Quality of Life and Loneliness Among American Military Veterans.

ABSTRACT: Quality of life and loneliness are closely associated with mental and physical health outcomes. This relationship is particularly important in Veterans who experience elevated rates of disabilities, comorbidities, and chronic health conditions as compared with non-Veterans. In the present project, we use data from the Military Health and Well-Being Project ( n = 1469, 67.2% men, 32.3% women, 0.5% transgender, nonbinary, prefer not to say) to investigate the link between five domains of quality of life ( i.e. , general quality of life, physical health, psychological health, social relationships, and environment) with loneliness in American Military Veterans. Findings indicated that every domain of quality of life was negatively and significantly associated with loneliness ( r 's < -0.45, p 's < 0.001), such that quality of life decreased as loneliness increased. We further found, using linear regression, that quality social relationships (ß = -0.385, t = -13.23), psychological functioning (ß = -0.196, t = -5.28), and physical health (ß = -0.133, t = -4.174) were related to low levels of loneliness. Taken together, these findings indicate that in this sample of Veterans 1) general quality of life, physical health, psychological health, social relationships, and environment are all strongly connected with loneliness, and 2) of these, social relationships, psychological health, and physical health seem to protect most against loneliness, with large robust effect sizes. We recommend that intervention and policy researchers continue to investigate and develop feasible, acceptable, and cost-effective ways to promote social relationships, psychological health, and physical health among Veterans. Data were collected during the COVID-19 pandemic, which may limit generalizability of these findings.

Randomized Controlled Comparative Effectiveness Trial of Risk Model-Guided Clinical Decision Support for Suicide Screening.

Suicide prevention requires risk identification, appropriate intervention, and follow-up. Traditional risk identification relies on patient self-reporting, support network reporting, or face-to-face screening with validated instruments or history and physical exam. In the last decade, statistical risk models have been studied and more recently deployed to augment clinical judgment. Models have generally been found to be low precision or problematic at scale due to low incidence. Few have been tested in clinical practice, and none have been tested in clinical trials to our knowledge. Methods: We report the results of a pragmatic randomized controlled trial (RCT) in three outpatient adult Neurology clinic settings. This two-arm trial compared the effectiveness of Interruptive and Non-Interruptive Clinical Decision Support (CDS) to prompt further screening of suicidal ideation for those predicted to be high risk using a real-time, validated statistical risk model of suicide attempt risk, with the decision to screen as the primary end point. Secondary outcomes included rates of suicidal ideation and attempts in both arms. Manual chart review of every trial encounter was used to determine if suicide risk assessment was subsequently documented. Results: From August 16, 2022, through February 16, 2023, our study randomized 596 patient encounters across 561 patients for providers to receive either Interruptive or Non-Interruptive CDS in a 1:1 ratio. Adjusting for provider cluster effects, Interruptive CDS led to significantly higher numbers of decisions to screen (42%=121/289 encounters) compared to Non-Interruptive CDS (4%=12/307) (odds ratio=17.7, p-value <0.001). Secondarily, no documented episodes of suicidal ideation or attempts occurred in either arm. While the proportion of documented assessments among those noting the decision to screen was higher for providers in the Non-Interruptive arm (92%=11/12) than in the Interruptive arm (52%=63/121), the interruptive CDS was associated with more frequent documentation of suicide risk assessment (63/289 encounters compared to 11/307, p-value<0.001). Conclusions: In this pragmatic RCT of real-time predictive CDS to guide suicide risk assessment, Interruptive CDS led to higher numbers of decisions to screen and documented suicide risk assessments. Well-powered large-scale trials randomizing this type of CDS compared to standard of care are indicated to measure effectiveness in reducing suicidal self-harm. ClinicalTrials.gov Identifier: NCT05312437.

Antenatal anxiety symptoms outperform antenatal depression symptoms and suicidal ideation as a risk factor for postpartum suicidal ideation.

