkansas for Medical SciencesLittle RockArkansas
- Department of Veterans Affairs, Health Services Research and DevelopmentCenter for Mental Healthcare and Outcomes ResearchLittle RockArkansas
| | - Gregory W. Dalack
- Department of PsychiatryUniversity of Michigan Medical SchoolAnn ArborMichigan
| | - Teresa L. Kramer
- Department of Psychiatry, College of MedicineUniversity of Arkansas for Medical SciencesLittle RockArkansas
| | - Lori J. Ferro
- Department of Psychiatry and Behavioral Sciences, School of MedicineUniversity of WashingtonSeattleWashington
| | - Karla Metzger
- Department of PsychiatryUniversity of Michigan Medical SchoolAnn ArborMichigan
| | - Jay H. Shore
- Helen and Arthur E. Johnson Depression CenterUniversity of Colorado Anschutz Medical CampusAuroraColorado
| | - Andrew D. Carlo
- Department of Psychiatry and Behavioral Sciences, School of MedicineUniversity of WashingtonSeattleWashington
| | - Sara Coates
- Michigan Primary Care AssociationLansingMichigan
| | | | - Ed Larkins
- Family Medical Center of MichiganTemperanceMichigan
| | - Erin Hafer
- Community Health Plan of WashingtonSeattleWashington
| | | | - Donald L. Weaver
- National Association of Community Health CentersBethesdaMaryland
| | - Jürgen Unützer
- Department of Psychiatry and Behavioral Sciences, School of MedicineUniversity of WashingtonSeattleWashington
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Panaite V, Bowersox NW, Zivin K, Ganoczy D, Kim HM, Pfeiffer PN. Individual and neighborhood characteristics as predictors of depression symptom response. Health Serv Res 2019; 54:586-591. [PMID: 30829408 DOI: 10.1111/1475-6773.13127] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [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: 11/29/2022] Open
Abstract
OBJECTIVE Assess whether neighborhood characteristics predict patient-reported outcomes for depression. DATA SOURCES VA electronic medical record data and U.S. census data. STUDY DESIGN Retrospective longitudinal cohort. DATA EXTRACTION METHODS Neighborhood and individual characteristics of patients (N = 4,269) with a unipolar depressive disorder diagnosis and an initial Patient Health Questionnaire (PHQ-9) score ≥10 were used to predict 50 percent improvement in 4-8-month PHQ-9 scores. PRINCIPAL FINDINGS The proportion of a patient's neighborhood living in poverty (OR = 0.98; 95% CI: 0.97-.1.00; P = 0.03) was associated with lower likelihood of depression symptom improvement in addition to whether the patient was black (OR = 0.76; 95% CI:0.61-0.96; P = 0.02) had PTSD (OR = 0.59; 95% CI:0.50-0.69; P < 0.001) or had any service-connected disability (OR = 0.73; 95% CI:0.61-0.87; P < 0.001). CONCLUSIONS Neighborhood poverty should be considered along with patient characteristics when determining likelihood of depression improvement.
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Affiliation(s)
- Vanessa Panaite
- James A. Haley Veterans' Hospital, Tampa, Florida.,University of South Florida, Tampa, Florida
| | - Nicholas W Bowersox
- VA QUERI Center for Evaluation and Implementation Resources (CEIR), Ann Arbor, Michigan.,VA Serious Mental Illness Treatment Resource and Evaluation Center (SMITREC), Ann Arbor, Michigan.,Department of Psychiatry, University of Michigan Medical School, Ann Arbor, Michigan
| | - Kara Zivin
- Department of Psychiatry, University of Michigan Medical School, Ann Arbor, Michigan.,School of Public Health, Health Management and Policy, University of Michigan, Ann Arbor, Michigan.,Survey Research Center, Institute for Social Research, Ann Arbor, Michigan.,VA Center for Clinical Management Research (CCMR), Ann Arbor, Michigan
| | - Dara Ganoczy
- VA Center for Clinical Management Research (CCMR), Ann Arbor, Michigan
| | - Hyungjin Myra Kim
- VA Center for Clinical Management Research (CCMR), Ann Arbor, Michigan.,Consulting for Statistics, Computing & Analytics Research, University of Michigan, Ann Arbor, Michigan
| | - Paul N Pfeiffer
- Department of Psychiatry, University of Michigan Medical School, Ann Arbor, Michigan.,VA Center for Clinical Management Research (CCMR), Ann Arbor, Michigan
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Denneson LM, Trevino AY, Kenyon EA, Ono SS, Pfeiffer PN, Dobscha SK. Health Coaching to Enhance Psychological Well-being Among Veterans with Suicidal Ideation: a Pilot Study. J Gen Intern Med 2019; 34:192-194. [PMID: 30251215 PMCID: PMC6374279 DOI: 10.1007/s11606-018-4677-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Lauren M Denneson
- Center to Improve Veteran Involvement in Care (CIVIC), VA Portland Health Care System, 3710 SW US Veterans Hospital Rd (R&D 66), Portland, OR, 97239, USA. .,Department of Psychiatry, Oregon Health & Science University, Portland, OR, USA.
