Evaluation of the Implementation of the FLOW Program for Increasing Access to Mental Health Care.

The FLOW program was designed to facilitate appropriate and safe transitions of patients from specialty mental health (SMH) to primary care (PC) as a method of improving access and reducing appointment burden on veterans who have improved or remitted. In this study, the team evaluated the implementation of FLOW across nine Veterans Affairs (VA) sites using a mixed-methods evaluation in a cluster-randomized stepped wedge trial design. Outcome assessments used data from VA databases, dashboards, and semi-structured interviews and were guided by the Reach, Adoption, Effectiveness, Implementation, and Maintenance (RE-AIM) framework. Across the sites, mean level reach was 1.36% of all specialty mental health patients transitioned to primary care (standard deviation [SD] = 1.05). Mean provider adoption was 10.2% (SD = 8.3%). Approximately 75% of veterans were fully satisfied with their transition and reported shared decision-making in the decision to transition. Rates of transitions did not decrease over the 6-month maintenance period following implementation. These data suggest that FLOW can be successfully implemented and maintained, although there was wide variation in implementation across sites. Future research should examine how to support sites that struggle with implementation.

Improving the transition of patients with mental health disorders back to primary care: A protocol for a partnered, mixed-methods, stepped-wedge implementation trial.

The current study protocol regards a partnered, mixed-methods, cluster-randomized stepped wedge trial of the implementation and effectiveness of the FLOW program. FLOW (not an acronym) is a collection of resources and strategies to assist in determining which recovered or stabilized specialty mental health (SMH) patients should transition back to primary care (PC) and tools to make the transition seamless. Transitioning appropriate patients to PC can increase access and timeliness of mental health care for newly referred mental health patients. Nine sites in one US region will be randomized to one of three waves in which they will receive implementation-facilitation to implement the FLOW program. Primary outcomes will include the reach of FLOW, provider adoption of the program, effectiveness in increasing access in SMH, implementation fidelity, and maintenance over time. A mixed-methods analysis of implementation factors associated with implementation success will also be conducted, including the following as possible predictors: staffing ratios, site resources, leadership and provider support for the program, and local champion characteristics. This study's results will provide evidence for the effectiveness of FLOW in increasing access and may provide generalizable information about characteristics of sites that are likely to be successful with implementing similar programs.

Rural American Indian and Alaska Native veterans' telemental health: A model of culturally centered care.

American Indian and Alaska Native (AI/AN) veterans living in rural areas have unique health care needs and face numerous barriers to accessing health care services. Among these needs is a disproportionate prevalence of posttraumatic stress disorder and other mental illnesses. Since 2001, 14 rural communities have partnered with the U.S. Department of Veterans Affairs and the Centers for American Indian and Alaska Native Health at the University of Colorado Anschutz Medical Campus to extend telemental health clinics to American Indian veterans. Administrative and, to some extent, clinical considerations of these clinics have been reviewed previously. This paper describes a model of care, evolved over a 14-year period, that weaves together evidence-based Western treatment, traditional Native healing, and rural Native communities into 4 main components: mental health care, technology, care coordination, and cultural facilitation. We delineate improvements to care made by addressing barriers such as system transference, provider-patient trust, and videoconferencing. Similarly, the discussion notes ways that the care model leverages strengths within Native communities, such as social cohesion and spirituality. Future steps include selection of appropriate performance indicators for systematic evaluation. The identification of key constructs of this care model will facilitate comparisons with other models of care in underserved populations with chronic and complex health conditions, and eventually advance the state of care for our warriors. (PsycINFO Database Record

Moving Beyond Self-Report: Implicit Associations about Death/Life Prospectively Predict Suicidal Behavior among Veterans.

Reliance on self-report limits clinicians' ability to accurately predict suicidal behavior. In this study the predictive validity of an objective measure, the death/suicide Implicit Association Test (d/sIAT), was tested among psychiatrically hospitalized veterans. Following acute stabilization, 176 participants completed the d/sIAT and traditional suicide risk assessments. Participants had similar d/sIAT scores regardless of whether they had recently attempted suicide. However, d/sIAT scores significantly predicted suicide attempts during the 6-month follow-up above and beyond other known risk factors for suicidal behavior (OR = 1.89; 95% CI: 1.15-3.12; based on 1SD increase). The d/sIAT may augment the accuracy of suicide risk assessment.

