Predictive modeling of initiation and delayed mental health contact for depression.

BACKGROUND: Depression is prevalent among Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) Veterans, yet rates of Veteran mental health care utilization remain modest. The current study examined: factors in electronic health records (EHR) associated with lack of treatment initiation and treatment delay; the accuracy of regression and machine learning models to predict initiation of treatment. METHODS: We obtained data from the VA Corporate Data Warehouse (CDW). EHR data were extracted for 127,423 Veterans who deployed to Iraq/Afghanistan after 9/11 with a positive depression screen and a first depression diagnosis between 2001 and 2021. We also obtained 12-month pre-diagnosis and post-diagnosis patient data. Retrospective cohort analysis was employed to test if predictors can reliably differentiate patients who initiated, delayed, or received no mental health treatment associated with their depression diagnosis. RESULTS: 108,457 Veterans with depression, initiated depression-related care (55,492 Veterans delayed treatment beyond one month). Those who were male, without VA disability benefits, with a mild depression diagnosis, and had a history of psychotherapy were less likely to initiate treatment. Among those who initiated care, those with single and mild depression episodes at baseline, with either PTSD or who lacked comorbidities were more likely to delay treatment for depression. A history of mental health treatment, of an anxiety disorder, and a positive depression screen were each related to faster treatment initiation. Classification of patients was modest (ROC AUC = 0.59 95%CI = 0.586-0.602; machine learning F-measure = 0.46). CONCLUSIONS: Having VA disability benefits was the strongest predictor of treatment initiation after a depression diagnosis and a history of mental health treatment was the strongest predictor of delayed initiation of treatment. The complexity of the relationship between VA benefits and history of mental health care with treatment initiation after a depression diagnosis is further discussed. Modest classification accuracy with currently known predictors suggests the need to identify additional predictors of successful depression management.

Mental health treatment utilization patterns among 108,457 Afghanistan and Iraq veterans with depression.

People with depression often underutilize mental health care. This study was conceived as a first step toward a clinical decision support tool that helps identify patients who are at higher risk of underutilizing care. The primary goals were to (a) describe treatment utilization patterns, early termination, and return to care; (b) identify factors associated with early termination of treatment; and (c) evaluate the accuracy of regression models to predict early termination. These goals were evaluated in a retrospective cohort analysis of 108,457 U.S. veterans who received care from the Veterans Health Administration between 2001 and 2021. Our final sample was 16.5% female with an average age of 34.5. Veterans were included if they had a depression diagnosis, a positive depression screen, and received general health care services at least a year before and after their depression diagnosis. Using treatment quality guidelines, the threshold for treatment underutilization was defined as receiving fewer than four psychotherapy sessions or less than 84 days of antidepressants. Over one fifth of veterans (21.6%) received less than the minimally recommended care for depression. The odds of underutilizing treatment increased with lack of Veterans Administration benefits, male gender, racial/ethnic minority status, and having received mental health treatment in the past (adjusted OR > 1.1). Posttraumatic stress disorder comorbidity correlated with increased depression treatment utilization (adjusted OR < .9). Models with demographic and clinical information from medical records performed modestly in classifying patients who underutilized depression treatment (area under the curve = 0.595, 95% CI [0.588, 0.603]). Most veterans in this cohort received at least the minimum recommended treatment for depression. To improve the prediction of underutilization, patient factors associated with treatment underutilization likely need to be supplemented by additional clinical information. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

The divide between daily event appraisal and emotion experience in major depression.

Appraisal theories predict that emotional experiences are tightly linked to context appraisals. However, depressed people tend to perceive a variety of emotional events more negatively and stressfully and their emotional experience has been described as context insensitive. This raises the question: how different is the intensity of context appraisals from related emotion experiences among depressed relative to healthy people? Surprisingly, we do not know how cohesive intensity of context appraisals and emotional experiences are in depression. In this study, we assessed differences in intensity of context appraisals and emotional experiences across 1634 daily events during three days within and between depressed participants (N = 41) and healthy controls (N = 33) using linear mixed models. Models compared intensities of stressfulness and unpleasantness appraisals to the intensity of negative affect, and intensity of pleasantness appraisals to the intensity of positive affect. Our findings partially supported our predictions of lower cohesiveness in depression: while intensities of pleasantness appraisals and positive affect were more alike among control participants, intensities of unpleasantness and stressfulness appraisals were more similar to the intensities of negative affect in the depressed group. Current work suggests that hedonic dysfunction in depression is possibly driven by a loosely tied positive context appraisal-emotion experience process.