| | - Amira Y Trevino
- Center to Improve Veteran Involvement in Care (CIVIC), VA Portland Health Care System, 3710 SW US Veterans Hospital Rd (R&D 66), Portland, OR, 97239, USA.,Department of Psychiatry, Oregon Health & Science University, Portland, OR, USA
| | - Emily A Kenyon
- Center to Improve Veteran Involvement in Care (CIVIC), VA Portland Health Care System, 3710 SW US Veterans Hospital Rd (R&D 66), Portland, OR, 97239, USA
| | - Sarah S Ono
- Center to Improve Veteran Involvement in Care (CIVIC), VA Portland Health Care System, 3710 SW US Veterans Hospital Rd (R&D 66), Portland, OR, 97239, USA.,Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Paul N Pfeiffer
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA.,VA Center for Clinical Management Research, VA Ann Arbor, Ann Arbor, MI, USA
| | - Steven K Dobscha
- Center to Improve Veteran Involvement in Care (CIVIC), VA Portland Health Care System, 3710 SW US Veterans Hospital Rd (R&D 66), Portland, OR, 97239, USA.,Department of Psychiatry, Oregon Health & Science University, Portland, OR, USA
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Pfeiffer PN, King C, Ilgen M, Ganoczy D, Clive R, Garlick J, Abraham K, Kim HM, Vega E, Ahmedani B, Valenstein M. Development and pilot study of a suicide prevention intervention delivered by peer support specialists. Psychol Serv 2018; 16:360-371. [PMID: 30382743 DOI: 10.1037/ser0000257] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Suicide rates in the United States have been increasing in recent years, and the period after an inpatient psychiatric hospitalization is one of especially high risk for death by suicide. Peer support specialists may play an important role in addressing recommendations that suicide prevention activities focus on protective factors by improving hope and connectedness. The present study developed a peer specialist intervention titled Peers for Valued Living (PREVAIL) to reduce suicide risk, incorporating components of motivational interviewing and psychotherapies targeting suicide risk into recovery-based peer support. A randomized controlled pilot study was conducted to assess the acceptability, feasibility, and fidelity of the intervention. A total of 70 adult psychiatric inpatients at high risk for suicide were enrolled into the study. Participants were randomized to usual care (n = 36) or to the 12-week PREVAIL peer support intervention (n = 34). Those in the PREVAIL arm completed an average of 6.1 (SD = 5.0) peer sessions over the course of 12 weeks. Fidelity was rated for 20 peer support sessions, and 85% of the peer specialist sessions demonstrated adequate fidelity to administering a conversation tool regarding hope, belongingness, or safety, and 72.5% of general support skills (e.g., validation) were performed with adequate fidelity. Participants' qualitative responses (n = 23) were highly positive regarding peer specialists' ability to relate, listen, and advise and to provide support specifically during discussions about suicide. Findings demonstrate that a peer support specialist suicide prevention intervention is feasible and acceptable for patients at high risk for suicide. (PsycINFO Database Record (c) 2019 APA, all rights reserved).
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Affiliation(s)
- Paul N Pfeiffer
- Department of Psychiatry, University of Michigan Medical School
| | - Cheryl King
- Department of Psychiatry, University of Michigan Medical School
| | - Mark Ilgen
- Department of Psychiatry, University of Michigan Medical School
| | | | - Rebecca Clive
- Department of Psychiatry, University of Michigan Medical School
| | - James Garlick
- Department of Psychiatry, University of Michigan Medical School
| | | | - H Myra Kim
- VA Center for Clinical Management Research
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36
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Sripada RK, Hoff R, Pfeiffer PN, Ganoczy D, Blow FC, Bohnert KM. Latent classes of PTSD symptoms in veterans undergoing residential PTSD treatment. Psychol Serv 2018; 17:84-92. [PMID: 30284867 DOI: 10.1037/ser0000284] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Although most veterans in the Department of Veterans Affairs (VA) health system are treated for posttraumatic stress disorder (PTSD) in the outpatient setting, the VA has approximately 40 residential PTSD treatment facilities across the country for those requiring more intensive care. The symptom profiles of these veterans are poorly understood. Thus, the current study was designed to characterize classes of PTSD symptoms in a national sample of veterans undergoing residential treatment. We analyzed latent classes of PTSD symptoms among 2,452 veterans entering VA PTSD residential treatment in fiscal year 2013. The model with the best fit was a 4-class model comprising a low symptom class, moderate symptom class with high reexperiencing symptoms, a moderate symptom class with high emotional numbing, and a high symptom class. Compared to classes identified in outpatient samples, these classes were similar in type but greater in severity. Classes differed by age, race/ethnicity, trauma type, co-occurring medical conditions, co-occurring psychiatric conditions, and social functioning. Compared to the moderate class with high emotional numbing, those in the moderate class with high reexperiencing symptoms were more likely to be non-White, have greater pain severity, greater sleep problems, and were less likely to be depressed. Our findings suggest that veterans in residential treatment who have more severe PTSD symptoms also experience other medical and psychosocial stressors. A better understanding of symptom profiles may help to create more individualized treatment planning and thus potentially improve care for these veterans. (PsycINFO Database Record (c) 2020 APA, all rights reserved).
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Affiliation(s)
| | - Rani Hoff
- Veteran Affairs Northeast Program Evaluation Center
| | | | - Dara Ganoczy
- Veterans Affairs Center for Clinical Management Research
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Duffy SA, Ignacio RV, Kim HM, Geraci MC, Essenmacher CA, Hall SV, Chow A, Pfeiffer PN, Sherman SE, Bohnert KM, Zivin K, Barnett PG. Effectiveness of tobacco cessation pharmacotherapy in the Veterans Health Administration. Tob Control 2018; 28:540-547. [PMID: 30181383 DOI: 10.1136/tobaccocontrol-2018-054473] [Citation(s) in RCA: 3] [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] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Revised: 07/30/2018] [Accepted: 08/07/2018] [Indexed: 11/03/2022]
Abstract
INTRODUCTION In 2003, the Veterans Health Administration (VHA) implemented a directive that cessation pharmacotherapy be made available to all who use tobacco and are interested in quitting. Despite the efficacy of cessation pharmacotherapy shown in clinical trials, the generalisability of the results in real-world settings has been challenged. Hence, the specific aim of this study was to determine the effectiveness of cessation pharmacotherapies in the VHA. METHODS This retrospective cohort study used VHA's electronic medical record data to compare quit rates among those who use tobacco and who did vs. did not receive any type of cessation pharmacotherapy. Included were 589 862 Veterans identified as current tobacco users during fiscal year 2011 who had not received cessation pharmacotherapy in the prior 12 months. Following a 6-month period to assess treatment, quit rates among those who were treated versus untreated were compared during the 7-18 months (12 months) post-treatment follow-up period. The estimated treatment effect was calculated from a logistic regression model adjusting for inverse probability of treatment weights (IPTWs) and covariates. Marginal probabilities of quitting were also obtained among those treated versus untreated. RESULTS Adjusting for IPTWs and covariates, the odds of quitting were 24% higher among those treated versus untreated (OR=1.24, 95% CI 1.23 to 1.25, p<0.001). The marginal probabilities of quitting were 16.7% for the untreated versus 19.8% for the treated based on the weighted model. CONCLUSION The increased quit rates among Veterans treated support the effectiveness and continuation of the VHA tobacco cessation pharmacotherapy policy.