BACKGROUND AND OBJECTIVES: Suicidal ideation (SI) during the postpartum phase is linked with suicide, a leading cause of death during this period. Antenatal depression and anxiety symptoms have both been linked with increased risk for postpartum SI. However, research aimed at examining the relative contributions of antenatal anxiety and depression symptoms towards postpartum SI remains nascent. In this study, we investigated the relative contribution of antenatal anxiety symptoms, depression symptoms, and SI towards postpartum SI. DESIGN: These data are from a longitudinal study in which American mothers were assessed during pregnancy and again at six- to eight weeks postpartum. METHODS: Data were analyzed using correlations and logistic regression models. RESULTS: Antenatal anxiety symptoms and antenatal depression symptoms were significantly correlated with postpartum SI. Results from a logistic regression model indicated that antenatal anxiety symptoms (T1; OR = 1.185 [1.125, 1.245], p = .004), but not antenatal depression symptoms (T1; OR = 1.018 [0.943, 1.093], p = .812) or antenatal SI (T1; OR = 1.58 [0.11, 22.29], p = 0.73), were significantly associated with postpartum SI. CONCLUSIONS: Antenatal anxiety symptoms, depression symptoms, and SI were positively associated with postpartum SI. When examined simultaneously, anxiety symptoms during the antenatal phase (but not depression symptoms or SI) predicted SI in the postpartum phase.

Developing a Quality Improvement Implementation Taxonomy for Organizational Employee Wellness Initiatives.

BACKGROUND: Standardized taxonomies (STs) facilitate knowledge representation and semantic interoperability within health care provision and research. However, a gap exists in capturing knowledge representation to classify, quantify, qualify, and codify the intersection of evidence and quality improvement (QI) implementation. This interprofessional case report leverages a novel semantic and ontological approach to bridge this gap. OBJECTIVES: This report had two objectives. First, it aimed to synthesize implementation barrier and facilitator data from employee wellness QI initiatives across Veteran Affairs health care systems through a semantic and ontological approach. Second, it introduced an original framework of this use-case-based taxonomy on implementation barriers and facilitators within a QI process. METHODS: We synthesized terms from combined datasets of all-site implementation barriers and facilitators through QI cause-and-effect analysis and qualitative thematic analysis. We developed the Quality Improvement and Implementation Taxonomy (QIIT) classification scheme to categorize synthesized terms and structure. This framework employed a semantic and ontological approach. It was built upon existing terms and models from the QI Plan, Do, Study, Act phases, the Consolidated Framework for Implementation Research domains, and the fishbone cause-and-effect categories. RESULTS: The QIIT followed a hierarchical and relational classification scheme. Its taxonomy was linked to four QI Phases, five Implementing Domains, and six Conceptual Determinants modified by customizable Descriptors and Binary or Likert Attribute Scales. CONCLUSION: This case report introduces a novel approach to standardize the process and taxonomy to describe evidence translation to QI implementation barriers and facilitators. This classification scheme reduces redundancy and allows semantic agreements on concepts and ontological knowledge representation. Integrating existing taxonomies and models enhances the efficiency of reusing well-developed taxonomies and relationship modeling among constructs. Ultimately, employing STs helps generate comparable and sharable QI evaluations for forecast, leading to sustainable implementation with clinically informed innovative solutions.

Loneliness partially mediates the relation between substance use and suicidality in Veterans.

America has experienced a rapid increase in loneliness, substance use, and suicidality. This increase is particularly deleterious for Veterans, who, as compared to nonmilitary-connected civilians, experience elevated rates of loneliness, substance use, and suicidality. In this project we investigated the link between loneliness, substance use, and suicidality, paying particular attention to the mediational role of loneliness between substance use and suicidality. 1,469 Veterans (male, n = 1004, 67.2%; female, n = 457, 32.3%; transgender/non-binary/prefer not to say, n = 8, 0.5%) answered online surveys in the Mental Health and Well-Being Project. Items assessed participants on psychosocial antecedents of health and wellness. Pearson correlations and mediational models were used to determine if loneliness, substance use, and suicidality were related and if loneliness mediated the link between substance use and suicidality. Results indicated that loneliness, substance use, and suicidality were significantly and positively related (rs = .33-.42, ps < .01). Additionally, loneliness partially mediated the link between substance use and suicidality (ß = .08 [.06-.10]), suggesting that, within the context of substance use in Veterans, loneliness may account for significant variance in suicidality. Together findings suggest the Veterans Health Administration should support, fund, and study community engagement activities that could reduce the development or intensity of substance use, loneliness, and suicidality in Veterans.