Multisite Agricultural Veterans Affairs Farming and Recovery Mental Health Services (VA FARMS) Pilot Program: Protocol for a Responsive Mixed Methods Evaluation Study.

BACKGROUND: Veterans Affairs Farming and Recovery Mental Health Services (VA FARMS) is an innovative pilot program to provide supportive resources for veterans with interests in agricultural vocations. Implemented at 10 pilot sites, VA FARMS will provide mental health services and resources for veterans while supporting training in gardening and agriculture. As each pilot site project has unique goals, outreach strategies, and implementation efforts based on the local environment and veteran population, evaluating the pilot program provides a unique challenge for evaluators. This paper describes the protocol to evaluate VA FARMS, which was specifically designed to enable site variation by providing both site-specific and cross-site understanding of site implementation processes and outcomes. OBJECTIVE: The objectives of this paper are to (1) describe the protocol used for evaluating VA FARMS, as an innovative Department of Veterans Affairs (VA) agriculturally based, mental health, and employment pilot program serving veterans at 10 pilot sites across the Veterans Health Administration enterprise; and (2) provide guidance to other evaluators assessing innovative programs. METHODS: This evaluation uses the context, inputs, process, product (CIPP) model, which evaluates a program's content and implementation to identify strengths and areas for improvement. Data collection will use a concurrent mixed methods approach. Quantitative data collection will involve quarterly program surveys, as well as three individual veteran participant surveys administered upon the veteran's entrance and exit of the pilot program and 3 months postexit. Quantitative data will include baseline descriptive statistics and follow-up statistics on veteran health care utilization, health care status, and agriculture employment status. Qualitative data collection will include participant observation at each pilot site, and interviews with participants, staff, and community stakeholders. Qualitative data will provide insights about pilot program implementation processes, veterans' experiences, and short-term participation outcomes. RESULTS: Evaluation efforts began in December 2018 and are ongoing. Between October 2018 and September 2020, 494 veterans had enrolled in VA FARMS and 1326 veterans were reached through program activities such as demonstrations, informational presentations, and town-hall discussions. A total of 1623 community members and 655 VA employees were similarly reached by VA FARMS programming during that time. Data were collected between October 2018 and September 2020 in the form of 336 veteran surveys, 30 veteran interviews, 27 staff interviews, and 11 community partner interviews. Data analysis is expected to be completed by October 2022. CONCLUSIONS: This evaluation protocol will provide guidance to other evaluators assessing innovative programs. In its application to the VA FARMS pilot, the evaluation aims to add to existing literature on nature-based therapies and the rehabilitation outcomes of agricultural training programs for veterans. Results will provide programmatic insights on the implementation of pilot programs, along with needed improvements and modifications for the future expansion of VA FARMS and other veteran-focused agricultural programs. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/40496.

Assessment of Outcome-Based Measures of Depression Care Quality in Veterans Health Administration Facilities.

To inform the potential use of patient-reported depression symptom outcomes as measures of care quality, this study collected and analyzed longitudinal Patient Health Questionnaire (PHQ9) scores among 1,638 patients who screened positive for major depression according to a PHQ9 ≥ 10 across 29 Department of Veterans Affairs facilities. The study found baseline PHQ9, prior mental health visits, physical functioning, and treatment expectancy were consistently associated with subsequent PHQ9 outcomes. No facilities outperformed any others on PHQ9 scores at the 6-month primary endpoint, and the corresponding intra-class coefficient was ≤ .01 for the entire sample (n = 1,214) and 0.03 for the subgroup of patients with new depression episodes (n = 629). Measures of antidepressant receipt, psychotherapy, or treatment intensification were not associated with 6-month PHQ9 scores. PHQ9 outcomes are therefore unlikely to be useful as quality indicators for VA healthcare facilities due to low inter-facility variation, and new care process measures are needed to inform care for patients with chronic depression prevalent in this sample.