Antipsychotic-Induced Movement Disorder: Screening via Telemental Health.

BACKGROUND: The purpose of this brief report is to make clinical and research recommendations to advance current knowledge and practices related to the assessment of antipsychotic drug-induced movement disorders (DIMDs) via live interactive videoconferencing. MATERIALS AND METHODS: The authors provide an overview of the frequent neurological side effects of antipsychotic drugs and review relevant telemedicine research. DIMD prevention is critical, but these disorders remain underdetected and under-reported. Although there are not yet formal recommendations for specific screening tools or screening frequency, baseline and annual assessments are generally agreed-upon minimums. As DIMD awareness increases and more specific guidelines are developed to steer assessments, telemental health may aid practitioners in efficiently and regularly monitoring onset and severity. Research shows that videoconferencing can be used for effective psychiatric treatments and assessment, with at least one study validating the use of videoconference assessment for a subset of movement disorders. RESULTS AND CONCLUSIONS: Clinical recommendations include developing practice-level protocols and procedures that include regular DIMD assessment (either in-person or via telemedicine) for the full spectrum of possible movement disorders for all patients taking antipsychotic medications. Research and evaluation recommendations include replicating and expanding upon the existing study using videoconferencing to assess movement disorder symptoms, using asynchronous telemental health assessments of DIMDs, and pilot-testing facial and movement recognition software to allow for clinical comparison of patients' movement patterns over time.

The impact of demographic differences on native veterans' outpatient service utilization.

Many Native veterans--including American Indian/Alaska Native (AIAN) and Native Hawaiian/Pacific Islanders (NHPI)--have served in the United States Armed Forces. Most of these veterans are eligible for medical care from the Department of Veterans Affairs (VA), but research examining the determinants of their service use is needed to inform policy and allocate appropriate resources for these unique groups. In a retrospective cohort study, we examined the impact of Native veterans' personal demographics on their outpatient utilization of VA-based primary care and mental health services. AIAN (n = 37,687) and NHPI (n = 46,582) veterans were compared with a non-Native reference (N = 262,212) using logistic and binomial regression. AIAN and NHPIs were more likely to be female, report military sexual trauma, and utilize the VA for posttraumatic stress disorder, traumatic brain injury, depression, addiction, anxiety, hypertension, and diabetes care. More AIAN and urban NHPI veterans served in Iraq and Afghanistan, and Native women reported more military sexual trauma than their non-Native counterparts. Primary care and mental health services were associated with race, number of diagnoses, and disability ratings. For mental health services, service era, military sexual trauma, and marital status were related to service utilization. Native veterans' medical need was elevated for primary and mental health care. Rural residence was associated with less mental health use. The findings underscore the need for additional specialized services in rural areas, more targeted outreach to Operation Enduring Freedom/Operation Iraqi Freedom Native veterans, and additional care directed toward Native women's health care needs.

Executive functioning and suicidal behavior among veterans with and without a history of traumatic brain injury.

OBJECTIVE: To examine the relationship between executive dysfunction, as a multidimensional construct (ie, decision-making, impulsivity, aggression, concept formation), and suicide attempt (SA) history in a high-risk sample of veterans with moderate to severe traumatic brain injury (TBI). DESIGN: Observational, 2×2 factorial design. To estimate group differences, linear regression was used to model the primary and secondary outcomes of interest as a function of history of SA, TBI, and the interaction between the 2 variables. Additionally, to determine the pattern of performance over the course of the Iowa Gambling Test (IGT), scores were modeled across the 5 IGT blocks by using a varying-coefficient model. SETTING: Veterans Health Administration. PARTICIPANTS: Veterans (N=133; no SA/no TBI, n=48; no SA/yes TBI, n=51; yes SA/no TBI, n=12; yes SA/yes TBI, n=22) completed the study measures. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: IGT, Immediate and Delayed Memory Test, State-Trait Anger Expression Inventory-2, Wisconsin Card Sorting Test. RESULTS: All groups demonstrated learning over the course of the IGT, except for veterans with a history of both SA and TBI. No group differences were identified on other measures of executive functioning. CONCLUSIONS: These findings highlight the potential, unique decision-making challenges faced by veterans with a history of TBI and SA. Specialized interventions focused on overall distress reduction and means restriction may be required to prevent future self-directed violence.