Anger as a Correlate of and Longitudinal Risk Factor for Suicidal Ideation in Adolescents.

Suicide a leading cause of death among adolescents and is nearly always preceded by suicidal ideation (SI). Concerningly, SI during adolescence is not uncommon, as it is reported by as much as 20% of American youth. As such, SI in adolescence has been the subject of substantial research. Literature points to anger in adolescence as a relatively strong correlate of SI. However, work is limited, focusing on cross-sectional associations between anger in adolescence and SI and conceptualizing anger as a broad construct, failing to investigate the many narrow facets that comprise it. We address these gaps by investigating anger in adolescence as a (1) cross-sectional and (2) prospective correlate of SI and (3) investigating broad versus narrow conceptualizations of anger in adolescence as they relate to SI. Among two samples (Study 1, nationally representative community-based youth, n = 1,729; Study 2, high-risk juvenile justice involved youth, n = 1,406), anger in adolescence was cross-sectionally related to SI. However, when controlling for SI at baseline, anger in adolescence was not a prospective risk factor for SI at follow-up, nine years later. Finally, narrow facets of anger (e.g., argumentative, defiant, irritable, resentful, spiteful) were not more closely related than broad conceptualizations of anger to SI. These findings indicate that while anger in adolescence is cross-sectionally associated with SI, it should not necessarily be viewed as a valid risk factor for development of SI over the course of nearly a decade. Further, findings did not elucidate any narrow facets of anger that are particularly linked with SI.

Developing a Quality Improvement Implementation Taxonomy for Organizational Employee Wellness Initiatives.

BACKGROUND: Standardized taxonomies (STs) facilitate knowledge representation and semantic interoperability within health care provision and research. However, a gap exists in capturing knowledge representation to classify, quantify, qualify, and codify the intersection of evidence and quality improvement (QI) implementation. This interprofessional case report leverages a novel semantic and ontological approach to bridge this gap. OBJECTIVES: This report had two objectives. First, it aimed to synthesize implementation barrier and facilitator data from employee wellness QI initiatives across Veteran Affairs health care systems through a semantic and ontological approach. Second, it introduced an original framework of this use-case-based taxonomy on implementation barriers and facilitators within a QI process. METHODS: We synthesized terms from combined datasets of all-site implementation barriers and facilitators through QI cause-and-effect analysis and qualitative thematic analysis. We developed the Quality Improvement and Implementation Taxonomy (QIIT) classification scheme to categorize synthesized terms and structure. This framework employed a semantic and ontological approach. It was built upon existing terms and models from the QI Plan, Do, Study, Act phases, the Consolidated Framework for Implementation Research domains, and the fishbone cause-and-effect categories. RESULTS: The QIIT followed a hierarchical and relational classification scheme. Its taxonomy was linked to four QI Phases, five Implementing Domains, and six Conceptual Determinants modified by customizable Descriptors and Binary or Likert Attribute Scales. CONCLUSION: This case report introduces a novel approach to standardize the process and taxonomy to describe evidence translation to QI implementation barriers and facilitators. This classification scheme reduces redundancy and allows semantic agreements on concepts and ontological knowledge representation. Integrating existing taxonomies and models enhances the efficiency of reusing well-developed taxonomies and relationship modeling among constructs. Ultimately, employing STs helps generate comparable and sharable QI evaluations for forecast, leading to sustainable implementation with clinically informed innovative solutions.

Posttraumatic Stress Disorder, Military Sexual Trauma, and Birth Experiences at the Veterans Health Administration.