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Affiliation(s)
- Sonia A Duffy
- College of Nursing, Ohio State University, Columbus, Michigan, USA.,Department of Veterans Affairs, VA Center for Clinical Management Research, Ann Arbor, Michigan, USA.,Department of Psychiatry, University of Michigan, Ann Arbor, Michigan, USA
| | - Rosalinda V Ignacio
- Department of Veterans Affairs, VA Center for Clinical Management Research, Ann Arbor, Michigan, USA.,Department of Psychiatry, University of Michigan, Ann Arbor, Michigan, USA
| | - Hyungjin Myra Kim
- Department of Veterans Affairs, VA Center for Clinical Management Research, Ann Arbor, Michigan, USA.,Center for Statistical Consultation and Research, University of Michigan, Ann Arbor, Michigan, USA
| | - Mark C Geraci
- Pharmacy Benefits Management Services, Department of Veterans Affairs, Hines, Illinois, USA
| | - Carol A Essenmacher
- Department of Veterans Affairs, Battle Creek VA Medical Center, Battle Creek, Michigan, USA
| | - Stephanie V Hall
- Department of Veterans Affairs, VA Center for Clinical Management Research, Ann Arbor, Michigan, USA
| | - Adam Chow
- Department of Veterans Affairs, Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, California, USA
| | - Paul N Pfeiffer
- Department of Veterans Affairs, VA Center for Clinical Management Research, Ann Arbor, Michigan, USA.,Department of Psychiatry, University of Michigan, Ann Arbor, Michigan, USA
| | - Scott E Sherman
- Department of Veterans Affairs, VA New York Harbor Healthcare System, New York, New York, USA.,Department of Population Health, NYU School of Medicine, New York University, New York, USA
| | - Kipling M Bohnert
- Department of Veterans Affairs, VA Center for Clinical Management Research, Ann Arbor, Michigan, USA.,Department of Psychiatry, University of Michigan, Ann Arbor, Michigan, USA
| | - Kara Zivin
- Department of Veterans Affairs, VA Center for Clinical Management Research, Ann Arbor, Michigan, USA.,Department of Psychiatry, University of Michigan, Ann Arbor, Michigan, USA
| | - Paul George Barnett
- Department of Veterans Affairs, Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, California, USA
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Sripada RK, Pfeiffer PN, Rauch SAM, Ganoczy D, Bohnert KM. Factors associated with the receipt of documented evidence-based psychotherapy for PTSD in VA. Gen Hosp Psychiatry 2018; 54:12-17. [PMID: 30029159 DOI: 10.1016/j.genhosppsych.2018.07.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [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: 03/07/2018] [Revised: 07/06/2018] [Accepted: 07/08/2018] [Indexed: 11/20/2022]
Abstract
OBJECTIVES The VA has mandated that evidence-based psychotherapies (EBPs) be offered to patients with PTSD, but only a small minority of the psychotherapy delivered to VA patients with PTSD is a documented EBP. It is unknown what factors are associated with receiving a documented EBP. METHOD Patients who received an EBP in FY2015 that was documented using a templated progress note (N = 21,808) were compared with patients who received psychotherapy for PTSD that was not documented using a template (N = 251,886). RESULTS Among psychotherapy recipients, VA patients with markers of clinical complexity such as service connection for PTSD, comorbid bipolar or psychotic disorder, longer duration of PTSD diagnosis, and a benzodiazepine prescription for PTSD had lower odds of receiving a documented EBP. CONCLUSIONS Recipients of documented EBPs differed from those who did not receive documented EBPs on several sociodemographic characteristics and indicators of treatment need. A limitation of our study is that some individuals in the group without EBP documentation may still have received an EBP, but did not receive EBP documentation in the electronic health record. Nevertheless, our results suggest that high-need or complex VA patients with PTSD may be less likely to receive documented EBPs.
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Affiliation(s)
- Rebecca K Sripada
- VA Center for Clinical Management Research, Ann Arbor, MI, USA; VA Ann Arbor Health Care System, Ann Arbor, MI, USA; University of Michigan, Department of Psychiatry, Ann Arbor, MI, USA.
