Suicide death over the first year of lithium versus valproate treatment in cohorts with and without bipolar disorder.

This study examined if lithium's association with suicide risk varies by diagnosis. We performed separate 1:1 high-dimensional propensity score (hdPS)-matching in US Veterans with and without bipolar disorder starting lithium or valproate. Among individuals with bipolar disorder, actively receiving lithium (compared to valproate) was not associated with suicide risk. However, in intent-to-treat analyses (following all individuals with bipolar disorder starting lithium or valproate for all 365 days, regardless of whether they stopped the medication), starting lithium was significantly associated with higher one-year risks of suicide (HR = 1.50, 95% CI: 1.05-2.15, p = 0.03). These intent-to-treat risks were attributable entirely to transiently elevated suicide risks observed among individuals no longer receiving lithium (significant at 180 days [HR = 6.10, CI: 1.37-27.3, p = 0.02] but not 365 days [HR = 2.05, CI: 0.88-4.79, p = 0.10]). Among individuals without bipolar disorder, depending on the analysis, actively receiving lithium was associated with nonsignificantly (HR = 0.43, CI: 0.15-1.20, p = 0.11) or significantly (HR = 0.28, CI: 0.08-0.98, p = 0.047) decreased one-year suicide risks. Study limitations included limited power, brief follow-up, and potential residual confounding. Residual confounding is suggested by the observation that more individuals diagnosed with suicidal ideation started lithium than valproate (with this difference being statistically significant for individuals with bipolar disorder, p = 0.0012). If it were possible to correct for this potential confounding, then the suicide-related risks associated with among individuals discontinuing lithium would be expected to be less, and the suicide-related benefits associated with actively receiving lithium (already statistically significant in some analyses among individuals without bipolar disorder) would be expected to increase. Further research is needed.

A nationally representative sample of veteran and matched non-veteran college students: Mental health symptoms, suicidal ideation, and mental health treatment.

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.

Technology-Facilitated Depression Self-Management Linked with Lay Supporters and Primary Care Clinics: Randomized Controlled Trial in a Low-Income Sample.

Purpose: To test whether technology-facilitated self-management support improves depression in primary care settings. Methods: We randomized 204 low-income primary care patients who had at least moderate depressive symptoms to intervention or control. Intervention participants received 12 months of weekly automated interactive voice response telephone calls that assessed their symptom severity and provided self-management strategies. Their patient-nominated supporter (CarePartner) received corresponding guidance on self-management support, and their primary care team received urgent notifications. Those randomized to enhanced usual care received printed generic self-management instructions. Results: One-year attrition rate was 14%. By month 6, symptom severity on the Patient Health Questionnaire-9 (PHQ-9) decreased 2.5 points more in the intervention arm than in the control arm (95% CI -4.2 to -0.8, p = 0.003). This benefit was similar at month 12 (p = 0.004). Intervention was also over twice as likely to lead to ≥50% reduction in symptom severity by month 6 (OR = 2.2 (1.1, 4.7)) and a decrease of ≥5 PHQ-9 points by month 12 (OR = 2.3 (1.2, 4.4)). Conclusions: Technology-facilitated self-management guidance with lay support and clinician notifications improves depression for primary care patients. Subsequent research should examine implementation and generalization to other chronic conditions. clinicaltrials.gov, identifier NCT01834534.

Effectiveness of Peer-Supported Computer-Based CBT for Depression Among Veterans in Primary Care.

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.

Possession of Household Firearms and Firearm-Related Discussions with Clinicians Among Veterans Receiving VA Mental Health Care.