BACKGROUND: Women are a growing portion of the U.S. veteran population, and every year the Veterans Health Administration (VHA) serves an increasing number of women seeking obstetrics services. Women veterans experience elevated rates of anxiety, depression, posttraumatic stress disorder (PTSD), and traumatic events, including military sexual trauma, as compared with women in the general population. It is possible that mental health disorders may be associated with birth experiences. OBJECTIVES: We investigated the link between anxiety, depression, PTSD, and military sexual trauma (MST; i.e., rape and sexual harassment) with perceived birth experience (i.e., Negative or Neutral vs. Positive). METHODS: Participants included 1,005 veterans who had recently given birth and were enrolled in the multisite, mixed methods study known as the Center for Maternal and Infant Outcomes Research in Translation study (COMFORT). Using χ2 tests, we investigated the relationship between mental health conditions including anxiety, depression, and PTSD and MST with birth experience (coded as Negative/Neutral vs. Positive). RESULTS: Findings indicated that participants who endorsed PTSD (39.5%), MST-rape (32.1%), or MST-harassment (51.4%; all p < .05) were significantly more likely to report a Negative/Neutral birth experience (14.7%) versus a Positive birth experience (85.3%). Anxiety and depression were not associated with birth experience. CONCLUSIONS: Veterans with PTSD and/or who experienced MST were more likely to report a negative or neutral birth experience. Thus, screening for PTSD and MST during obstetrics services as well as providing trauma-informed obstetrics care during pregnancy, labor, birth, and recovery may be important among veterans seeking obstetric services.

A Digital Diabetes Storytelling Intervention for the Hmong Community: A Pilot Study.

Hmong-Americans experience higher rates of diabetes and poorer diabetes-related health outcomes than their White peers. Traditional methods of diabetes education do not reach Hmong patients effectively due to known socioeconomic and literacy barriers. The purpose of this study is to examine the acceptability of a culturally informed diabetes self-management education video tool, using digital storytelling that was created using a community-engaged approach, administered in a single academic clinic that sees a large percentage of Hmong patients. The video tool was successful in the areas of acceptability, story transformation, and story identification; 96% of participants stated that the video felt like something from their community, 88% stated that they could identify with the story, 79% stated that they wanted to know what happened next, and 70% of participants reported that they were motivated to do something different after watching. New methods to improve diabetes education and improve health outcomes in Hmong communities are needed. Culturally informed digital storytelling is one tool, which may be used to improve diabetes health outcomes in this population.

The role of sleep duration in suicide risk among sexual and gender minority adolescents.

BACKGROUND: Short sleep duration is linked with suicide risk in adolescence. Sexual and gender minority (SGM) adolescents experience substantially increased risk for suicide compared to their non-SGM peers. METHODS: We investigated the role of sleep duration in SGM adolescent suicide risk using population-based, cross-sectional data from the 2022 Minnesota Student Survey (MSS; N = 85,610, Mage = 14.8). Adolescents reported average school-night sleep duration; those reporting <6 h were classified as having very short sleep duration. The MSS additionally assessed past-year suicidal ideation and suicide attempt. Mediation analyses assessed the role of sleep duration in explaining associations between SGM identity and suicide risk. Further, to examine intervention mechanisms, among SGM adolescents (n = 20,171, 23.6%), a logistic regression model assessed associations among demographic factors, perceived parental care, and very short sleep duration. RESULTS: As compared to non-SGM adolescents, SGM adolescents reported substantially higher prevalence of past-year suicidal ideation and suicide attempt and 2.6× higher prevalence of very short sleep duration (all p < 0.001). Mediation analyses demonstrated that very short sleep duration partially mediated the pathway between SGM identity and past-year suicidal ideation (15.5% mediated) and suicide attempt (17.2% mediated). Among SGM adolescents, a striking positive dose-response relationship was observed between level of perceived parental care and very short sleep duration. As perceived parental care decreased, so too did hours of sleep. DISCUSSION: Sleep duration is a crucial and understudied mechanism underlying suicide risk disparities affecting SGM adolescents. Family-based interventions may improve SGM adolescent sleep and reduce suicide risk.

Traumatic brain injury and suicidality among military veterans: The mediating role of social integration.