Provider reported value and use of virtual resources in extended primary care prior to and during COVID-19.

BACKGROUND: A proactive approach to delivering care using virtual resources, while reducing in-person contact, is needed during the COVID-19 pandemic. OBJECTIVE: In the current study we describe pre- to post- COVID-19 pandemic onset related changes in electronic delivery of primary care. METHODS: A longitudinal, pre-post within-subjects design was used. Patient-aligned care team providers from one VA medical center, a primary care annex, and four affiliated community-based outpatient clinics completed both a baseline and follow up survey (N = 62) or the follow-up survey only (N = 85). The follow-up survey contained questions about COVID-19. RESULTS: The majority of providers (88%) reported they would continue virtual care once pandemic restrictions were lifted. Most (83%) felt prepared to transition to virtual care when pandemic restrictions began. Use of My HealtheVet, Telehealth, and mobile apps showed a significant increase (22.7%; 31.1%; 48.5%). Barriers to virtual care included (1) internet connectivity; (2) patients' lack of technology comfort and skills; and (3) technical issues. Main supports to provide virtual care to patients were (1) peers/ colleagues; (2) technology support through help desk; (3) equipment such as laptops and dual screens; (4) being able to use doximety and virtual care manager, and (5) training. CONCLUSIONS: Overall, provider-use and perceptions related to using virtual care improved over time. Providers adapted quickly to providing virtual care during COVID-19 and planned to provide virtual care long-term.

Primary care virtual resource use prior and post COVID-19 pandemic onset.

BACKGROUND: The COVID-19 pandemic has been a catalyst for rapid uptake of virtual care through the use of virtual health resources (VHR). In the Department of Veterans Affairs (VA) Healthcare System, virtual care has been critical to maintaining healthcare access for patients during COVID-19. In the current study we describe primary care patient aligned care team (PACT) VHR use patterns within one VA medical center (i.e., hospital facility and five community-based outpatient clinics) pre- and post-COVID-19 onset. METHODS: VHR provider and patient use data from 106 individual PACTs were extracted monthly between September 2019 to September 2020. Data were extracted from VHA web-based project application and tracking databases. Using longitudinal data, mixed effect models were used to compare pre- and post-COVID onset slopes. RESULTS: Findings highlight an increase in patient users of secure messaging (SM) and telehealth. The rate of utilization among these patients increased for SM but not for telehealth visits or online prescription refill (RxRefill) use. Finally, VetLink Kiosk check ins that are done at in person visits, diminished abruptly after COVID-19 onset. CONCLUSIONS: These data provide a baseline of VHR use at the PACT level after the initial impact of the COVID-19 pandemic and can inform healthcare delivery changes within the VA systems over time. Moreover, this project produced a data extraction blueprint, that is the first of its kind to track VA VHR use leveraging secondary data sources.

The Value of Extracting Clinician-Recorded Affect for Advancing Clinical Research on Depression: Proof-of-Concept Study Applying Natural Language Processing to Electronic Health Records.

BACKGROUND: Affective characteristics are associated with depression severity, course, and prognosis. Patients' affect captured by clinicians during sessions may provide a rich source of information that more naturally aligns with the depression course and patient-desired depression outcomes. OBJECTIVE: In this paper, we propose an information extraction vocabulary used to pilot the feasibility and reliability of identifying clinician-recorded patient affective states in clinical notes from electronic health records. METHODS: Affect and mood were annotated in 147 clinical notes of 109 patients by 2 independent coders across 3 pilots. Intercoder discrepancies were settled by a third coder. This reference annotation set was used to test a proof-of-concept natural language processing (NLP) system using a named entity recognition approach. RESULTS: Concepts were frequently addressed in templated format and free text in clinical notes. Annotated data demonstrated that affective characteristics were identified in 87.8% (129/147) of the notes, while mood was identified in 97.3% (143/147) of the notes. The intercoder reliability was consistently good across the pilots (interannotator agreement [IAA] >70%). The final NLP system showed good reliability with the final reference annotation set (mood IAA=85.8%; affect IAA=80.9%). CONCLUSIONS: Affect and mood can be reliably identified in clinician reports and are good targets for NLP. We discuss several next steps to expand on this proof of concept and the value of this research for depression clinical research.