| | - Paul N Pfeiffer
- VA Center for Clinical Management Research, Ann Arbor, MI, USA; VA Ann Arbor Health Care System, Ann Arbor, MI, USA; University of Michigan, Department of Psychiatry, Ann Arbor, MI, USA
| | - Sheila A M Rauch
- Department of Psychiatry and Behavioral Sciences, Emory University, Atlanta, GA, USA; Atlanta VA Medical Center, Decatur, GA, USA
| | - Dara Ganoczy
- VA Center for Clinical Management Research, Ann Arbor, MI, USA
| | - Kipling M Bohnert
- VA Center for Clinical Management Research, Ann Arbor, MI, USA; VA Ann Arbor Health Care System, Ann Arbor, MI, USA; University of Michigan, Department of Psychiatry, Ann Arbor, MI, USA
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Kim HM, Gerlach LB, Yosef M, Stano C, Conroy DA, Valenstein M, Pfeiffer PN, Sales AE, Zivin K. Responsiveness of Veterans Affairs Health Care System to Zolpidem Safety Warnings. J Clin Sleep Med 2018; 14:1135-1141. [PMID: 29991420 PMCID: PMC6040786 DOI: 10.5664/jcsm.7210] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [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: 11/10/2017] [Revised: 02/08/2018] [Accepted: 03/14/2018] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES Sedative hypnotic medications are routinely prescribed for insomnia treatment, but have been associated with significant risks of morning-after impairment. We evaluated responsiveness in the Veterans Health Administration (VHA) facilities to two drug safety warnings recommending against high-dose zolpidem use-a 2007 Veterans Administration Pharmacy Benefits Management Service warning and a 2013 Food and Drug Administration (FDA) warning. METHODS We used interrupted time-series design to assess how the two warnings influenced prescribing within the VHA in outpatients from 2005 to 2014. We assessed two outcomes: monthly outpatient use of (1) higher-than-recommended dose of zolpidem among zolpidem users and (2) any-dose zolpidem among all VHA users. In sensitivity analyses, we compared zolpidem prescribing to prescribing other sleep medications not subject to safety warnings. RESULTS After the 2007 VHA warning, high-dose zolpidem use decreased significantly among both sexes from approximately 10% to 2%. Following the 2013 FDA warning, high-dose zolpidem use declined again; however, approximately half of women Veterans remained on high doses. Overall zolpidem use nearly quadrupled between the 2007 VHA and 2013 FDA warnings, but the overall use declined after the 2013 FDA warning. Increase in sedating antidepressant use was seen after the FDA warning, suggesting potential substitution. CONCLUSIONS Higher than recommended dose use within the VHA decreased after each zolpidem high dose warning. Although overall use also decreased after the FDA warning, almost 50% of high-dose use among women Veterans is concerning. Different strategies to communicate the warnings should be examined. COMMENTARY A commentary on this article appears in this issue on page 1093.
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Affiliation(s)
- Hyungjin Myra Kim
- Consulting for Statistics, Computing and Analytics Research, University of Michigan, Ann Arbor, Michigan
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Lauren B. Gerlach
- Department of Psychiatry, University of Michigan Medical School, Ann Arbor, Michigan
| | - Matheos Yosef
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Claire Stano
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Deirdre A. Conroy
- Department of Psychiatry, University of Michigan Medical School, Ann Arbor, Michigan
| | - Marcia Valenstein
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
- Department of Psychiatry, University of Michigan Medical School, Ann Arbor, Michigan
| | - Paul N. Pfeiffer
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
- Department of Psychiatry, University of Michigan Medical School, Ann Arbor, Michigan
| | - Anne E. Sales
- Department of Psychiatry, University of Michigan Medical School, Ann Arbor, Michigan
- Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor, Michigan
| | - Kara Zivin
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
- Department of Psychiatry, University of Michigan Medical School, Ann Arbor, Michigan
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40
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Ignacio RV, Barnett PG, Kim HM, Geraci MC, Essenmacher CA, Hall SV, Chow A, Pfeiffer PN, Sherman SE, Bohnert KM, Zivin K, Duffy SA. Trends and Patient Characteristics Associated with Tobacco Pharmacotherapy Dispensed in the Veterans Health Administration. Nicotine Tob Res 2017; 20:1173-1181. [DOI: 10.1093/ntr/ntx229] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Accepted: 09/29/2017] [Indexed: 11/15/2022]
Affiliation(s)
- Rosalinda V Ignacio
- VA Center for Clinical Management and Research, Department of Veterans Affairs Healthcare System, Ann Arbor, MI
- Department of Psychiatry, University of Michigan, Ann Arbor, MI
| | - Paul G Barnett
- Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, CA
| | - Hyungjin Myra Kim
- VA Center for Clinical Management and Research, Department of Veterans Affairs Healthcare System, Ann Arbor, MI
- Center for Statistical Consultation and Research, University of Michigan, Ann Arbor, MI
| | - Mark C Geraci
- Pharmacy Benefits Management Services, Department of Veterans Affairs, Hines, IL
| | | | - Stephanie V Hall
- VA Center for Clinical Management and Research, Department of Veterans Affairs Healthcare System, Ann Arbor, MI
| | - Adam Chow
- Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, CA
| | - Paul N Pfeiffer
- VA Center for Clinical Management and Research, Department of Veterans Affairs Healthcare System, Ann Arbor, MI
- Department of Psychiatry, University of Michigan, Ann Arbor, MI
| | - Scott E Sherman
- VA New York Harbor Healthcare System, New York, NY
- Department of Population Health, NYU School of Medicine, New York, NY
| | - Kipling M Bohnert
- VA Center for Clinical Management and Research, Department of Veterans Affairs Healthcare System, Ann Arbor, MI
- Department of Psychiatry, University of Michigan, Ann Arbor, MI
| | - Kara Zivin
- VA Center for Clinical Management and Research, Department of Veterans Affairs Healthcare System, Ann Arbor, MI
- Department of Psychiatry, University of Michigan, Ann Arbor, MI
| | - Sonia A Duffy
- VA Center for Clinical Management and Research, Department of Veterans Affairs Healthcare System, Ann Arbor, MI
- Department of Psychiatry, University of Michigan, Ann Arbor, MI
- College of Nursing, Ohio State University, Columbus, OH
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Sripada RK, Bohnert KM, Ganoczy D, Pfeiffer PN. Documentation of Evidence-Based Psychotherapy and Care Quality for PTSD in the Department of Veterans Affairs. Adm Policy Ment Health 2017; 45:353-361. [DOI: 10.1007/s10488-017-0828-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Kim HM, Levine DS, Pfeiffer PN, Blow AJ, Marchiondo C, Walters H, Valenstein M. Postdeployment Suicide Risk Increases Over a 6-month Period: Predictors of Increased Risk among Midwestern Army National Guard Soldiers. Suicide Life Threat Behav 2017; 47:421-435. [PMID: 27704587 DOI: 10.1111/sltb.12303] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [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] [Received: 01/11/2016] [Accepted: 06/01/2016] [Indexed: 10/20/2022]
Abstract
National Guard (NG) soldiers returning from deployments in Iraq and Afghanistan were surveyed at 6 and 12 months following their return (N = 970). The overall prevalence of suicide risk at 6 and 12 months following their return was assessed, as were changes in suicide risk among soldiers initially at high or low risk. Factors associated with changes in risk were assessed. The percentage of NG soldiers with high suicide risk increased from 6.8% at 6 months to 9.2% at 12 months (odds ratio = 1.7, p = .02). In the 882 soldiers initially at low risk, 5.9% (52/882) became high risk at 12 months; in the 64 soldiers initially at high risk, 46.9% (30/64) became low risk at 12 months. Initial levels of depressive symptoms were predictive of changing to high risk; this association appeared to be partially explained by soldier reports of increased search in the meaning in life and higher levels of perceived stress. Because suicide risk increases over the first 12 months, continued risk assessments during this time period should be considered. Supporting soldiers to find meaning in their life after deployment and enhancing their capacity to cope with perceived stress may help prevent increases in suicide risk over time.