Objectives: To assess possession of household firearms among veterans receiving mental health care and the frequency of their discussions with clinicians about firearms. Methods: We surveyed random samples of veterans receiving mental health care in each of five purposively chosen, geographically diverse VA facilities; 677 (50% of recipients) responded. Results: 45.3% (95% CI 41.2, 49.3) of veteran respondents reported household firearms; 46.9% of those with suicidal thoughts and 55.6% with a suicide plan had household firearms. Only 27.5% of all veteran respondents and 44% of those with recent suicidal ideation and household firearms had had a firearm-related discussion with a clinician. Discussion: Many veterans receiving mental health care can readily access firearms, a highly lethal means for suicide. Increasing clinician-patient discussions and health system efforts to reduce firearm access might reduce suicide in this clinical population.

The Cost-Effectiveness of Cognitive Behavioral Therapy Versus Second-Generation Antidepressants for Initial Treatment of Major Depressive Disorder in the United States: A Decision Analytic Model.

Background: Most guidelines for major depressive disorder recommend initial treatment with either a second-generation antidepressant (SGA) or cognitive behavioral therapy (CBT). Although most trials suggest that these treatments have similar efficacy, their health economic implications are uncertain. Objective: To quantify the cost-effectiveness of CBT versus SGA for initial treatment of depression. Design: Decision analytic model. Data Sources: Relative effectiveness data from a meta-analysis of randomized controlled trials; additional clinical and economic data from other publications. Target Population: Adults with newly diagnosed major depressive disorder in the United States. Time Horizon: 1 to 5 years. Perspectives: Health care sector and societal. Intervention: Initial treatment with either an SGA or group and individual CBT. Outcome Measures: Costs in 2014 U.S. dollars, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios. Results of Base-Case Analysis: In model projections, CBT produced higher QALYs (3 days more at 1 year and 20 days more at 5 years) with higher costs at 1 year (health care sector, $900; societal, $1500) but lower costs at 5 years (health care sector, -$1800; societal, -$2500). Results of Sensitivity Analysis: In probabilistic sensitivity analyses, SGA had a 64% to 77% likelihood of having an incremental cost-effectiveness ratio of $100 000 or less per QALY at 1 year; CBT had a 73% to 77% likelihood at 5 years. Uncertainty in the relative risk for relapse of depression contributed the most to overall uncertainty in the optimal treatment. Limitation: Long-term trials comparing CBT and SGA are lacking. Conclusion: Neither SGAs nor CBT provides consistently superior cost-effectiveness relative to the other. Given many patients' preference for psychotherapy over pharmacotherapy, increasing patient access to CBT may be warranted. Primary Funding Source: Department of Veterans Affairs, National Institute of Mental Health.

Developing Telemental Health Partnerships Between State Medical Schools and Federally Qualified Health Centers: Navigating the Regulatory Landscape and Policy Recommendations.

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.

Development and pilot study of a suicide prevention intervention delivered by peer support specialists.

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).

Intimate Relationships Buffer Suicidality in National Guard Service Members: A Longitudinal Study.

OBJECTIVE: Members of the U.S. military are at a high suicide risk. While studies have examined predictors of suicide in the U.S. military, more studies are needed which examine protective factors for suicide. Informed by the interpersonal theory of suicide, this study examined the strength of the intimate relationship and its role as a buffer of suicidality in National Guard service members. METHOD: A total of 712 National Guard residing in a Midwestern state, who had all recently returned home from a deployment, took part in this study and completed surveys at 6 and 12 months postdeployment. They were assessed on suicide risk, mental health (depression, post-traumatic stress disorder, anxiety), and relationship satisfaction. RESULTS: Lower relationship satisfaction and more depressive symptoms at the 6-month assessment were significantly related to greater suicide risk at 12 months. Each interaction between couple satisfaction and three mental health variables (PTSD, depression, and anxiety) at the 6-month assessment was significantly associated with suicide risk at 12 months. CONCLUSIONS: The strength of the intimate relationship serves as a buffer for suicide in National Guard service members who have PTSD, anxiety, or depression. Interventions that strengthen these intimate relationships could reduce suicide in service members.

Responsiveness of Veterans Affairs Health Care System to Zolpidem Safety Warnings.

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.