Validating the traumatic brain injury-4 screening measure for veterans seeking mental health treatment with psychiatric inpatient and outpatient service utilization data.

OBJECTIVE: To determine whether a positive screen on the Traumatic Brain Injury-4 (TBI-4) can be used to identify veterans who use more inpatient and outpatient mental health services. DESIGN: Validation cohort. SETTING: Medical center. PARTICIPANTS: Individuals seeking Veterans Health Administration mental health services (N=1493). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: One year of inpatient and outpatient mental health utilization data after the TBI-4 screen date. RESULTS: In the year postmental health intake, those who answered positively to any of the 4 TBI-4 screening questions (criterion 1) or question 2 (criterion 2; ever having been knocked out) had significantly more psychiatric hospitalizations than those who met neither criterion. Those who were positive by criterion 2 also had significantly fewer outpatient mental health contacts. CONCLUSIONS: Veterans screening positive for history of traumatic brain injury on the TBI-4 had more hospital stays in the year postmental health intake. Those who reported having been knocked out also had fewer outpatient mental health visits. These findings may suggest an overall relation in this population between greater needs for mental health care and likelihood of prior injury. For those with a history of loss of consciousness, the reduced use of outpatient care may reflect greater problems engaging in treatment or with preventive aspects of the health care system during non-crisis periods. Using a screener (eg, the TBI-4) could facilitate identification of veterans who might benefit from targeted and intensive outpatient interventions to avoid frequent inpatient psychiatric hospitalization.

Rural native veterans in the Veterans Health Administration: characteristics and service utilization patterns.

PURPOSE: The Department of Veterans Affairs (VA) and the Indian Health Service (IHS) signed a Memo of Understanding in 2010 to strengthen their partnership in improving health care services for Native veterans, who are disproportionately rural. This paper describes the demographic and service use profile of rural Native veterans who access VA health care. METHODS: Data were abstracted from the 2008 Veteran Health Administration (VHA) medical dataset, and the characteristics of rural Native veterans were compared to rural non-Native veterans. FINDINGS: Rural Native veterans were more rural (41% vs 35%) and more highly rural (8% vs 2%) compared to non-Native veterans. Rural Native veterans were younger, more likely to be female, and earned about the same median income compared to rural non-Native veterans. Although rural Native veterans had fewer diagnoses on average, they were more likely to have served in combat areas and to have higher levels of service-connected disability compared to other rural veterans. CONCLUSIONS: Demographic and service-related characteristics of rural Native veterans who accessed VA care differ from those of rural non-Native veterans. Identifying specific health care and service use characteristics will assist in the development of appropriate policy and programs to serve rural Native veterans.

Prevalence and screening of traumatic brain injury among veterans seeking mental health services.

OBJECTIVES: To assess the prevalence of traumatic brain injury (TBI) among Veterans seeking mental health services using a 4-item tool, the Traumatic Brain Injury-4 (TBI-4), and to establish the classification accuracy of the TBI-4 using the Ohio State University TBI-Identification Method as the criterion standard. STUDY DESIGN: Archival and observational data collected from individuals seeking care at a Mountain State VA Medical Center. PARTICIPANTS: The sample for the archival study was 1810. Three hundred sixteen Veterans completed observational study measures. MAIN MEASURES: For the archival study, TBI-4 and demographic data extracted from electronic medical records. For the observational study, the Ohio State University TBI-Identification Method and a demographic questionnaire were used. TBI-4 data were also obtained from electronic medical records. RESULTS: The prevalence of probable TBI among those seeking VA MH treatment was 45%. Sensitivity and specificity of the TBI-4 were 0.74 and 0.56, respectively. Veterans with all levels of TBI severity sought care within this VA mental health setting. CONCLUSIONS: The prevalence of TBI in this VA mental health treatment population was higher than expected. Additional research is required to assess the clinical utility of screening for TBI among this population of Veterans.

Traumatic brain injury, executive functioning, and suicidal behavior: a brief report.