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Affiliation(s)
- Hyungjin Myra Kim
- Consulting for Statistics, Computing and Analytics Research, University of Michigan, Ann Arbor, MI, USA.,VA Center for Clinical Management Research, Ann Arbor Health Care System, Ann Arbor, MI, USA
| | - Debra Siegel Levine
- Department of Veterans Affairs, VA Center for Clinical Management Research, Ann Arbor, MI, USA
| | - Paul N Pfeiffer
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA.,Department of Veterans Affairs, SMITREC/HSR&D, Ann Arbor, MI, USA
| | - Adrian J Blow
- Department of Human Development and Family Studies, Michigan State University, East Lansing, MI, USA
| | | | - Heather Walters
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
| | - Marcia Valenstein
- VA Center for Clinical Management Research, Ann Arbor Health Care System, Ann Arbor, MI, USA.,Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
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Levine DS, McCarthy JF, Cornwell B, Brockmann L, Pfeiffer PN. Primary Care-Mental Health Integration in the VA Health System: Associations Between Provider Staffing and Quality of Depression Care. Psychiatr Serv 2017; 68:476-481. [PMID: 28045351 DOI: 10.1176/appi.ps.201600186] [Citation(s) in RCA: 8] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVES The study examined whether staffing of Primary Care-Mental Health Integration (PCMHI) services in the Department of Veterans Affairs (VA) health system is related to quality of depression care. METHODS Site surveys and administrative data from 349 VA facilities for fiscal year 2013 were used to calculate PCMHI staffing (full-time equivalents) per 10,000 primary care patients and discipline-specific staffing proportions for PCMHI psychologists, social workers, nurses, and psychiatric medication prescribers. Multivariable regression analyses were conducted at the facility level and assessed associations between PCMHI staffing ratios and the following indicators of depression treatment in the three months following a new episode of depression: any antidepressant receipt, adequacy of antidepressant receipt, any psychotherapy receipt, and psychotherapy engagement (three or more visits). RESULTS Higher facility PCMHI staffing ratios were associated with a greater percentage of patients who received any psychotherapy treatment (B=1.16, p<.01) and who engaged in psychotherapy (B=.39, p<.01). When analyses controlled for total PCMHI staffing, the proportion of social workers as part of PCMHI was positively correlated with the percentage of patients with adequate antidepressant treatment continuation (B=3.16, p=.03). The proportion of nurses in PCMHI was negatively associated with the percentage of patients with engagement in psychotherapy (B=-2.83, p=.02). CONCLUSIONS PCMHI programs with greater overall staffing ratios demonstrated better performance on indicators of psychotherapy for depression but not on indicators of antidepressant treatment. Further investigation is needed to determine whether differences in discipline-specific staffing play a causal role in driving associated differences in receipt of treatment.
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Affiliation(s)
- Debra S Levine
- Dr. Levine, Dr. McCarthy, Ms. Cornwell, and Ms. Brockmann are with the Office of Mental Health Operations, Serious Mental Illness Treatment Resource and Evaluation Center (SMITREC), and Dr. Pfeiffer is with the Center for Clinical Management Research, all at the Department of Veterans Affairs (VA), Ann Arbor, Michigan. Dr. Pfeiffer is also with the Department of Psychiatry, University of Michigan, Ann Arbor, where Dr. McCarthy is affiliated. Send correspondence to Dr. Pfeiffer (e-mail: )
| | - John F McCarthy
- Dr. Levine, Dr. McCarthy, Ms. Cornwell, and Ms. Brockmann are with the Office of Mental Health Operations, Serious Mental Illness Treatment Resource and Evaluation Center (SMITREC), and Dr. Pfeiffer is with the Center for Clinical Management Research, all at the Department of Veterans Affairs (VA), Ann Arbor, Michigan. Dr. Pfeiffer is also with the Department of Psychiatry, University of Michigan, Ann Arbor, where Dr. McCarthy is affiliated. Send correspondence to Dr. Pfeiffer (e-mail: )
| | - Brittany Cornwell
- Dr. Levine, Dr. McCarthy, Ms. Cornwell, and Ms. Brockmann are with the Office of Mental Health Operations, Serious Mental Illness Treatment Resource and Evaluation Center (SMITREC), and Dr. Pfeiffer is with the Center for Clinical Management Research, all at the Department of Veterans Affairs (VA), Ann Arbor, Michigan. Dr. Pfeiffer is also with the Department of Psychiatry, University of Michigan, Ann Arbor, where Dr. McCarthy is affiliated. Send correspondence to Dr. Pfeiffer (e-mail: )
| | - Laurie Brockmann
- Dr. Levine, Dr. McCarthy, Ms. Cornwell, and Ms. Brockmann are with the Office of Mental Health Operations, Serious Mental Illness Treatment Resource and Evaluation Center (SMITREC), and Dr. Pfeiffer is with the Center for Clinical Management Research, all at the Department of Veterans Affairs (VA), Ann Arbor, Michigan. Dr. Pfeiffer is also with the Department of Psychiatry, University of Michigan, Ann Arbor, where Dr. McCarthy is affiliated. Send correspondence to Dr. Pfeiffer (e-mail: )
| | - Paul N Pfeiffer
- Dr. Levine, Dr. McCarthy, Ms. Cornwell, and Ms. Brockmann are with the Office of Mental Health Operations, Serious Mental Illness Treatment Resource and Evaluation Center (SMITREC), and Dr. Pfeiffer is with the Center for Clinical Management Research, all at the Department of Veterans Affairs (VA), Ann Arbor, Michigan. Dr. Pfeiffer is also with the Department of Psychiatry, University of Michigan, Ann Arbor, where Dr. McCarthy is affiliated. Send correspondence to Dr. Pfeiffer (e-mail: )
