Monitoring mental health treatment acceptance and initial treatment adherence in veterans: veterans of Operations Enduring Freedom and Iraqi Freedom versus other veterans of other eras.

Identifying factors that influence mental health outcomes in veterans can aid in the redesign of programs to maximize the likelihood of early resolution of problems. To that end, we examined demographic and clinical process data from 2,684 veterans who scored positive on a mental health screen. We investigated this data set for patterns and possible predictors of mental health referral acceptance and attendance. The majority of patients had not received mental health treatment within the last two years (76%). Veterans of Operations Enduring Freedom and Iraqi Freedom (OEF/OIF) were more likely to accept a mental health referral for depression but were equally likely to attend a mental health visit as other era veterans. Decreased acceptance was associated with provider type and contact method, clinic location, depression only, and specific age ranges (65-74). Among those who accepted a referral, decreased attendance was associated with clinic location, depression only, and retirement. No variables predicted OEF/OIF acceptance/attendance. In conclusion, our findings illustrate the importance of close, continual monitoring of clinical process data to help reveal targets for improving mental health care for veterans.

Using motivational interviewing as a supplement to obesity treatment: a stepped-care approach.

OBJECTIVE: This investigation was designed to improve behavioral weight loss program (BWLP) treatment outcomes by providing stepped care (SC) to individuals experiencing difficulties with weight loss during treatment. SC entails transition to more intensive treatments when less intensive treatments fail to meet treatment goals. In a BWLP, motivational interviewing (MI) may increase participants' motivation toward behavioral change and thus complement the acquisition of behavioral change skills. It was hypothesized that BWLP+SC (MI) participants (i.e., participants who failed to meet weight loss goals and received MI) would demonstrate superior treatment outcomes when compared with BWLP (SC matched) participants (i.e., participants who failed to meet weight loss goals but did not receive MI). DESIGN: Fifty-five obese, sedentary adults were randomly assigned to a BWLP+SC or a BWLP. MAIN OUTCOME MEASURES: Changes in weight, cardiorespiratory fitness, self-reported physical activity, and diet (i.e., calories, percentage daily intake of fat, protein, and carbohydrates) in response to treatment were assessed. RESULTS: Participants significantly decreased their weight, increased physical activity/fitness, and improved dietary intake (ps<.05). BWLP+SC (MI) participants lost more weight and engaged in greater weekly exercise than BWLP (SC matched) participants who did not receive MI (ps<.05). CONCLUSION: For individuals experiencing weight loss difficulties during a BWLP, MI may have considerable promise.

The relationship between self-monitoring, outcome expectancies, difficulties with eating and exercise, and physical activity and weight loss treatment outcomes.

BACKGROUND/PURPOSE: During a behavioral weight loss program (BWLP), weight loss and exercise can vary considerably from week to week. Weekly fluctuations in outcome expectancies and perceived difficulties with eating and exercise may be associated with weekly variability in weight loss and exercise. Also, inconsistent self-monitoring of exercise may be associated with poor weight loss and physical activity treatment outcomes. METHODS: Forty obese, sedentary participants completed a 6-month BWLP. Body weight, outcome expectancies, and difficulties with eating and exercise were assessed weekly. Weekly self-monitoring of exercise was computed from physical activity diaries. Physical activity, VO2max, and caloric intake were assessed pre- and posttreatment. RESULTS: Within-subjects analyses indicated that participants exercised less during weeks that participants reported greater difficulties with exercise, relative to weeks participants reported fewer difficulties. Participants lost significantly more weight during weeks that participants reported more positive outcome expectancies and greater difficulties with exercise, compared to weeks participants reported less positive outcome expectancies and fewer difficulties with exercise. Consistent self-monitoring of exercise was associated with fewer difficulties with exercise and greater exercise and weight loss. CONCLUSIONS: Interventions that are targeted to increase self-monitoring and to improve transient difficulties with exercise and diminished outcome expectancies may improve BWLP treatment outcomes.

Applying a stepped-care approach to the treatment of obesity.

OBJECTIVE: In a stepped-care (SC) approach to treatment, more intensive interventions are implemented when less intensive interventions prove to be insufficient. It was hypothesized that a behavioral weight loss program with SC (BWLP+SC) would evidence superior treatment outcomes when compared with a BWLP without SC (BWLP). METHODS: Forty-four obese, sedentary adults were randomly assigned to a BWLP+SC [i.e., problem-solving therapy (PST)] or a BWLP. RESULTS: Participants in the BWLP+SC lost significantly more weight and body fat, reported greater physical activity and greater improvements in diet, and were more likely to achieve their within-treatment weight loss goals than BWLP participants. Participants in the BWLP+SC who received PST (BWLP+SC [PST]) also evidenced superior treatment outcomes including superior weight loss maintenance (through 12 months posttreatment) compared with BWLP participants matched on SC eligibility [BWLP (SC matched)]. CONCLUSION: BWLP+SC may improve treatment outcomes and participant motivation to achieve preestablished weight loss goals.

Education on the glycemic index of foods fails to improve treatment outcomes in a behavioral weight loss program.

The glycemic index (GI) may play an important role in weight management by helping to control appetite and insulin levels. The impact of adding education on the GI of foods to a behavioral weight loss program (BWLP) was examined. Fifty-three obese, sedentary participants were randomly assigned to receive either a BWLP or a BWLP+GI education. Pre- and posttreatment weight loss, body fat, and diet were assessed. Weight loss and body fat were assessed at 1-year posttreatment. GI education had no significant impact on weight loss treatment outcomes at posttreatment or 1-year follow-up. Average weight loss was 7.6 kg (p<0.05). Participants in the BWLP+GI education group had significantly greater GI knowledge (p<0.05) and consumed foods with a lower average daily GI (p<0.05), than participants in the BWLP at posttreatment. At 1-year posttreatment, participants regained 59% of their posttreatment weight loss and 34% of their lost body fat. GI education did not improve BWLP treatment outcomes in this investigation.

