Delivery of Exposure and Response Prevention Among Veterans with Obsessive-Compulsive Disorder.

Veterans with obsessive-compulsive disorder (OCD) often face barriers to receiving evidence-based treatments such as exposure and response prevention (ERP). Through retrospective review of electronic medical records, this study examined the rates of ERP delivery in a national sample of 554 veterans newly diagnosed with OCD in the Veterans Health Administration between 2016 and 2017. Results indicated that only 4% of veterans (n = 22) received any ERP treatment; and, of those, 16 veterans received "true ERP." Veterans who received any ERP were younger than those who did not. ERP was primarily delivered by psychologists in urban facilities along the East and West coasts of the USA. The findings from this study emphasize the need to train more providers to effectively deliver ERP in addition to providing telehealth services to increase access to care for veterans in rural areas.

Evidence of Phone vs Video-Conferencing for Mental Health Treatments: A Review of the Literature.

PURPOSE OF REVIEW: The goal of this paper is to provide a comparative review of using phone (audio-only) or video for mental health treatments. Our review includes evidence of phone and video's effectiveness in terms of reduced symptomology, retention, satisfaction, therapeutic alliance, and other outcomes of interest. This review also discusses how patients and providers' experiences and attitudes differ between these two modalities. Finally, we present information on different usage rates of phone and video across patient populations and mental health provider types, and different implementation strategies. RECENT FINDINGS: Treatments through phone and video are both able to reduce symptoms related to mental health conditions and have both been found to be non-inferior to in-person care. Both phone and video are more convenient to patients. Video offers important visual information that can be important to diagnosing mental health conditions. Phone, however, is more broadly accessible and may come with fewer technological issues. In the context of mental health care, where non-verbal cues are tied to symptomology and diagnosing, and a strong relationship between patient and provider can enhance treatment, we encourage the use of video, especially for psychotherapeutic services. However, as phone is more accessible, we ultimately recommend an accommodating approach, one that flexibly makes use of both phone and video. Future studies on telehealth should focus on direct, head-to-head comparisons between phone and video and conduct more rigorous testing on whether clinical differences exist.

Increasing access to care for trauma-exposed rural veterans: A mixed methods outcome evaluation of a web-based skills training program with telehealth-delivered coaching.

PURPOSE: While rural veterans with trauma exposure report high rates of posttraumatic stress disorder (PTSD), depression, and functional impairment, utilization of health services is low. This pilot study used mixed qualitative and quantitative methods to evaluate the potential benefits of a transdiagnostic web-based skills training program paired with telehealth-delivered coaching to address a range of symptoms and functional difficulties. The study directed substantial outreach efforts to women veterans who had experienced military sexual trauma given their growing representation in the Veterans Healthcare Administration (VHA) and identified need for services. METHODS: Participants were 32 trauma-exposed veterans enrolled in rural-serving VHA facilities who screened positive for either PTSD or depression. Symptoms of PTSD, depression, emotion regulation, and interpersonal problems were assessed at baseline, midpoint, posttreatment, and 3-month follow-up. Veterans completed exit interviews to identify benefits and limitations of the program. RESULTS: Intent-to-treat analyses revealed significant symptom reduction for all outcomes, with large to moderate effect sizes at 3-month follow-up. Outcomes did not differ by gender or military sexual trauma status. Veterans' rating of the therapeutic alliance was high and interview responses indicated that the presence of the coach was critical to success in the program. CONCLUSION: This remotely delivered transdiagnostic intervention provided significant benefits across a range of symptoms and functional outcomes and was viewed positively by veterans. The results indicate that further research (ie, a randomized controlled trial) is warranted. Attention to the role of the coach as a means by which to increase engagement and retention in technology-delivered interventions is warranted.

A pilot open trial of video telehealth-delivered exposure and response prevention for obsessive-compulsive disorder in rural Veterans.