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Sripada RK, Pfeiffer PN, Rampton J, Ganoczy D, Rauch SAM, Polusny MA, Bohnert KM. Predictors of PTSD Symptom Change Among Outpatients in the U.S. Department of Veterans Affairs Health Care System. J Trauma Stress 2017; 30:45-53. [PMID: 28103415 DOI: 10.1002/jts.22156] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [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] [Received: 02/03/2016] [Revised: 09/21/2016] [Accepted: 09/22/2016] [Indexed: 11/09/2022]
Abstract
Although the U.S. Department of Veterans Affairs (VA) has prioritized care for posttraumatic stress disorder (PTSD), many patients with PTSD remain symptomatic. Patterns of PTSD symptom change are not well understood. Thus, the current study was designed to categorize and investigate potential predictors of symptom trajectories in patients with PTSD. The sample comprised 2,237 VA patients who were diagnosed with PTSD in 2013 and completed at least 4 PTSD Checklist (PCL) assessments over 12 weeks. Latent trajectory analysis was used to identify latent classes of patients based on PCL scores. Based on model fit indices, 3 trajectories were identified. Compared to patients in the mild-improving trajectory (21.9%), those in the severe-stable trajectory (34.3%) were more likely to be male, relative risk ratio (RRR) = 1.48, 95% CI [1.08, 2.02]; non-White, RRR = 1.77, 95% CI [1.33, 2.35]; Hispanic, RRR = 2.07, 95% CI [1.40, 3.04]; and have comorbid depression, RRR = 1.58, 95% CI [1.25, 1.99]. Compared to patients in the moderate-improving trajectory (43.8%), those in the severe-stable trajectory were more likely to have sleep disorders, RRR = 1.25, 95% CI [1.01, 1.55]. Our findings suggest that male veterans, minority veterans, and veterans with certain comorbid conditions may be less likely to achieve improved PTSD symptoms. Targeted efforts are needed to improve outcomes for PTSD patients on nonremitting trajectories and to improve the consistency of PTSD assessment across the VA health care system.
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Affiliation(s)
- Rebecca K Sripada
- Veterans Affairs Center for Clinical Management Research, Health Services Research and Development, Ann Arbor, Michigan, USA.,Veterans Affairs Ann Arbor Health Care System, Ann Arbor, Michigan, USA.,Department of Psychiatry, University of Michigan, Ann Arbor, Michigan, USA
| | - Paul N Pfeiffer
- Veterans Affairs Center for Clinical Management Research, Health Services Research and Development, Ann Arbor, Michigan, USA.,Veterans Affairs Ann Arbor Health Care System, Ann Arbor, Michigan, USA.,Department of Psychiatry, University of Michigan, Ann Arbor, Michigan, USA
| | - Jessica Rampton
- Veterans Affairs Center for Clinical Management Research, Health Services Research and Development, Ann Arbor, Michigan, USA
| | - Dara Ganoczy
- Veterans Affairs Center for Clinical Management Research, Health Services Research and Development, Ann Arbor, Michigan, USA.,Veterans Affairs Ann Arbor Health Care System, Ann Arbor, Michigan, USA
| | - Sheila A M Rauch
- Department of Psychiatry and Behavioral Sciences, Emory University, Atlanta, Georgia, USA.,Atlanta Veteran Affairs Health Care System, Atlanta, Georgia, USA
| | - Melissa A Polusny
- Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota, USA.,Veteran Affairs Center for Chronic Disease Outcomes Research, Health Services Research and Development, Minneapolis, Minnesota, USA.,Department of Psychiatry, University of Minnesota, Minneapolis, Minnesota, USA
| | - Kipling M Bohnert
- Veterans Affairs Center for Clinical Management Research, Health Services Research and Development, Ann Arbor, Michigan, USA.,Veterans Affairs Ann Arbor Health Care System, Ann Arbor, Michigan, USA.,Department of Psychiatry, University of Michigan, Ann Arbor, Michigan, USA
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Pfeiffer PN, Valenstein M, Ganoczy D, Henry J, Dobscha SK, Piette JD. Pilot study of enhanced social support with automated telephone monitoring after psychiatric hospitalization for depression. Soc Psychiatry Psychiatr Epidemiol 2017; 52:183-191. [PMID: 27783130 DOI: 10.1007/s00127-016-1288-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [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: 05/31/2016] [Accepted: 10/10/2016] [Indexed: 01/16/2023]
Abstract
BACKGROUND Following discharge, patients hospitalized for depression are at high risk for poor retention in outpatient care and adverse outcomes. AIMS Pilot tests a post-hospital monitoring and enhanced support program for depression. METHOD 48 patients at a Veterans Affairs Medical Center discharged following a depression-related inpatient stay received weekly visits or phone calls for 6 months from their choice of either a family member/friend (n = 19) or a certified peer support specialist (n = 29). Participants also completed weekly automated telephone monitoring calls assessing depressive symptoms and antidepressant medication adherence. RESULTS Over 90% of participants were more satisfied with their care due to the service. The mean change from baseline to 6 months in depression symptoms was -7.9 (p < 0.05) according to the Patient Health Questionnaire and -11.2 (p < 0.05) according to the Beck Depression Inventory-II for those supported by a family member/friend, whereas those supported by a peer specialist had mean changes of -3.5 (p < 0.05) and -1.7 (p > 0.10), respectively. CONCLUSIONS Increased contact with a chosen support person coupled with automated telephone monitoring after psychiatric hospitalization is an acceptable service for patients with depression. Those who received the service, and particularly those supported by a family member/friend, experienced reductions in symptoms of depression.