Reducing cardiovascular risk factors in postmenopausal women through a lifestyle change intervention.

BACKGROUND: The impact of a 6-month lifestyle change intervention on cardiovascular risk factors in obese, sedentary, postmenopausal women was examined. A secondary aim of this investigation was to determine whether the addition of self-control skills training to an empirically supported lifestyle change intervention would result in greater cardiovascular risk reduction. METHODS: Forty-four women were randomly assigned to receive either a lifestyle change or a lifestyle change with self-control skills intervention. Pretreatment and posttreatment weight loss, body composition, physical activity, cardiorespiratory fitness, diet, blood pressure (BP), blood lipids, and psychosocial functioning were assessed. Also, at 1-year posttreatment, weight loss, body composition, self-reported physical activity, and psychosocial functioning were assessed. RESULTS: The women significantly increased their physical activity (+39.6%) and cardiorespiratory fitness (+13.5%) and reduced their body weight (-6.5%), fat mass (-7.4%), body fat (-2.4%), BP (SBP -6.2%, DBP -9.2%), total cholesterol (-7.4%), triglycerides (-16.5%), and low-density lipoprotein (LDL) cholesterol (9.1%) and improved their diet (p < 0.05). At the 1-year follow-up, women had regained approximately 63% of their posttreatment weight loss (p < 0.05), but had maintained their previous increases in physical activity. Additionally, there were no significant changes in fat free mass, body fat, anxiety, or depression between the end of treatment and 1-year posttreatment. The addition of self-control skills training did not significantly improve cardiovascular risk reduction. CONCLUSIONS: Lifestyle change interventions may be an effective means for reducing cardiovascular risk in obese, sedentary, postmenopausal women. However, greater attention should be devoted to the maintenance of these positive lifestyle changes.

An ecological momentary assessment of relapse crises in dieting.

Much of the research on relapse crises in dieting has focused on isolated lapse events and relied heavily on retrospective self-report data. The present study sought to overcome these limitations by using ecological momentary assessment (EMA) techniques to examine situations of dietary temptation and lapse with a sample of obese, formerly sedentary, postmenopausal women (N = 37) during the final week of a weight-loss intervention. Mood was associated with reports of dietary lapse. Abstinence-violation effects were more strongly associated with dietary lapses than temptations. Finally, coping responses distinguished dietary temptations from lapses. Education on the factors associated with relapse crises in dieting may be imperative for weight loss success and maintenance.

Psychosocial functioning and physical symptoms in heart failure patients: a within-individual approach.

OBJECTIVE: Heart failure (HF) markedly diminishes an individual's quality of life. However, little is known about how psychosocial functioning is related to heart failure physical symptom expression (e.g., chest pain or heaviness, shortness of breath) on a day-to-day basis. METHODS: Fifty-eight HF patients completed daily diaries that evaluated mood, social support, coping, and physical symptoms for 2 weeks. RESULTS: After being prewhitened for serial dependencies, the data were entered into regression analyses to determine the concurrent and lagged relationships among them. Significant concurrent relationships were obtained between physical symptoms and depression, social conflict, positive and negative mood, and symptom-focused coping. Furthermore, negative mood and distraction coping predicted greater physical symptoms the next day, while action/acceptance coping predicted fewer physical symptoms the next day. CONCLUSION: Our data provide evidence for an association between daily psychosocial functioning and HF physical symptoms. Implications for research and clinical work with HF patients are discussed.

The association between emotional upset and cardiac arrhythmia during daily life.

Ventricular arrhythmia exhibits considerable within-subject variability that cannot be attributed to clinical status alone. This investigation examined the extent to which cardiac arrhythmia was associated with psychological and physical factors assessed during the hour preceding arrhythmic or nonarrhythmic activity. Approximately twice hourly, 46 patients randomly completed a diary assessing mood and physical symptoms during 24-hr electrocardiographic monitoring. Greater negative emotion was associated with increased arrhythmia. Additionally, greater negative emotion was significantly associated with increased arrhythmia among participants in a low left ventricular ejection fraction group (LVEF). However, this relationship between negative emotion and arrhythmia was not observed among higher LVEF participants. These findings contribute to a larger body of evidence suggesting that negative moods may exacerbate cardiac conditions.

The early identification of poor treatment outcome in a women's weight loss program.

Research examining factors associated with program attrition or failure to lose weight during active treatment has yielded mixed findings. The goal of the current investigation was to confirm and extend prior research on the predictors and correlates of attrition and failure to lose weight during treatment. This investigation examined whether baseline characteristics, early weight loss, attendance, weight-related quality of life, confidence and difficulties with eating and exercise, and diet-related thoughts and feelings during the final week of treatment were associated with percentage change in body weight. Forty-four, obese, sedentary, postmenopausal women were recruited to participate in a 24-session weight loss intervention. Poor treatment outcome (i.e., percentage change in body weight) was significantly associated with several baseline characteristics including higher body mass index (BMI), greater fat and lower carbohydrate consumption, poor body image, and greater expectations for program success. Poor treatment outcome was also significantly associated with poor program attendance, unsatisfactory early weight loss, unsatisfactory improvements in weight-related quality of life, and lower self-control and self-confidence. By the end of active treatment, women with poor treatment outcome evidenced significantly higher levels of guilt and feelings of failure. The need for early identification and intervention with participants at risk for treatment failure is discussed.