Future Well-Being Among U.S. Youth Who Attempted Suicide and Survived.

To what extent does a suicide attempt impair a person's future well-being? We estimated the prevalence of future well-being (FWB) among suicide attempt survivors using a nationally representative sample of 15,170 youths. Suicide attempt survivors were classified as having high FWB if they reported (a) a suicide attempt at Wave I, (b) no suicidal ideation or attempts over the past year at Wave III (7 years after), and (c) a well-being profile at or above the top quartile of nonsuicidal peers. Seventy-five of 574 suicide attempt survivors (∼13%) met criteria for FWB at Wave III, compared to 26% of nonsuicidal peers. Wave I well-being levels, not depressive symptoms, predicted the likelihood of FWB at Wave III (OR = 1.23, 95% CI [1.05, 1.44], p < .05). In conclusion, a nonfatal suicide attempt reduced but did not preclude FWB in a large national sample. The observation that a segment of the population of suicide attempt survivors achieves FWB carries implications for the prognosis of suicidal behavior and the value of incorporating well-being into investigations of suicide-related phenomena.

Preliminary Evidence on the Association of Complementary and Integrative Health Care Program Participation and Medical Cost in Veterans.

INTRODUCTION: Transforming Health and Resilience through Integration of Values-based Experiences (THRIVE) is a complimentary and integrative health program. THRIVE is delivered through shared medical appointments where participants engage in provider-led education and group discussion on wellness-related topics. THRIVE has been associated with improved patient-reported outcomes in a female veteran cohort. This quality improvement study evaluated the association between THRIVE participation and Veterans Health Administration (VHA) healthcare costs across a 1 year period. MATERIALS AND METHODS: A cohort study design (n = 184) used VHA administrative data to estimate the cost difference between 1 year pre- and post-THRIVE participation. The 1 year post-cost of the THRIVE cohort was then compared to the 1 year cost of a quasi-experimental waitlist control group (n = 156). Data sources included VHA administrative and electronic health records. RESULTS: Patients were roughly 51 years old, were typically White/Caucasian, and had a service priority level representing catastrophic disability. The adjusted post-THRIVE cost was $26,291 [95% confidence interval (CI): $23,014-29,015]; $1,720 higher than the previous year's cost but was not statistically significant (P = 0.289). However, a comparison between the THRIVE cohort and a group of waitlist THRIVE patients (n = 156) the intervention group on average was $8,108 more than the waitlist group (95% CI: $3,194-14,005; P < 0.01). CONCLUSIONS: In summary, data analysis of veterans' annual healthcare cost trajectories were inconclusive. This preliminary study produced mixed results requiring more research with larger samples and randomized control trial methodology. Evidence of whether the THRIVE intervention can maintain cost effectiveness while maintaining its supported evidence of healthcare quality is needed.

Informing Proactive integrated virtual healthcare resource use in primary care.