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Affiliation(s)
- Paul N Pfeiffer
- University of Michigan Medical School, Ann Arbor, MI, USA. .,VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA.
| | - Marcia Valenstein
- University of Michigan Medical School, Ann Arbor, MI, USA.,VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Dara Ganoczy
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Jennifer Henry
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Steven K Dobscha
- VA Center for Veteran Involvement in Care, Portland Veterans Affairs Medical Center, Portland, MI, USA.,Oregon Health & Science University, Portland, OR, USA
| | - John D Piette
- University of Michigan Medical School, Ann Arbor, MI, USA.,VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA.,University of Michigan School of Public Health, Ann Arbor, MI, USA
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Pfeiffer PN, Bowersox N, Birgenheir D, Burgess J, Forman J, Valenstein M. Preferences and Barriers to Care Following Psychiatric Hospitalization at Two Veterans Affairs Medical Centers: A Mixed Methods Study. J Behav Health Serv Res 2017; 43:88-103. [PMID: 25779387 DOI: 10.1007/s11414-015-9460-0] [Citation(s) in RCA: 8] [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] [Indexed: 11/30/2022]
Abstract
Patient preferences and barriers to care may impact receipt of adequate mental health treatment following psychiatric hospitalization and could inform quality improvement initiatives. This study assessed preferences for a broad range of post-hospital services and barriers to counseling by surveying 291 patients and interviewing 25 patients who had recently been discharged from an inpatient psychiatric stay at one of the two Veterans Affairs Medical Centers. Individual counseling was the most frequently reported service that survey respondents preferred, but did not receive; whereas, open-ended survey responses and interviews also identified telephone follow-up "check-in" calls as a frequently preferred service. Difficulty with transportation was the most commonly cited barrier to counseling among survey respondents and in interviews; however, patients strongly preferred in-person counseling to telephone or internet-video alternatives. Increasing support from family and support from an individual Veteran peer were also perceived to be helpful in the majority of survey respondents.
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Affiliation(s)
- Paul N Pfeiffer
- Department of Veterans Affairs, VA Center for Clinical Management Research, Ann Arbor, MI, USA. .,Department of Psychiatry, University of Michigan Medical School, Ann Arbor, MI, USA. .,North Campus Research Complex, 2800 Plymouth Rd, Building 14, Ann Arbor, MI, 48109, USA.
| | - Nicholas Bowersox
- Department of Veterans Affairs, VA Center for Clinical Management Research, Ann Arbor, MI, USA.,Department of Psychiatry, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Denis Birgenheir
- Department of Veterans Affairs, VA Nebraska-Western Iowa Health Care System, Omaha, NE, USA
| | - Jennifer Burgess
- Department of Veterans Affairs, VA Center for Clinical Management Research, Ann Arbor, MI, USA
| | - Jane Forman
- Department of Veterans Affairs, VA Center for Clinical Management Research, Ann Arbor, MI, USA
| | - Marcia Valenstein
- Department of Veterans Affairs, VA Center for Clinical Management Research, Ann Arbor, MI, USA.,Department of Psychiatry, University of Michigan Medical School, Ann Arbor, MI, USA
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Sripada RK, Bowersox NW, Ganoczy D, Valenstein M, Pfeiffer PN. Self-Determination Theory and Outpatient Follow-Up After Psychiatric Hospitalization. Community Ment Health J 2016; 52:662-6. [PMID: 26319610 DOI: 10.1007/s10597-015-9929-6] [Citation(s) in RCA: 4] [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: 11/06/2014] [Accepted: 08/11/2015] [Indexed: 11/28/2022]
Abstract
The objective of this study was to assess whether the constructs of self-determination theory-autonomy, competence, and relatedness-are associated with adherence to outpatient follow-up appointments after psychiatric hospitalization. 242 individuals discharged from inpatient psychiatric treatment within the Veterans Health Administration completed surveys assessing self-determination theory constructs as well as measures of depression and barriers to treatment. Medical records were used to count the number of mental health visits and no-shows in the 14 weeks following discharge. Logistic regression models assessed the association between survey items assessing theory constructs and attendance at mental healthcare visits. In multivariate models, none of the self-determination theory factors predicted outpatient follow-up attendance. The constructs of self-determination theory as measured by a single self-report survey may not reliably predict adherence to post-hospital care. Need factors such as depression may be more strongly predictive of treatment adherence.
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Affiliation(s)
- Rebecca K Sripada
- VA Serious Mental Illness Treatment Resource and Evaluation Center (SMITREC), 2800 Plymouth Road Bldg 16, Ann Arbor, MI, 48109, USA. .,VA Ann Arbor Health Care System, Ann Arbor, MI, USA. .,Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA.