Suicide is a widespread public health concern, including among military Veterans. Traumatic brain injuries (TBIs) and lack of social integration have both been shown to increase risk for suicidality, an outcome that includes, among other suicide-related variables, suicidal ideation, suicide attempts, and suicide death. Interestingly, TBIs have also been identified as a risk factor for social integration problems. In this cross-sectional study we investigated associations between TBI, social integration, and suicidality. Additionally, mediation analysis was used to test whether social integration mediated the association between TBI and suicidality. A sample of 1469 military Veterans (male, n = 1004, 67.2 %; female, n = 457, 32.3 %; transgender/non-binary/prefer not to say, n = 8, 0.5 %) completed an online survey as part of the Military Health and Well-Being Project. TBI was negatively associated with social integration (r = -0.084, p < .001) and positively with suicidality (r = 0.205, p < .001). Social integration was negatively associated with suicidality (r = -0.161, p < .001). Finally, social integration partially mediated the relationship between TBI and social integration (B = 0.121, 95 % CI [0.031-0.23]). This work shows that in the context of TBI, lack of social integration may promote suicidality. It provides support for many theories of suicide which propose social problems as a risk factor of suicide-related outcomes. It further highlights social integration as potential fodder for novel interventions for suicidality, an approach that would have transtheoretical support.

A Comparison of Patients Presenting with Suicide Attempts, Psychopathology Symptoms, or Pain within Emergency Departments.

Previous suicide attempts, psychopathology symptoms, and pain significantly increase risk of suicide, a leading cause of death. It is possible that patients across these three groups exhibit key differences that could provide insights into unique interventions for suicide-related outcomes. Data were collected using a standardized form at 432 emergency departments (EDs; 14,018 participants [females, n = 8,042; 57.4%; males, n = 5,976; 42.6%]). We conducted a series of ANOVAs to investigate if patients presenting for (1) suicide attempts (n = 33; 0.2%), (2) psychopathology symptoms (n = 1,104; 7.9%), or (3) pain (n = 12,881; 91.9%) varied across a variety of healthcare-relevant variables. Findings indicated that patients presenting with suicide attempts were seen with more urgency (F[2,12054] = 66.41, p < .001) and were more likely to be admitted to hospitalization (F[2,14015] = 187.296, p < .001), observation unit overall (F[2,14015] = 78.572, p < .001), or transferred to another hospital (F[2,14015] = 406.568, p < .001); they also required longer visits (F [2, 12054] = 66.41, p < .001) as compared to patients with psychopathology symptoms or pain. Notably, potentially important similarities between groups emerged: groups did not differ across leaving without medical screening, leaving against medical advice, or contact with healthcare providers in the long-term (i.e., twelve months) or short-term (i.e., 72 hours) preceding ED admission. These findings in particular indicate that there could be ample time (1) prior to admission to intervene and (2) during care in EDs to connect patients to goal-oriented, time-limited evidence based psychotherapies at a time when they may be particularly willing to engage in care.

Outcomes From a Randomized Trial of a Bilingual mHealth Social Media Intervention to Increase Care Engagement Among Young Gay, Bisexual, and Other Men Who Have Sex With Men and Transgender Women With HIV.

BACKGROUND: The North Carolina Community Research Partnership developed, implemented, and tested weCare, a 12-month bilingual mHealth social media intervention designed to reduce missed HIV care appointments and increase viral suppression among racially/ethnically diverse gay, bisexual, and other men who have sex with men (GBMSM) and transgender women living with HIV by harnessing established social media platforms (i.e., Facebook, texting, and dating apps). METHODS: We randomized 198 GBMSM and transgender women (mean age = 26) living with HIV to the weCare intervention (n = 100) or usual-care (n = 98) group. Inclusion criteria included being newly diagnosed or not in care. Participants completed structured assessments at baseline and 6-month postintervention follow-up (18 months after baseline data collection). HIV care appointment and viral load data were abstracted from each participant's electronic health record at baseline and follow-up. Follow-up retention was 85.5%. RESULTS: Among participants, 94% self-identified as cisgender men, 6% as transgender, 64% as African American/Black, and 13% as Latine. Participants in both groups significantly reduced missed HIV care appointments and increased viral suppression at follow-up compared with baseline. However, there were no significant differences between weCare and usual-care participants for either outcome at follow-up. CONCLUSIONS: An intervention effect was not identified for our two primary outcomes. Several factors may have influenced the lack of significant differences between weCare and usual-care participants at follow-up, including intervention implementation (e.g., staffing changes and lack of fidelity to the intervention as originally designed by the partnership), data collection (e.g., data collection time points and retention strategies), and clinical (e.g., contamination) factors.

