Developing community capacity to treat post-deployment mental health problems: A public health initiative.

Meeting the mental health needs of Veterans returning from recent deployment requires the coordinated effort of partnerships across Department of Defense (DoD), Department of Veterans Affairs (VA), and state and local communities. Although the proportion of Veterans of Iraq and Afghanistan who have accessed VA health care has grown, the majority of these new combat Veterans have yet to present for VA care. The stigma associated with reporting a deployment-related mental health problem may be one factor in this, but access to treatment may also be an important concern among the one third of American Veterans who live in rural or highly rural areas. As these Veterans are more likely to present to a primary care, faith-based or mental health provider in their own community, partnerships between community providers, DoD, and VA are of critical importance in ensuring appropriate care, regardless of treatment setting. In an effort to improve services and access to services, especially to rural Veterans, an educational public health initiative was created to educate community providers about military culture, deployment-related mental health issues, VA resources, and evidence-based treatments. We describe the development, dissemination and evaluation of this initiative, as well as lessons learned for future similar endeavors. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Treatment of Department of Veterans Affairs primary care patients with posttraumatic stress disorder.

Posttraumatic stress disorder (PTSD) is common among Veterans Affairs (VA) primary care patients and may be managed via multiple treatment pathways. Using the Behavioral Model of Health Service Use (Anderson, 1995), this retrospective study based on medical chart review examined factors associated with three types of mental health treatment: intervention by a 1) primary care provider (PCP), 2) primary care-mental health integration (PC-MHI) provider, and 3) specialty mental health (SMH) provider. A second goal was to describe PTSD treatment services for patients not receiving SMH by detailing the content of mental health treatment provided by PCPs and PC-MHI providers. Electronic medical record data for a five year time period for 133 Veterans were randomly selected for review from a population 6,637 primary care patients with PTSD. Results indicated that the evaluated needs of participants (i.e., number of unique medical and psychiatric disorders) were associated with Veterans receiving more intensive services (i.e., SMH). PCPs commonly addressed patients' mental health concerns, but patients often declined referrals for mental health treatment. PC-MHI consultations most often focused on medication management and supportive psychotherapy. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Is the SADPERSONS Scale accurate for the veterans affairs population?

The SADPERSONS Scale is a simple, easily administered instrument developed to determine the likelihood for suicidal behavior in the community mental health setting. In order to determine if this instrument can be used within the Veterans Affairs (VA) system, it was completed on 271 veteran patients at a large Midwest Veterans Affairs Medical Center (VAMC). Results indicated that the veteran population is different enough from the general mental health population that the use of this instrument results in unacceptable false-positive and false-negative identification rates. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Circumventing mental health stigma by embracing the warrior culture: Lessons learned from the Defender's Edge program.

Despite considerable efforts on the part of the Department of Defense, Department of Veterans Affairs, and the wider mental health community, mental health stigma continues to be a significant barrier to seeking help by service members, highlighting the need for newer modes of thought. A significant factor contributing to this stigma is the fundamental difference between traditional mental health approaches and the warrior culture. As a mental health prevention initiative, the Defender's Edge (DEFED) program was specifically developed to fit within the United States Air Force Security Forces (SF) charged with ground combat operations while deployed to Iraq. DEFED adopted a strengths-based philosophy and integrated a psychologist into the SF culture. Evaluative feedback from 192 program participants is presented, demonstrating high programmatic acceptability and feasibility suggestive of success in circumventing mental health stigma. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Suicidality and veterans with a history of traumatic brain injury: Precipitating events, protective factors, and prevention strategies.

Objectives: To increase understanding regarding precipitating and preventative factors of suicidal behavior and to highlight past experiences and recommendations regarding services aimed at suicide prevention among Veterans with a history of traumatic brain injury (TBI). Study Design: Qualitative. Participants: Sample of 13 Veterans with a history of TBI, and a history of clinically significant suicidal ideation or behavior. Method: In-person interviews were conducted and data were analyzed using a hermeneutic approach. Results: Shared precipitants noted included loss-of-self post-TBI, cognitive sequelae, and psychiatric and emotional disturbances. Common protective factors noted included social supports, a sense of purpose regarding the future, religion and spirituality, and mental health care. Means of improving care were also identified (e.g., increasing the availability of services and mental health professionals’ knowledge regarding TBI, providing more structured treatment). Conclusions: Findings highlight potential areas of importance in the assessment and treatment of suicidal Veterans with a history of TBI. Recommendations regarding means of improving care are also presented. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Predictors of mental and physical health service utilization among Vietnam veterans.