OBJECTIVE: The aim of this pilot study was to explore the relationship between executive dysfunction and suicidal behavior in two groups of participants: (Group 1, n = 18) veterans with traumatic brain injury (TBI) and a history of at least one suicide attempt (SA), and (Group 2, n = 29) veterans with TBI and no history of SA. Controlling for the severity of TBI, it was hypothesized that participants in Group 1 would perform more poorly than those in Group 2 on measures of executive functioning. DESIGN: The primary outcome variable was decision making as assessed by performance on the Iowa Gambling Task (IGT). Secondary outcome variables included laboratory-measured impulsivity as measured by the Immediate and Delayed Memory Test (IMT/DMT), abstract reasoning as measured by the Wisconsin Card Sorting Test (WCST), and aggression as measured by the Lifetime History of Aggression (LHA) scale. RESULTS: Among those in Group 1, time between TBI and first suicide attempt postinjury varied widely (months to nearly 30 years). Only the WCST perseverative errors score differed significantly between individuals with and without histories of one or more suicide attempts (SAs). CONCLUSION: Suggestions for future study of SA among those with TBI are provided. When working with individuals with TBI, clinicians are encouraged to incorporate suicide risk assessment into their practice. Augmenting this process with a measure of perseveration may be beneficial.

Personal characteristics affecting veterans' use of services for posttraumatic stress disorder.

OBJECTIVE: Posttraumatic stress disorder (PTSD) is widespread among veterans, but many veterans with PTSD use few health services. This study examined how individual characteristics influenced use of outpatient visits by veterans with PTSD. METHODS: The study assessed number of annual visits by 414,748 veterans with PTSD who sought care from October 2007 through September 2008 at U.S. Department of Veteran Affairs (VA) facilities. Negative binomial regression and adjusted risk ratios assessed the relationship of number of visits and demographic characteristics as well as place of residence, era of service, extent to which disability was connected to service history, and having comorbid illnesses. RESULTS: Veterans from rural or highly rural areas had 19% (confidence interval [CI]=.80-.82) and 25% (CI=.72-.79), respectively, fewer visits than urban-dwelling veterans. Iraq and Afghanistan veterans had 21% fewer visits than veterans of prior eras (CI=.78-.81). Veterans with comorbid conditions had 64% more visits than veterans with only PTSD (CI=1.62-1.66). Veterans from rural or highly rural areas had 22% (CI=.87-.89) and 33% (CI=.64-.71), respectively, fewer visits to PTSD specialty clinics than veterans from urban areas. CONCLUSIONS: Service use by veterans is lower in rural areas. The VA should build on existing efforts to provide more outreach and care opportunities, including telemental health and specialized PTSD services, in rural areas and for veterans of the current service era. Future research should investigate the impact of fewer visits on aspects of functioning, such as interpersonal factors, and the impact of system-level variables on service utilization.

Review of American Indian veteran telemental health.

Rural American Indian veterans have unique healthcare needs and face numerous barriers to accessing healthcare services. Over the past decade, the Department of Veterans Affairs in conjunction with the University of Colorado Denver has turned to the promising field of telemental health to develop a series of videoconferencing-based clinics to reach this vulnerable population and improve mental healthcare services. The ongoing development, implementation, and expansion of these clinics have been assessed as part of a program improvement. The outcomes of these assessments have been documented in a series of published articles, controlled studies, program and case reports, and model descriptions. This article summarizes a decade of experience with the American Indian Telemental Health Clinics, the clinic model, and the literature arising from these clinics and presents lessons learned while establishing, maintaining, and evaluating these clinics. The ability to tailor the clinics to individual sites and cultures and to provide various services has been critical to the operation of the clinics. Culturally specific care through culturally knowledgeable providers, onsite tribal outreach workers, and collaboration with community services has proven essential in operating the clinics, as well as building rapport, trust, and engagement with the target patient population. It is hoped that the lessons learned and practices presented here can not only assist others working to improve the care for rural Native veterans but also serve as a model in the use of telemental health services for improving care and access to rural veteran and non-veteran populations.

Implementation of a suicide nomenclature within two VA healthcare settings.