Exposure and response prevention (ERP) is the gold-standard, evidence-based psychotherapy for obsessive-compulsive disorder (OCD), but few receive it. Video telehealth can increase access to ERP for OCD and may enhance the salience of exposures. This study examined the feasibility, acceptability, and preliminary effectiveness of video telehealth-delivered ERP. We conducted a pilot open trial with 11 Veterans, using mixed quantitative and qualitative methods. Treatment completers (n = 9) had significantly reduced OCD and posttraumatic stress disorder symptoms posttreatment. Patients expressed greater comfort in engaging in ERP at home than in clinics. Therapists reported that seeing patients' home environments helped them understand their symptoms and identify relevant OCD exposures. Results suggest that video telehealth-delivered ERP is feasible and acceptable to patients and therapists and promising for reducing OCD symptoms. Future research should compare its effectiveness to usual care and evaluate patients' preferences for treatment delivery. Abbreviations: ERP: exposure and response prevention; GAD-7: Generalized Anxiety Disorder-7 scale; OCD: obsessive-compulsive disorder; OCI-R: Obsessive-Compulsive Inventory, Revised; PCL-5: PTSD Checklist; PHQ-9: Patient Health Questionnaire; PTSD: posttraumatic stress disorder; VA: epartment of Veterans Affairs; Y-BOCS: Yale-Brown Obsessive Compulsive Scale, self report form.

Seeing the Value of Video: A Qualitative Study on Patient Preference for Using Video in a Veteran Affairs Telemental Health Program Evaluation.

Background: As the use of telemental health-mental health care delivered through video or phone-has increased in the era of COVID, it is important to understand patients' preferences and perspectives regarding the use of video for telehealth visits. A new web-based treatment program for veterans uses video visits with mental health experts to supplement its online cognitive behavioral therapy to treat clinically significant symptoms of depression and/or post-traumatic stress disorder. Objective: As part of the program evaluation, Veterans were asked, "How important was it for you to be able to physically see your provider through video telehealth?" to understand whether they thought using video was important and why it may or may not be important. Materials and Methods: The study uses data from the program's exit survey and exit interview. The surveys and interviews were conducted over a 19-month period. Surveys and interviews were conducted over the phone with note taking. Matrix and content analyses were used to analyze the qualitative data-predetermined themes and emergent themes were analyzed and inform findings. Results: Seventy-three veterans completed a survey. Of these, 64 completed an interview. The majority of veterans surveyed (75%) said that it was "very important" to physically see their provider through video telehealth, 23% said that it was at least "somewhat important" or "not at all important." This study highlights three main themes found in the qualitative data: patients discuss (1) advantages of using video, (2) why they dislike video, and (3) technological barriers to using video. Conclusions: Being able to visually see a provider, and be seen by a provider, has distinct benefits for care and relationship building that are difficult to achieve over the phone. This has important implications for the future delivery of telemental health care and deserves consideration as patients and providers decide whether to use phone or video for remotely delivered care.

Identifying psychiatric diagnostic errors with the Safer Dx Instrument.

OBJECTIVE: Diagnostic errors in psychiatry are understudied partly because they are difficult to measure. The current study aimed to adapt and test the Safer Dx Instrument, a structured tool to review electronic health records (EHR) for errors in medical diagnoses, to evaluate errors in anxiety diagnoses to improve measurement of psychiatric diagnostic errors. DESIGN: The iterative adaptation process included a review of the revised Safer Dx-Mental Health Instrument by mental health providers to ensure content and face validity and review by a psychometrician to ensure methodologic validity and pilot testing of the revised instrument. SETTINGS: None. PARTICIPANTS: Pilot testing was conducted on 128 records of patients diagnosed with anxiety in integrated primary care mental health clinics. Cases with anxiety diagnoses documented in progress notes but not included as a diagnosis for the encounter (n = 25) were excluded. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): None. RESULTS: Of 103 records meeting the inclusion criteria, 62 likely involved a diagnostic error (42 from use of unspecified anxiety diagnosis when a specific anxiety diagnosis was warranted; 20 from use of unspecified anxiety diagnosis when anxiety symptoms were either undocumented or documented but not severe enough to warrant diagnosis). Reviewer agreement on presence/absence of errors was 88% (κ = 0.71). CONCLUSION: The revised Safer Dx-Mental Health Instrument has a high reliability for detecting anxiety-related diagnostic errors and deserves testing in additional psychiatric populations and clinical settings.

"It didn't fit for me:" A qualitative examination of dropout from prolonged exposure and cognitive processing therapy in veterans.