| | - Nicholas W Bowersox
- VA Serious Mental Illness Treatment Resource and Evaluation Center (SMITREC), 2800 Plymouth Road Bldg 16, Ann Arbor, MI, 48109, USA.,VA Ann Arbor Health Care System, Ann Arbor, MI, USA.,Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
| | - Dara Ganoczy
- VA Serious Mental Illness Treatment Resource and Evaluation Center (SMITREC), 2800 Plymouth Road Bldg 16, Ann Arbor, MI, 48109, USA.,VA Ann Arbor Health Care System, Ann Arbor, MI, USA
| | - Marcia Valenstein
- VA Serious Mental Illness Treatment Resource and Evaluation Center (SMITREC), 2800 Plymouth Road Bldg 16, Ann Arbor, MI, 48109, USA.,VA Ann Arbor Health Care System, Ann Arbor, MI, USA.,Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
| | - Paul N Pfeiffer
- VA Serious Mental Illness Treatment Resource and Evaluation Center (SMITREC), 2800 Plymouth Road Bldg 16, Ann Arbor, MI, 48109, USA.,VA Ann Arbor Health Care System, Ann Arbor, MI, USA.,Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
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Abstract
Background Text messaging services could increase access to psychotherapeutic content for individuals with depression by avoiding barriers to in-person psychotherapy such as cost, transportation, and therapist availability. Determining whether text messages reflecting different psychotherapeutic techniques exhibit differences in acceptability or effectiveness may help guide service development. Objectives We aimed to determine: (1) the feasibility of delivering a psychotherapy-based text messaging service to people with depression identified via the internet, (2) whether there is variation in satisfaction with messages according to the type of psychotherapeutic technique they represent, and (3) whether symptoms of depression vary according to receipt of each message type and participants' satisfaction with the messages they received. Methods For this study 190 US adults who screened positive for a major depressive episode (Patient Health Questionnaire (PHQ-9) score ≥10) were recruited from online advertisements. Participants received a daily psychotherapy-based text message 6 days per week for 12 weeks. Text messages were developed by a team of psychiatrists, psychologists, and social workers to reflect three psychotherapeutic approaches: acceptance and commitment therapy (ACT), behavioural activation, and cognitive restructuring. Each week the message type for the week was randomly assigned from one of the three types, allowing for repeats. Participants were asked daily to rate each message. On the 7th day of each week, participants completed a two-item depression screener (PHQ-2). Web-based surveys at baseline, 6, and 12 weeks were used as the primary measure of depressive symptoms (PHQ-9). Results Of the 190 participants enrolled, 85 (45%) completed the 6-week web survey and 67 (35%) completed the 12-week survey. The mean baseline PHQ-9 score was 19.4 (SD 4.2) and there was a statistically significant mean improvement in PHQ-9 scores of -2.9 (SD 6.0; p < 0.001) at 6 weeks and -4.8 (SD 6.6; p < 0.001) at 12 weeks. Mean satisfaction ratings did not vary across message types. There was generally no association between the number of weeks in which participants received a given message type and PHQ-9 scores at follow-up. However, among individuals with more severe depression at baseline (PHQ-9 ≥ 20; n = 30), the number of weeks of behavioural activation messages received was associated with less symptom improvement (ρ = 0.37; p = 0.04) at 12 weeks. Participants who gave higher satisfaction ratings to messages regardless of type had greater reductions in PHQ-9 scores at 6 weeks. Conclusions Study participants exhibited borderline clinically significant improvement in depressive symptoms at 12 weeks suggesting the effects of the intervention, if any, were small. Although there was no overall variation in changes in PHQ-9 according to users' exposure to the three message types, effectiveness among severely depressed participants could potentially be improved by tailoring towards fewer behavioural activation messages. Controlled studies to determine effectiveness of texting interventions such as this one are indicated considering that even small effects may be cost effective given the low cost of delivering text messages.
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Affiliation(s)
- Paul N Pfeiffer
- 1 Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA.,2 Department of Psychiatry, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Jennifer Henry
- 1 Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Dara Ganoczy
- 1 Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - John D Piette
- 1 Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA.,3 Department of Health Behavior and Health Education, School of Public Health, University of Michigan, Ann Arbor, MI, USA.,4 Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
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Sripada RK, Bohnert KM, Ganoczy D, Blow FC, Valenstein M, Pfeiffer PN. Initial group versus individual therapy for posttraumatic stress disorder and subsequent follow-up treatment adequacy. Psychol Serv 2016; 13:349-355. [PMID: 27175477 DOI: 10.1037/ser0000077] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Accessibility of psychotherapy for individuals with posttraumatic stress disorder (PTSD) and retention in treatment are major concerns for the Veterans Health Administration (VA). Group therapy is a common method for improving access to psychotherapy; however, PTSD patients may prefer individual therapy. This study assessed whether initial treatment with individual versus group psychotherapy relates to subsequent psychotherapy adequacy among VA patients with PTSD. The sample consisted of all VA patients who received a new PTSD diagnosis during a subspecialty PTSD clinical team visit in fiscal year 2010. Logistic and negative binomial regression analyses examined the relationship between modality of the first psychotherapy encounter and subsequent number of psychotherapy encounters within 14 weeks. Among 35,144 VA patients who initiated treatment for PTSD, 38% initiated group therapy and 62% initiated individual therapy. Patients who initiated with group therapy received a greater mean number of psychotherapy visits than those who initiated with individual therapy (4.7 vs. 2.8), and were about twice as likely (29.5% vs. 14.2%) to receive a minimally effective dose of 8 or more psychotherapy encounters. Group therapy predicted a greater number of psychotherapy visits (β = 0.46, SE = .01, p < .001) and greater likelihood of 8 or more sessions of psychotherapy (OR = 2.31, 95% CI [2.19, 2.45], p < .001), after adjusting for differences in demographic characteristics, comorbid conditions, and other service use. Greater treatment adequacy among group therapy participants suggests that these patients have greater access to frequent psychotherapy sessions or are more likely to persist with psychotherapy for PTSD than those treated individually. (PsycINFO Database Record
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Affiliation(s)
| | | | - Dara Ganoczy
- Veterans Affairs Center for Clinical Management Research
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Sripada RK, Bohnert KM, Ganoczy D, Blow FC, Pfeiffer PN. Facility-level factors associated with guideline-concordant prazosin dosing for Veterans with posttraumatic stress disorder. J Clin Psychiatry 2016; 77:548. [PMID: 27137423 DOI: 10.4088/jcp.15lr10250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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