BACKGROUND: Proactive integrated virtual healthcare resource (VHR) use can improve efficiency, maximize resource capacity for delivering optimal coordinated care and improve patient outcomes. Proactive integrated VHR use is vital for delivering high quality care. Our objectives were to identify proactive integrated VHR use among primary care teams, best practices and targeted implementation strategies to promote proactive integrated VHR use. METHODS: This is a mixed-method descriptive study. We employed a community-based participatory approach to collect data and the Consolidated Framework for Implementation Research to analyze and contextualize findings. A cross-sectional sample of primary care team members (n = 65) from a Department of Veterans Affairs medical center participated in focus groups, follow-up interviews (n = 16), and respond to self-report surveys. Operational subject matter experts (n = 15) participated in informant interviews. RESULTS: Survey data described current use and factors that influenced singular VHR use and were convergent with qualitative findings. Focus group and interview data described no evidence of proactive integrated VHR use. Differences and similarities were identified between both utilization groups, such as facilitators and barriers, recommendations, patient education and preferred implementation strategies. All groups reported issues around VHR availability knowledge and access and functionality. Participants identified the need for best practices that are specific to care tasks and performance measures. Expert informant interviews identified a list of VHR tools that could be proactively integrated across the healthcare continuum. CONCLUSIONS: Health systems are leveraging technologies to proactively integrate VHR to maximize information exchange, clinical decision support and patient engagement. VHR is critical during global pandemics, such as COVID-19, to maintain access to care coordination and delivery while abiding by public health recommendations. Though recent requirements for reducing contact create an intrinsic motivation, cultural change through education and best practices of proactive integrated use across the healthcare continuum is needed to create a culture of VHR super users.

Clozapine utilization at the United States Veterans Health Administration: a descriptive report of prescribing patterns and patient characteristics among Operation Enduring Freedom/Operation Iraqi Freedom Veterans.

To identify the clozapine utilization rate at Veterans Health Administration, as well as patient characteristics, and correlates of use to garner a better understanding of the Veterans Health Administration-treated clozapine population. A longitudinal retrospective cohort analysis was conducted on all Operation Enduring Freedom/Operation Iraqi Freedom Veterans treated with clozapine prescriptions through Veterans Health Administration from 2006 to 2016. Descriptive and inferential analyses were conducted. The sample of 1.3 million veterans had 15 416 with schizophrenia-spectrum disorders, however; only 197 filled outpatient clozapine prescriptions through Veterans Health Administration, a clozapine utilization rate of 1.28%. Median days on clozapine were 305. Median number of antipsychotic medications was 12, with a median rank of clozapine being the eighth antipsychotic trialed. 59.90% of individuals had at least one period of maintenance clozapine treatment. The median number of psychiatric hospitalizations was four, and Clozapine rank was strongly associated with number of hospitalizations. There were no associations between acute versus maintenance clozapine use and either hospitalizations or mortality. Clozapine utilization was very low relative to recommended prescribing rates. Delayed initiation of clozapine was noted and was associated with increased number of hospitalizations. Lack of observed differences in mortality may be explained by low number of mortalities.

Daily Affective Dynamics Predict Depression Symptom Trajectories Among Adults with Major and Minor Depression.

Affective dynamics have been increasingly recognized as important indicators of emotional health and well-being. Depression has been associated with altered affective dynamics, but little is known about how daily life affective dynamics predict depression's naturalistic course. We investigated positive and negative affective dynamics (e.g., inertia, variability, and instability) among adults with depressive disorders (N = 60) and healthy controls (N = 38) in both cross-sectional and prospective analyses predicting weekly depression symptoms over 6 months. Relative to controls, depressed individuals showed elevated daily negative affect (NA) and NA variability along with decreased positive affect (PA). However, groups did not significantly differ on other affective dynamic indices. Based on multivariate prospective analyses of depressed individuals (follow-up N = 36), higher daily NA and lower daily PA were independently associated with higher and average weekly depressive symptom severity over the subsequent 6 months. Exploratory analyses of depression symptom trajectory shape revealed that higher NA and PA variability, NA inertia, and NA instability all predicted an initial increase and eventual return to higher depression symptom levels over the 6-month follow-up period. Daily life affective dynamics may have utility for predicting the naturalistic course of depression, which may help guide interventions targeting affective dynamics in vulnerable individuals.

Optimal Well-Being after Major Depression.