Longitudinal patterns of PTSD symptom classes among US National Guard service members during reintegration.

PURPOSE: The purpose of this study was to identify posttraumatic stress disorder (PTSD) symptom groups and assess their longitudinal progression during their first year of reintegration among United States (US) National Guard (NG) service members. METHODS: A cohort of NG service members (n = 886) completed surveys at 6 and 12 months following their return from deployment to Iraq or Afghanistan. Latent class analysis (LCA) and latent transition analysis (LTA) were used to empirically derive groups based on their PTSD symptoms and examine their longitudinal course, respectively. RESULTS: The best fitting model at both assessments was the four-class model, comprising an asymptomatic class (6 months = 54%; 12 months = 55%), a mild symptom class with elevated hyperarousal symptoms (6 months = 22%; 12 months = 17%), a moderate symptom class (6 months = 15%; 12 months = 15%), and a severe symptom class (6 months = 10%; 12 months = 13%). Based on LTA, stability of class membership at the two assessments was 0.797 for the asymptomatic class, 0.453 for the mild class, 0.560 for the moderate class, and 0.580 for the severe class. Estimated transition probabilities were greater with respect to transitioning to less severe, rather than more severe, classes over time. CONCLUSIONS: The four latent PTSD classes were distinguished primarily by severity; however, the mild symptom class was characterized by higher levels of hyperarousal than other symptoms. Although the absolute number of individuals within classes remained fairly constant between 6 and 12 months, there was movement between severity classes. Most NG service members without symptoms continued to do well during the first year, with only an estimated 7% moving to the moderate or severe class.

Intervention effects on reflectivity explain change in positive parenting in military families with young children.

Military families with young children often experience stress related to the unique circumstances of military families (e.g., deployment), and there is a need for interventions that are specifically tailored to military families with young children. The Strong Military Families (SMF) intervention responds to this need, and consists of two versions: A Multifamily Group (N = 34), and a Homebased psychoeducational written material program (N = 42; treated as the comparison group in this report). The Multifamily Group utilized an attachment-based parenting education curriculum and in vivo support of separations and reunions, encouraged peer support among parents, and connected families to additional services. In the present nonrandomized trial, we examine intervention effects on observed parenting behavior and affect, and test whether changes in parenting reflectivity account for intervention-related changes in observed parenting. Observed parenting behavior and affect were coded from the Caregiver-Child Structured Interaction Procedure (Crowell & Fleischmann, 1993), and parenting reflectivity was coded from the Working Model of the Child Interview (Zeanah & Benoit, 1995). Results suggest that relative to Homebased participants, Multifamily Group participants showed pre- and post- improvements in aspects of positive parenting (Emotional Responsivity, Positive Affect), but no decreases in negative parenting. The efficacy of the SMF Multifamily Group intervention does not appear to depend on parent risk level or preintervention parent behavior and affect. Further, a mediation model demonstrated that the intervention effects on parents' observed positive affect in an interaction task with their child were partially accounted for by intervention-related changes in their parenting reflectivity. (PsycINFO Database Record

Differences in Mental Health Service Use Among Unemployed Veterans of Different Eras.

Mental disorders have been linked to unemployment among veterans. Improving mental health conditions, such as depression, can improve veteran employment outcomes. This study compared mental health treatment among unemployed Operation Enduring Freedom (OEF; in Afghanistan) and Operation Iraqi Freedom (OIF; in Iraq) veterans and veterans from other service eras. The study included 3165 unemployed veterans from six Veterans Affairs medical centers with a positive screen that indicates a possible mental disorder. Chi-squared tests and logistic regression analyses assessed whether veteran era was associated with mental health treatment. Unemployed OEF/OIF veterans were less likely to receive psychotropic medication and four or more psychotherapy sessions compared to veterans from other eras. Multivariable analyses controlling for age found associations based on younger age rather than era. Younger unemployed veterans received fewer mental health services, which is concerning because reducing mental health symptoms may increase employment and employment may reduce symptoms, which are key factors in reintegration into civilian life.