Shifts in Pharmacists' Responsibilities in Family Medicine Residency Programs during COVID-19.

Background: The role of clinical pharmacists in family medicine residency programs (FMRPs) has become increasingly commonplace in the last several years, with mixed responsibilities, however largely involving teaching and patient care. The COVID-19 pandemic affected all facets of healthcare, pharmacists included. Assessment of the impact of COVID-19 on the role of the pharmacist in FMRPs is needed. Methods: A survey tool was developed and distributed through two national listservs clinical pharmacists in FMRPs commonly subscribe to. Results: A total of 32 responses were received. The majority of pharmacist participants indicated no change in their overall time allocation to the FMRP. Patient care was affected by transitions to virtual or remote care for those in the outpatient setting, which in some cases were sustained changes. Teaching responsibilities increased for the majority, largely impacted by the need to transition to virtual platforms. Barriers to relationship development resulted from both of these transitions. Innovations and positive results were reported by participants in patient care, teaching, and research. Conclusions: These results highlight the many silver linings of the COVID-19 pandemic. The new challenges, such as the increased teaching need, use of virtual platforms and using creative ways to find connections and build relationships in an ongoing, semi-virtual world, are opportunities for continued innovation for clinical pharmacists as they fit within our strengths and scope within FMRPs.

Integrating social determinants into pharmacotherapy courses: A case-based learning approach.

BACKGROUND: The recognition of social determinants as major drivers of health outcomes has important implications for health care providers, including pharmacists. It is therefore imperative that providers have the requisite knowledge, skills, and attitudes to adequately address the contributions of social determinants of health (SDOH) alongside the impact of medical care on health and treatment outcomes. Case-based learning is a common practice in pharmacy education. Patient cases used in pharmacotherapy courses typically highlight clinical parameters and quantitative indices, often to the exclusion of sociocultural contexts. In actual practice, pharmacists (and other health care providers) must consider both clinical information and the context of SDOH in order to deliver responsive and effective patient care. EDUCATIONAL ACTIVITY AND SETTING: The aim of the project was to build patient cases that reflect both aspects. The intent is to use these cases in the core pharmacy curriculum to teach students how to concurrently consider both clinical and social elements in patient care. Eleven pharmacists and educators participated in three work groups to develop 10 cases for pharmacotherapy courses in cardiovascular disease, diabetes management, and mental health. Two of the cases were facilitated with fourth year students on advanced pharmacy practice experiences. SUMMARY: Feedback from case developers and students highlights features of the cases that lend them to utility in the pharmacy curriculum. The integration of SDOH in patient cases provides opportunity for students to build the relevant competencies that will enable them to provide holistic patient care.

Suicide Risk During COVID-19: Correlates of Peri-pandemic Suicidal Ideation Controlling for Pre-pandemic Ideation.

Suicide is a public health concern which warrants considerable attention, especially with the onset of the COVID-19 pandemic. The current study sought to examine the relationship between behavioral, psychological, and economic impacts of COVID-19 on suicidal ideation severity in a sample of 90 undergraduate students who completed a comprehensive survey on mental health in January 2020 and were re-assessed in April, June, and July of 2020. Multiple regression analyses showed that changes in experience of loneliness, loneliness due to social distancing, pandemic-related concerns, COVID contagion anxiety, and quarantining alone positively and significantly correlated with peri-pandemic suicidal ideation severity after accounting for pre-pandemic suicidal ideation and sexual orientation, while time spent talking to romantic partner and time spent talking to friends and family were negatively correlated. Findings provide insights into the psychological and behavioral effects of social distancing measures and the pandemic, but further research is needed to generalize findings. Supplementary Information: The online version contains supplementary material available at 10.1007/s41811-022-00140-2.