Implementation of a Telemental Health Training Program Across a Mental Health Department.

Introduction: Telemental health (TMH) has increased substantially. However, health care systems have found it challenging to implement TMH ubiquitously. A quality improvement project guided by implementation science methodology was used to design and implement a TMH training program. Materials and Methods: Implementation science methodology (Promoting Access to Research Implementation in Health Services, Reach-Effectiveness-Adoption-Implementation-Maintenance, Implementation/Facilitation) provided the framework to design and implement the training program. A total of 100 interdisciplinary mental health providers from outpatient mental health clinics participated. Results: Providers reported satisfaction with the training program. Results indicated that the training increased providers' TMH knowledge and competence. The number of providers using TMH and patients who received TMH nearly doubled. Conclusions: Implementation science methodology was important in creating an organizational framework at this facility to design, evaluate, and implement an innovative TMH training program.

Telemental health training in the Veterans Administration Puget Sound Health Care System.

As a pioneer of training in the field of psychology, the Veterans Affairs (VA) HealthCare System serves as a leader in the training in and provision of Telemental Health (TMH) services in the United States. To meet goals toward continued expansion of these services, the VA TMH training program includes both web-based didactic courses and a skills competency test at a basic level with supervision and consultation in TMH for more advanced training and is available to staff psychologists and psychologist trainees. Despite these efforts, barriers for training in and implementation of TMH occur at the provider, system, and patient level. At the national level, the VA is actively working to resolve these barriers and we share site-specific examples implemented by the VA Puget Sound Health Care System promoting access through TMH team to further address barriers to training and implementation.

A Review of Telemental Health as a Modality to Deliver Suicide-Specific Interventions for Rural Populations.

Introduction: Despite recent advancements in the development of new suicide prevention interventions, suicide rates continue to rise in the United States. As such, suicide prevention efforts must continue to focus on expanding dissemination of suicide-specific interventions. Methods: This review explores telemental health through two-way synchronous clinical video telehealth (CVT) technologies as one approach to improving access to suicide-specific interventions. Results: Studies were reviewed if (1) the modality of interest was telemental health by CVT and (2) management, assessment, or intervention of suicidal thoughts or behaviors was discussed. A total of 22 studies were included. Conclusions: Findings from the limited existing studies are synthesized, and recommendations are provided for future research, clinical, and educational advancements.

Recommendations for Using Clinical Video Telehealth with Patients at High Risk for Suicide.

There is increasing evidence that the delivery of mental health services via clinical video telehealth (CVT) is an effective means of providing services to individuals with access barriers, such as rurality. However, many providers have concerns about working with individuals at risk for suicide via this modality, and many clinical trials have excluded individuals with suicide risk factors. The present article reviews the literature, professional guidelines, and laws that pertain to the provision of mental health services via CVT with high-risk patients and provides suggestions for adapting existing best-practice recommendations for assessing and managing suicide risk to CVT delivery.

Clinical and Ethical Considerations for Delivering Couple and Family Therapy via Telehealth.

Studies have generally supported telehealth as a feasible, effective, and safe alternative to in-office visits. Telehealth may also be of particular benefit to couples/families interested in relational treatments, as it addresses some of the barriers that may be more prominent for families, such as childcare and scheduling difficulties. Therapists interested in expanding their practice to include telehealth should understand ethical and practical considerations of this modality. This article discusses areas unique to the delivery of telehealth to couples and families. Each broad domain is then elaborated upon with case examples from actual clinical practice and specific recommendations for addressing potential difficulties. Authors recommend further empirical research examining differences in modality outcome, as well as feasibility of the suggestions proposed here.

Relationship satisfaction, PTSD symptom severity, and mental healthcare utilization among OEF/OIF veterans.

Despite the availability of evidence-based PTSD treatments at most facilities within the VA Healthcare System, most Iraq and Afghanistan veterans returning from deployments with posttraumatic stress symptoms do not receive an adequate dose of mental health treatment, prompting the need to identify potential barriers to or facilitators of mental health care utilization. Previous research demonstrated self-reported mental health care utilization in the prior year varies as a function of PTSD symptom severity, and the interaction of PTSD symptom severity and romantic relationship satisfaction (Meis et al., 2010). We extended these findings by objectively measuring the degree of utilization over a 1-year period (i.e., number of sessions attended) in a sample of 130 Iraq and Afghanistan veterans who presented to primary care/deployment health and completed an initial mental health evaluation. Results indicated main and interactive effects of PTSD symptom severity and relationship satisfaction, such that greater PTSD symptom severity was associated with greater utilization at average to high relationship satisfaction (p < .05), but not low relationship satisfaction. Implications for future research and couple/family based interventions for veterans with PTSD are discussed. (PsycINFO Database Record

The relationships of posttraumatic stress disorder and depression symptoms with health-related quality of life and the role of social support among Veterans.

PURPOSE: The presence of posttraumatic stress disorder (PTSD) or depression symptoms is associated with poor quality of life. Social support buffers against developing symptoms of PTSD and depression and is associated with greater quality of life. We examined the relationships between PTSD and depression symptom severity with physical (PCS) and mental (MCS) health-related quality of life (HRQoL), and whether social support moderated these relationships. METHODS: Randomly selected Veterans with at least one Primary Care or PTSD Clinical Team visit received a mailed survey including self-report measures of health and wellness. Among the 717 respondents, we examined the association between symptom severity and HRQoL using linear regression. We included interaction terms between symptom severity and social support to examine whether social support moderated these associations. RESULTS: Social support did not moderate the association between symptom severity and mental HRQoL. Higher PTSD and depression symptom severity were associated with lower MCS scores, whereas higher social support was associated with higher MCS scores. When examining physical HRQoL, social support moderated the association with PTSD and depression symptom severity. Among individuals with high social support, there was a negative association between symptom severity and PCS scores, whereas there was no association among those with low social support. CONCLUSIONS: Although there are contexts in which social support is helpful, in some cases it may interfere with HRQoL among those with mental health conditions. Thus, it is important to educate support providers about behaviors that enhance the benefits and minimize the costs of social support.