Moving Towards Wellness: Physical activity practices, perspectives, and preferences of users of outpatient mental health service.

OBJECTIVE: This study assessed the beliefs, barriers and preferences for physical activity (PA) among users of outpatient mental health (MH) services. Outpatient discussions with MH providers were also evaluated. METHOD: Between September-December 2014, patient advisors approached adult and family members in an academic MH clinic's waiting room on high volume patient visit days during peak clinic hours; 83% participated in the survey. Analyses were restricted to MH services users (n=295). RESULTS: Fully 84% of respondents reported a link between PA and their mood or anxiety level and 85% wanted to be more active. Less than half currently met US PA guidelines (≥150min/week). Most (52%) reported their mood limited their involvement in PA. Only 37% reported their MH providers regularly discussed PA with them. Beliefs about the benefits of physical activity (p<0.0001), mood limiting their ability to be physically active (p=0.03), and wanting to be more physically active (p=0.02) were significant predictors of PA (min/week) in the multivariate linear regression model. CONCLUSIONS: Most MH outpatients may need and want assistance in increasing PA. Patient-centered research could inform the development of PA programs in MH settings.

Reengagement in PTSD psychotherapy: A case-control study.

OBJECTIVE: This study sought to identify patient characteristics and care processes related to reengagement in VA psychotherapy. METHODS: Using national VA data, a retrospective cohort was constructed (N=24,492) of veterans who received a new PTSD diagnosis in FY08/FY09 and attended only one to five PTSD psychotherapy sessions. A nested case-control study was conducted comparing veterans who reengaged in psychotherapy (n=9649) in a 1:5 ratio with those who did not reengage by the end of FY12. Conditional logistic regression models were run to examine differences in sociodemographic, mental health, and service utilization factors between cases and controls. RESULTS: Among veterans in the study cohort, 39.4% reengaged in psychotherapy. In adjusted analyses, all measured types of health system encounters (primary care [OR=1.61], primary care mental health [OR=1.61], non-PTSD psychotherapy [OR=1.76], other non-PTSD mental health care [OR=1.43], other non-psychotherapy PTSD care [OR=3.31], emergency room [OR=1.14], and psychiatric hospitalization [OR=1.56]) were related to greater odds of reengagement in PTSD psychotherapy. CONCLUSIONS: Veterans' receipt of a broad range of care services may play an important role in reengagement in PCT psychotherapy, suggesting providers across care settings should be knowledgeable in how to support a Veteran's return to psychotherapy for PTSD.

Mental Health Treatment Seeking Among Veteran and Civilian Community College Students.

OBJECTIVE: A Web-based survey examined treatment seeking among community college students to inform the design of engagement interventions. METHODS: Veteran and civilian community college students (N=765) were screened for mental disorders and reported perceptions of treatment need, effectiveness, and stigma, as well as service use. Regression analysis identified predictors of pharmacotherapy and psychotherapy use. RESULTS: Of the 511 students who screened positive for a current mental disorder or reported a perceived need for treatment (149 veterans and 362 civilians), 30% reported past-year use of psychotropic medications. Predictors were perceived treatment need (odds ratio [OR]=7.81, p<.001) and the perception that psychotropic medications are effective (OR=3.38, p=.012). Eleven percent of participants reported past-year psychotherapy use, and predictors were a positive screen for posttraumatic stress disorder (OR=2.78, p=.04) and poorer financial status. CONCLUSIONS: Modifiable barriers, including perceived need for and effectiveness of treatment, were correlated with pharmacotherapy use and should be targeted by engagement interventions.

Pilot study of enhanced social support with automated telephone monitoring after psychiatric hospitalization for depression.

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.

Postdeployment Suicide Risk Increases Over a 6-month Period: Predictors of Increased Risk among Midwestern Army National Guard Soldiers.

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.