Veteran Engagement in Survey Research to Prevent Suicide.

Suicide rates among veterans remain high, underscoring the necessity of identifying modifiable suicide risk and protective factors that can be targeted through public health approaches. One way to ensure that survey-based research yields information necessary to translate findings into patient-centered interventions is through veteran engagement. The current manuscript describes perspectives of members of a national Veterans Engagement Board (VEB) in contributing to the Assessing Social and Community Environments with National Data (ASCEND) for Veteran Suicide Prevention project. Contributions have included strengthening communication with potential veteran participants, addressing sensitive survey topics such as firearms and suicide, and ensuring that ASCEND is responsive to current national and global events. Additionally, Veterans Engagement Board members described the personal impact of engagement. These contributions highlight the value of veteran engagement as an integral component of suicide risk and prevention research.

Together With Veterans: VA National Strategy Alignment and Lessons Learned from Community-Based Suicide Prevention for Rural Veterans.

BACKGROUND: Rural veterans are at increased risk for dying by suicide compared with urban veterans, yet interventions for preventing suicide among rural veterans have been limited. OBJECTIVES: (1) Describe how Together With Veterans (TWV), a community-based intervention to prevent suicide among veterans in rural communities, aligns with the VA National Strategy for Preventing Veteran Suicide; (2) share lessons learned while beginning to implement TWV in rural communities. METHODS: Together With Veterans is being implemented in four rural communities and comprises six suicide prevention best practices: (1) reducing stigma and promoting help-seeking; (2) lethal means safety, with an emphasis on firearms; (3) gatekeeper training; (4) training primary care providers; (5) improving access to crisis services; and (6) enhancing support for high-risk veterans. RESULTS: Together With Veterans best practices align with most, but not all, of the strategies in the VA National Strategy for Preventing Veteran Suicide. Community veteran partners have shown a willingness to collaborate and provide local leadership, enthusiasm, and a sense of duty. CONCLUSIONS: By supporting and facilitating local veteran leaders and their community partners in increasing suicide prevention knowledge, public awareness, and resources, we propose that TWV offers an acceptable and feasible approach that builds on the strengths of rural communities. Systematic evaluation is warranted.

Association of functional polymorphisms from brain-derived neurotrophic factor and serotonin-related genes with depressive symptoms after a medical stressor in older adults.

Depressive symptoms are common in older adults after a disabling medical event and interfere with rehabilitation and recovery from the disability. This prospective study examined the role of genetic polymorphisms implicated in synaptic integrity and stress-associated depression as predictors of depressive symptoms after hip fracture. We recruited healthy comparisons from the community and participants with hip fracture after surgical fixation from Saint Louis, Missouri hospitals. We examined the valine (Val) to methionine (Met) polymorphism in brain-derived neurotrophic factor (BDNF), serotonin 1A receptor (5HT1a-rs6295) polymorphism, and the serotonin transporter-linked polymorphic region (5HTTLPR) interaction with the rs25531 A to G single nucleotide polymorphism (5HTTLPR-rs25531) as predictors of depressive symptoms. We also examined whether depressive symptoms mediate the influence of BDNF genotype on functional recovery. Among 429 participants with hip fracture, BDNF Met/Met carriers developed significantly more depressive symptoms than Val/Val carriers during a four-week period after the fracture (p=.012). BDNF genotype also predicted functional recovery over the ensuing year, mediated by its effects on depressive symptoms (CI: 0.07-3.37). Unlike prior studies of stressful life events, the S' 5HTTLPR-rs25531 variant did not predict higher levels of depressive symptoms; instead, we report an exploratory finding of an epistatic effect between BDNF and 5HTTLPR-rs25531 whereby the compounded effects of two LA alleles and BDNF Met/Met genotype elevate risk of depressive symptoms after hip fracture (p=.006). No differences between 5HT1a genotypes were found. Our findings suggest plasticity-related genetic factors contribute to the neural mechanisms of mental and functional well-being after a disabling medical stressor.