Trauma-focused psychotherapies, such as prolonged exposure and cognitive processing therapy, are the most effective forms of treatment for posttraumatic stress disorder. These treatments are commonly delivered in the Veterans Health Administration; however, dropout means that some veterans fail to benefit. Ending treatment prematurely is a common problem across psychotherapies, with on average, 20% to 25% of patients dropping out. The purpose of this study was to examine veterans' self-reported reasons for dropping out of prolonged exposure or cognitive processing therapy. Veterans who dropped out from prolonged exposure or cognitive processing therapy (N = 28) completed qualitative interviews about their experiences. Interviews were coded by 2 coders using grounded theory. Therapy-related barriers were the largest category reported, and included lack of buy-in to the rationale or specific therapy tasks, believing that treatment was not working, alliance issues, or switching to a different treatment. Practical barriers and finding treatment "too stressful" were also common reasons for dropout. This research provides information that can shape how PTSD treatments are delivered in health care settings. Therapy-related barriers were the largest group, suggesting that providers may need to find more effective ways to communicate the rationale for these therapies or to tailor them to individual patients' needs. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Personalized Implementation of Video Telehealth.

This article describes the Personalized Implementation for Video Telehealth strategy to increase adoption of video telehealth to home (VTH) across a large, urban Veterans Health Administration medical center and applications for broader use in non-VHA settings. The authors fully integrated VTH into existing mental health clinics, resulting in (1) a significant increase in the number of patients receiving VTH, (2) a significant increase in the number of VTH visits relative to median national improvement, (3) a greater number of unique specialty mental health clinics offering VTH in Houston, and (4) a greater number of community clinics active in delivering VTH.

Utilization of genomic testing in advanced non-small cell lung cancer among oncologists in the Veterans Health Administration.

Current national guidelines recommend genomic testing on all stage 4 non-small cell lung cancers (NSCLC) of adenocarcinoma histology. Mutations are most often found among young, Asian, females without a history of smoking. As these characteristics are uncommon in the Veterans Health Administration (VHA) patient population, we sought to understand oncologists' decision-making processes regarding utilization of genomic testing in the VHA. We conducted in-depth qualitative interviews with 30 VHA-based medical oncologists. Interviews aimed to elicit oncologists' experiences and decision-making processes regarding genomic testing in patients with stage 4 non-small cell lung cancer with adenocarcinoma histology. Analysis was guided by principles of framework analysis. Sample size was determined by thematic saturation. We identified a wide variation in medical oncologists' genomic testing practices. Consistent with guidelines, advanced stage and adenocarcinoma histology most often influenced practice patterns among our participants. However, patient characteristics like gender, age, smoking status, and performance status were also taken in to account by some oncologists when making testing decisions. This does not reflect a widespread adoption of national guidelines for genomic testing in the VHA. Qualitative interviews with VHA-based oncologists demonstrated that genomic testing decisions are not always consistent with current national guidelines. Efforts should be made to address modifiable barriers to genomic testing in the VHA setting.

Failure to engage: A qualitative study of veterans who decline evidence-based psychotherapies for PTSD.

Low engagement in posttraumatic stress disorder (PTSD) psychotherapy is a common problem in the U.S. Department of Veteran Affairs (VA), with up to half of veterans who are referred to an evidence-based psychotherapy failing to engage in that treatment. Prior research has focused on identifying general barriers to mental health treatment rather than barriers specific to evidence-based treatments for PTSD. The purpose of the current study was to identify barriers for veterans who referred specifically for evidence-based psychotherapy (i.e., cognitive processing therapy or prolonged exposure) but who did not attend any sessions of those psychotherapies. Qualitative interviews (N = 24) were used to gain a better understanding of the experiences and attitudes of these veterans. Most veterans reported multiple barriers to treatment engagement (M = 4.2 barriers), suggesting that an accumulation of barriers contributes to poor engagement. Barriers fell into 5 categories: practical, knowledge, emotional, therapy-related, and VA-system-related. The most-endorsed category, mentioned by two thirds of the sample, was VA-system-related barriers, including inefficiencies and delays, negative experiences with VA staff and providers, discomfort with the VA environment, and difficulty navigating the VA system. Veterans' experienced barriers to beginning PE and CPT were diverse but, overall, highlighted the need to transform the VA to a more patient-centered model of care. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Barriers and Facilitators to the Use of Genomic-Based Targeted Lung Cancer Therapies in the VA: Qualitative Findings.