Posttraumatic Stress Disorder Symptom Severity and Relationship Functioning Among Partnered Heterosexual and Lesbian Women Veterans.

PURPOSE: Few studies have examined associations of posttraumatic stress disorder (PTSD) and relationship satisfaction among women Veterans, and no research has explored these factors in lesbian women Veterans, a large subgroup that may have unique concerns. This study examined the link between PTSD and relationship satisfaction in partnered heterosexual and lesbian women Veterans and evaluated potential moderation by sexual orientation, partner support, and conflict. METHODS: Women Veterans (heterosexual n = 260; lesbian n = 128) were recruited nationally to complete a cross-sectional online survey. Multiple linear regression models were used to evaluate moderation, using two- and three-way interactions. RESULTS: Partner support moderated the association between PTSD symptoms and relationship satisfaction to a different degree for heterosexual and lesbian women Veterans, playing a more prominent role in this association for lesbian women. Specifically, for lesbians with low partner support, as PTSD symptoms worsened, relationship satisfaction decreased at a steeper rate than for heterosexual women with low partner support. On the other hand, for lesbians with high partner support, as PTSD symptoms worsened, relationship satisfaction decreased less sharply than for heterosexual women with high partner support. Degree of conflict was highly correlated with relationship satisfaction and also appeared to moderate these relations differently by sexual orientation. CONCLUSION: These findings suggest that women Veterans with PTSD experience impairments in their romantic relationships, which vary by sexual orientation, partner support, and conflict. Partner support and conflict may be important targets in assessment and therapy for women Veterans with PTSD, and especially so for sexual minorities.

Marital quality and health: a meta-analytic review.

This meta-analysis reviewed 126 published empirical articles over the past 50 years describing associations between marital relationship quality and physical health in more than 72,000 individuals. Health outcomes included clinical endpoints (objective assessments of function, disease severity, and mortality; subjective health assessments) and surrogate endpoints (biological markers that substitute for clinical endpoints, such as blood pressure). Biological mediators included cardiovascular reactivity and hypothalamic-pituitary-adrenal axis activity. Greater marital quality was related to better health, with mean effect sizes from r = .07 to .21, including lower risk of mortality (r = .11) and lower cardiovascular reactivity during marital conflict (r = -.13), but not daily cortisol slopes or cortisol reactivity during conflict. The small effect sizes were similar in magnitude to previously found associations between health behaviors (e.g., diet) and health outcomes. Effect sizes for a small subset of clinical outcomes were susceptible to publication bias. In some studies, effect sizes remained significant after accounting for confounds such as age and socioeconomic status. Studies with a higher proportion of women in the sample demonstrated larger effect sizes, but we found little evidence for gender differences in studies that explicitly tested gender moderation, with the exception of surrogate endpoint studies. Our conclusions are limited by small numbers of studies for specific health outcomes, unexplained heterogeneity, and designs that limit causal inferences. These findings highlight the need to explicitly test affective, health behavior, and biological mechanisms in future research, and focus on moderating factors that may alter the relationship between marital quality and health.

Common principles of couple therapy.

The similarity in efficacy of evidence-based couple therapies suggests that it may be useful to identify those treatment principles they hold in common. Expanding on the previous description of a unified protocol for couple therapy (Christensen, 2010), this article outlines five common principles: (a) altering the couple's view of the presenting problem to be more objective, contextualized, and dyadic; (b) decreasing emotion-driven, dysfunctional behavior; (c) eliciting emotion-based, avoided, private behavior; (d) increasing constructive communication patterns; and (e) emphasizing strengths and reinforcing gains. For each of these five elements of the unified protocol, the paper addresses how and to what extent the most common forms of evidence-based couple therapy carry out this principle. Implications for clinical practice, treatment research, and basic research on intimate relationships are discussed.

Antecedents and consequences of demand/withdraw.

The authors examined the immediate antecedents and consequences of the demand/withdraw interaction pattern within naturally occurring conflicts. Both partners in 75 couples, including gay, lesbian, and straight couples, were interviewed individually regarding 2 recent conflicts, 1 chosen by each partner, and completed postinterview questionnaires. Interviews were coded for antecedents (e.g., upset prior to conflict), consequences (e.g., resolution of conflict), and demand/withdraw behaviors. In the postinterview questionnaires, participants rated demand/withdraw behaviors and their satisfaction with the outcome of the discussion. Results demonstrated that demand/withdraw behavior shifts depending on whose issue is under discussion, but other proximal antecedents did not significantly predict demand/withdraw. Regarding consequences, results indicated that most conflicts do not result in resolution, and most resolutions do not involve agreed-on change. Demand/withdraw did not predict a decreased likelihood of resolution. However, for those issues that were resolved, demand/withdraw resulted in a decreased likelihood of changes being agreed on. Furthermore, demand/withdraw predicted less satisfaction with the outcome of the discussion, even when controlling for the substantive outcome. Results were generally replicated across both self-report and coder ratings of demand/withdraw.