Suicide and suicide attempts are significant issues for military, Veterans Affairs (VA), and civilian healthcare systems. The lack of uniform terms related to self-directed violence (SDV) has inhibited epidemiological surveillance efforts, limited the generalizability of empirical studies of suicide and non-lethal forms of SDV, and complicated the implementation of evidence-based assessment and treatment strategies for individuals with suicidal thoughts and/or behaviors. The Department of Veterans Affairs recently adopted the Centers for Disease Control and Prevention's (CDC) SDV Classification System (SDVCS). This paper describes an implementation study of the SDVCS in two VA Medical Centers. The Veterans Integrated Service Network (VISN) 19 Mental Illness Research, Education and Clinical Center (MIRECC) training program for the SDVCS, including the SDVCS Clinical Tool (CT), will be discussed. Although preliminary data suggest that the CT and SDVCS are generally perceived as being acceptable and useful, further work will likely be required to facilitate widespread adoption. Potential next steps in this process are presented.

Family-focused therapy via videoconferencing.

A 30-year-old veteran with a diagnosis of schizoaffective disorder and his mother were referred for family-focused therapy (FFT), an empirically-supported, manual-based treatment. The veteran had had multiple hospitalizations and experienced chronic auditory hallucinations for self-harm. Minor modifications to FFT were made for implementation via videoconferencing (at a bandwidth of 384 kbit/s). This may have enhanced the treatment by making the process of communication and problem-solving more explicit. The course of FFT was successfully completed, and the veteran and family showed a high level of satisfaction with care as well as improved medication adherence, good quality of life, high levels of hope, good interpersonal functioning, and very mild negative and positive psychiatric symptoms. This veteran had previous exposure to telemental health, which may have influenced his willingness to receive tele-FFT and perhaps affected the outcome of the case. The ability to provide this type of service to people in rural areas is important.

Improved p50 auditory gating with ondansetron in medicated schizophrenia patients.

OBJECTIVE: Most schizophrenia patients have a deficit in auditory sensory gating, which appears to be mediated by the alpha-7 nicotinic receptor, that is not improved with conventional antipsychotic treatment. This study examined the effects of ondansetron, a highly selective 5-HT3 antagonist, on the P50 auditory evoked potential. METHOD: Eight medicated outpatients with schizophrenia were given either ondansetron (16 mg) or placebo in a double-blind, placebo-controlled design. Evoked potentials were recorded at baseline and 1 hour, 2 hours, and 3 hours after receipt of drug. RESULTS: There was a highly significant improvement in P50 gating after ondansetron treatment. The maximal treatment difference was at 2 hours posttreatment (ondansetron: mean=41.4%, SD=39.7%; placebo: mean=80.2%, SD=21.3%). CONCLUSIONS: Ondansetron significantly enhanced P50 auditory gating in schizophrenia patients treated with typical antipsychotics.

Varied effects of atypical neuroleptics on P50 auditory gating in schizophrenia patients.

OBJECTIVE: Sensory gating deficits found in schizophrenia can be assessed by using a paired auditory stimulus paradigm to measure auditory evoked response. The ratio of the P50 response amplitude of the second or test stimulus to that of the first or conditioning stimulus is expressed as a percentage. Normal subjects generally suppress the second response and typically have ratios of less than 40%. Subjects with schizophrenia and half their first-degree relatives have deficits in sensory gating, with P50 ratios that are generally greater than 50%. Treatment with typical neuroleptics does not reverse this deficit. However, previous studies have shown that treatment with clozapine, an atypical neuroleptic, ameliorates this deficit in clinically responsive patients. This study sought to determine whether other atypical neuroleptics improve P50 ratios. METHOD: P50 evoked potential recordings were obtained from 132 patients with schizophrenia and 177 healthy comparison subjects. Eighty-eight patients were being treated with atypical neuroleptics (clozapine [N=26], olanzapine [N=31], risperidone [N=22], and quetiapine [N=9]). Thirty-four patients were taking typical neuroleptics, and 10 were unmedicated. RESULTS: Healthy subjects exhibited P50 suppression that was significantly better than the schizophrenia patients receiving typical neuroleptics (mean=19.8% [SD=21.0%] versus 110.1% [SD=87.9%]). Patients receiving atypical neuroleptics had a mean P50 ratio that fell between these two means (mean=70.4%, SD=53.7%). When patients treated with different atypical neuroleptics were compared, only the clozapine group had mean P50 ratios that were in the normal range. All other groups exhibited auditory P50 response inhibition that was significantly poorer than that of the healthy subjects. CONCLUSIONS: Improvement in P50 gating appears to be greatest in patients treated with clozapine.