Mindfulness-based stress reduction for older adults with worry symptoms and co-occurring cognitive dysfunction.

BACKGROUND: Mindfulness-based stress reduction (MBSR) has the potential to reduce worry and improve cognitive functioning. OBJECTIVES: In this treatment development project, we examined MBSR in older adults with worry symptoms and co-occurring cognitive dysfunction. We examined (i) acceptability of MBSR, (ii) whether MBSR needs to be lengthened providing more repetition, (iii) MBSR's benefits for worry reduction and cognitive improvements, and (iv) continued use of MBSR techniques during follow-up. METHODS: Two sites (St. Louis and San Diego) enrolled individuals aged 65 years or older with significant anxiety-related distress plus subjective cognitive dysfunction, into traditional 8-session MBSR groups and 12-session groups that had the same content but more repetition of topics and techniques. We examined measures of mindfulness, worry, and a neuropsychological battery focused on memory and executive function before and after the MBSR program, and we followed up participants for 6 months after the completion of MBSR regarding their continued use of its techniques. RESULTS: Participants (N = 34) showed improvements in worry severity, increases in mindfulness, and improvements in memory as measured by paragraph learning and recall after a delay, all with a large effect size. Most participants continued to use MBSR techniques for 6 months post-instruction and found them helpful in stressful situations. There was no evidence that the extended 12-week MBSR produced superior cognitive or clinical outcomes, greater satisfaction, or greater continuation of MBSR techniques than 8-week MBSR. CONCLUSIONS: These preliminary findings are promising for the further testing and use of MBSR in older adults suffering from clinical worry symptoms and co-occurring cognitive dysfunction. These are common problems in a broad range of older adults, many of whom have anxiety and mood disorders; therefore, stress reduction intervention for them may have great public health value.

Enhanced medical rehabilitation increases therapy intensity and engagement and improves functional outcomes in postacute rehabilitation of older adults: a randomized-controlled trial.

OBJECTIVES: For millions of disabled older adults each year, postacute care in skilled nursing facilities is a brief window of opportunity to regain enough function to return home and live independently. Too often this goal is not achieved, possibly because of therapy that is inadequately intense or engaging. This study tested Enhanced Medical Rehabilitation, an intervention designed to increase patient engagement in, and intensity of, daily physical and occupational therapy sessions in postacute-care rehabilitation. DESIGN: Randomized controlled trial of Enhanced Medical Rehabilitation versus standard-of-care rehabilitation. SETTING: Postacute care unit of a skilled nursing facility in St Louis, MO. PARTICIPANTS: Twenty-six older adults admitted from a hospital for postacute rehabilitation. INTERVENTION: Based on models of motivation and behavior change, Enhanced Medical Rehabilitation is a set of behavioral skills for physical and occupational therapists that increase patient engagement and intensity, with the goal of improving functional outcome, through (1) a patient-directed, interactive approach, (2) increased rehabilitation intensity, and (3) frequent feedback to patients on their effort and progress. MEASUREMENTS: Therapy intensity: assessment of patient active time in therapy sessions. Therapy engagement: Rehabilitation Participation Scale. Functional and performance outcomes: Barthel Index, gait speed, and 6-minute walk. RESULTS: Participants randomized to Enhanced Medical Rehabilitation had higher intensity therapy and were more engaged in their rehabilitation sessions; they had more improvement in gait speed (improving from 0.08 to 0.38 m/s versus 0.08 to 0.22 in standard of care, P = .003) and 6-minute walk (from 73 to 266 feet versus 40 to 94 feet in standard of care, P = .026), with a trend for better improvement of Barthel Index (+43 points versus 26 points in standard of care, P = .087), compared with participants randomized to standard-of-care rehabilitation. CONCLUSION: Higher intensity and patient engagement in the postacute rehabilitation setting is achievable, with resultant better functional outcomes for older adults. Findings should be confirmed in a larger randomized controlled trial.