Can people achieve optimal well-being and thrive after major depression? Contemporary epidemiology dismisses this possibility, viewing depression as a recurrent, burdensome condition with a bleak prognosis. To estimate the prevalence of thriving after depression in United States adults, we used data from the Midlife Development in the United States (MIDUS) study. To count as thriving after depression, a person had to exhibit no evidence of major depression, and had to exceed cut offs across nine facets of psychological well-being that characterize the top 25% of US nondepressed adults. Overall, nearly 10% of adults with study documented depression were thriving ten years later. The phenomenon of thriving after depression has implications for how the prognosis of depression is conceptualized and for how mental health professionals communicate with patients. Knowing what makes thriving outcomes possible offers new leverage points to help reduce the global burden of depression.

Individual and neighborhood characteristics as predictors of depression symptom response.

OBJECTIVE: Assess whether neighborhood characteristics predict patient-reported outcomes for depression. DATA SOURCES: VA electronic medical record data and U.S. census data. STUDY DESIGN: Retrospective longitudinal cohort. DATA EXTRACTION METHODS: Neighborhood and individual characteristics of patients (N = 4,269) with a unipolar depressive disorder diagnosis and an initial Patient Health Questionnaire (PHQ-9) score ≥10 were used to predict 50 percent improvement in 4-8-month PHQ-9 scores. PRINCIPAL FINDINGS: The proportion of a patient's neighborhood living in poverty (OR = 0.98; 95% CI: 0.97-.1.00; P = 0.03) was associated with lower likelihood of depression symptom improvement in addition to whether the patient was black (OR = 0.76; 95% CI:0.61-0.96; P = 0.02) had PTSD (OR = 0.59; 95% CI:0.50-0.69; P < 0.001) or had any service-connected disability (OR = 0.73; 95% CI:0.61-0.87; P < 0.001). CONCLUSIONS: Neighborhood poverty should be considered along with patient characteristics when determining likelihood of depression improvement.

Dysregulated behavioral responses to hedonic probes among youth with depression histories and their high-risk siblings.

Affect dysregulation in response to rewarding stimuli has been proposed as a vulnerability factor for major depressive disorder (MDD). However, it remains unclear how affective behavioral dynamics may be altered among individuals who are at high risk for depression but not currently depressed. We examined the dynamics of affective facial behavior during hedonic probes among 3 groups of adolescents: remitted probands who had histories of childhood-onset MDD (n = 187), never-depressed siblings of probands (high familial risk; n = 207), and healthy controls (n = 166). Participants' happy and sad facial expressions were coded during 3 hedonic laboratory tasks: receiving a preferred prize, describing a positive autobiographical memory, and watching a humorous film. Happy and sad behavioral dynamics were indexed by mean level- and time-dependent reactivity, variability (mean of the squared successive differences), and inertia (autocorrelation). Relative to controls, probands and siblings exhibited a more rapid decrease in happy behaviors, and probands exhibited higher inertia of sad behaviors during hedonic probes. Both probands and siblings exhibited lower inertia of sad behaviors while receiving a desired prize, which highlights the importance of context variation in testing hypotheses. Overall, our study provides new evidence that hedonic behavioral dysregulation, as reflected in dynamic facial behavior, may highlight depression vulnerability. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Emotion regulation and mood brightening in daily life vary with depressive symptom levels.

Naturalistic studies of emotional reactivity in depression have repeatedly found larger decreases in negative affect (NA) among depressed individuals in response to daily positive events. This so-called mood-brightening (MB) effect represents a theoretical and empirical oddity. The current study is a secondary analysis investigating whether the MB effect is moderated by spontaneous use of emotion regulation strategies, which have been implicated in the maintenance and modulation of NA in prior work. Participants (N = 95) representing a large spectrum of depressive symptom severity reported their experiences of NA and the occurrence of positive events in daily life over the course of seven days using the experience sampling method. Our findings replicate and build upon those of prior studies relating to the MB effect in the following ways: (1) we observed the MB effect for specific negative emotions of sadness, anger, anxiety; and (2) we found evidence that the MB effect is moderated by spontaneous use of rumination, distraction, and expressive suppression, which have been shown to enhance or dampen NA. The role of emotion regulation strategies in daily emotional reactivity to pleasant events is discussed.