Reflexive testing, standardization of the mutation test ordering procedure and results reporting, and elimination of the preauthorization requirements could facilitate the utilization of targeted therapies.

Surveillance endoscopy is associated with improved outcomes of oesophageal adenocarcinoma detected in patients with Barrett's oesophagus.

BACKGROUND: The effectiveness of surveillance endoscopy in patients with Barrett's oesophagus (BE) for reducing oesophageal adenocarcinoma (EAC)-related mortality in patients with BE is unclear. METHODS: This is a cohort study of patients with BE diagnosed in the National Veterans Affairs hospitals during 2004-2009 excluding those with conditions that affect overall survival. We identified those diagnosed with EAC after BE diagnosis through 2011 and conducted chart reviews to identify BE surveillance programme, and indication for EAC diagnosis, verify diagnosis, stage, therapy and cause of death. We examined the association between surveillance indication for EAC diagnosis with or without surveillance programme and EAC stage and treatment receipt in logistic regression models, and with time to death or cancer-related death using a Cox proportional hazards regression model. RESULTS: Among 29 536 patients with BE, 424 patients developed EAC during a mean follow-up of 5.0 years. A total of 209 (49.3%) patients with EAC were in BE surveillance programme and were diagnosed as a result of surveillance endoscopy. These patients were more likely to be diagnosed at an early stage (stage 0 or 1: 74.7% vs 56.2, p<0.001), survived longer (median 3.2 vs 2.3 years; p<0.001) and have lower cancer-related mortality (34.0% vs 54.0%, p<0.0001) and had a trend to receive oesophagectomy (51.2% vs 42.3%; p=0.07) than 215 patients diagnosed by non-BE surveillance endoscopy (17.2% of whom were BE surveillance failure). BE surveillance endoscopy was associated with a decreased risk of cancer-related death (HR 0.47, 0.35 to 0.64), which was largely explained by the early stage of EAC at the time of diagnosis. Similarly, the adjusted mortality for patients with cancer in a prior surveillance programme for overall death was 0.63 (0.47 to 0.84) compared with patients with cancer not in a surveillance programme. CONCLUSIONS: Surveillance endoscopy among patients with BE is associated with significantly better EAC outcomes including cancer-related mortality compared with other non-surveillance endoscopy.

The incidence of esophageal adenocarcinoma in a national veterans cohort with Barrett's esophagus.

OBJECTIVES: The increasing incidence of esophageal adenocarcinoma (EA) in the United States may have leveled off in recent years. The risk of EA among patients with Barrett's esophagus (BE) seems to be decreasing in several European cohorts, but these estimates are unknown in the United States. We aimed to determine the risk of developing EA in a national cohort of BE patients in the US Veterans Health Administration and to account for the use of endoscopic ablation and esophagectomy. METHODS: This was a retrospective cohort study from a total of 121 facilities in the Veterans Health Administration. Veteran patients with BE diagnosed between 1 October 2003 and 30 September 2009 were included and followed until esophageal cancer diagnosis, death or 30 September 2011. All EA diagnoses were verified in detailed structured reviews of medical records. RESULTS: We identified 29,536 patients with BE who met our eligibility criteria. Most were men (96.9%) and White (83.2%), with a mean age of 61.8 years. During 144,949 person-years of follow-up, 466 patients developed EA, yielding an incidence rate of 3.21 per 1,000 person-years (95% confidence interval (CI) 2.94-3.52). Excluding those who developed EA within 1 year of their index BE date lowered the incidence rate to 1.75 per 1,000 person-years. However, including additional patients who underwent endoscopic ablation or esophagectomy for HGD or EA increased the incidence rate to 4.79 (95% CI 4.44-5.16). CONCLUSIONS: The incidence of EA in a US national cohort of mostly male veterans may be lower than previous estimates. Almost half of the EA cases were diagnosed within 1 year of their BE index date.