This study investigated predictors of mental and physical health care service utilization among 1,632 male (n = 1,200) and female (n = 432) Vietnam veterans who participated in the National Vietnam Veterans Readjustment Study. Using Anderson's theory as a model (Anderson & Bartkus, 1973), the authors examined both direct and mediated relationships among predisposing factors (i.e., age, marital status, and combat exposure), enabling factors (e.g., household income and insurance), and need factors (e.g., medical and psychological symptomatology) and physical and mental health care utilization outcomes. Need factors were the most consistent and strongest mediators of predisposing variables for both physical and mental health care service utilization, although there were differences between male and female veterans. For men, combat exposure indirectly predicted mental health care utilization through the need variables (with the effects of posttraumatic stress disorder being greatest). For women, physical health problems mediated the relationship between combat exposure and physical health outpatient care utilization. These findings have implications for screening and outreach efforts. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Long-term patterns of service use and cost among patients with both psychiatric and substance abuse disorders

OBJECTIVES: This is a longitudinal study designed to determine: (1) if patients dually diagnosed with psychiatric and substance abuse disorders incur higher health care costs than other psychiatric patients and (2) if higher costs can be attributed to particular subgroups of the dually diagnosed or types of care. METHODS: Two cohorts of veterans treated in Veterans Affairs mental health programs at the start of fiscal year 1991 were followed for 6 years: one cohort of inpatients (n = 9,813) and the other of outpatients (n = 58,001). Data were analyzed on utilization of all types of Veterans Affairs health care. Repeated measures analysis of variance was used to examine cost differentials between dually diagnosed patients and other patients. RESULTS: Dually diagnosed outpatients incurred consistently higher health care costs than other psychiatric outpatients, attributable to higher rates of inpatient psychiatric and substance abuse care; however, this difference decreased with time. Costs were substantially higher in the inpatient cohort overall, but there were no differences in cost between dually diagnosed and other patients. CONCLUSIONS: In an atmosphere of cost cutting and moves toward outpatient care, the dually diagnosed may lose access to needed mental health services. Possibilities of developing more intensive outpatient services for these patients should be explored.     

Developing and Applying a Systematic Process for Evaluation of Clinical Outcome Assessment Instruments.

In recent years, there has been increasing demand within the mental health field for practitioners and administrators to evaluate and demonstrate the effectiveness of psychological services delivered to the populations they serve. In response to these demands, there has been a proliferation of outcome assessment instruments. The purpose of this article is to describe the development and application of a systematic process for evaluating and selecting clinical outcome measures for use by mental health organizations. A group of Veterans Affairs Medical Center psychologists systematically applied criteria to a set of brief, commonly used, self-report outcome instruments. Results of this evaluation process are discussed, and the implications for selecting outcome measures for other mental health settings and outcome measurement in general are addressed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Female veterans' use of Department of Veterans Affairs health care services

OBJECTIVES: As access of women to mental health services has become increasingly important, empirical research has begun to examine the determinants of mental health care utilization across gender. This article examines the effect of being an extreme minority on utilization of Department of Veterans Affairs (VA) health services by female veterans. METHODS: Data were collected on a representative national sample of veterans in 1992 as part of the National Survey of Veterans. These data included information on sociodemographic variables, military service variables, physical health and disability, and health services utilization. The authors examined whether women who used health services in 1992, and who were eligible for VA care, differed from men on the likelihood of using any VA health services and on the likelihood of use of VA outpatient and inpatient health services. In addition, we compared VA health care utilization among subgroups of veterans with physical and mental disorders, and compared self-reported reasons for choice of health care provider, across gender. RESULTS: Results indicated that female veterans were less likely than male veterans to use VA health services. This difference was explained by lower utilization by women of VA outpatient services, since inpatient admission rates were the same across gender. The lower outpatient utilization was specific to women with self-reported mental disorders. Women with physical conditions did not differ from men with similar conditions in their VA outpatient utilization. Finally, men and women did not differ on their reasons for choosing VA or non-VA care. CONCLUSIONS: The authors conclude that extreme gender minority status appears to affect outpatient utilization rates at the VA among women with mental disorders, perhaps because of the more personal or sensitive nature of the services involved. Further research is needed to understand why certain women may be underutilizing VA outpatient services and on the consequences of minority gender status for health service utilization, more generally.     

The role of psychologists in the care of Iraq and Afghanistan veterans in primary care settings.

Although military personnel serving in Iraq and Afghanistan are at high risk of developing mental health problems, many report significant barriers to care and few seek help. Integrated primary care is a comprehensive model of health care that aims to improve access to care and provides a framework to assess and meet the complex psychiatric needs of newly returning veterans by embedding mental health specialists within primary care. We describe the role of psychologists in a Department of Veterans Affairs (VA) integrated primary care clinic that serves veterans of Iraq and Afghanistan. Psychologists based in primary care can assist veterans with reintegration to civilian life by providing rapid mental health assessment, normalizing re-adjustment concerns, planning for veterans’ safety, implementing brief interventions within primary care, facilitating transition to additional mental health care, and informing veterans of other available psychosocial services. A case example demonstrating the psychologist’s role highlights the benefits of an integrated care model. Implications of employing this model include reduction of symptoms and impairment by reducing stigma and barriers to seeking mental health care, increased motivation to engage in treatment, and implementation of early interventions. This model may also be beneficial in the civilian health care sector with groups that are at high risk for mental health problems, yet experience barriers to care, particularly stigma. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Veterans Administration psychology: Six decades of public service (1946-2006).

Psychologists in the Veterans Administration (VA), now the Department of Veterans Affairs, have contributed 60 years of public service to the treatment of our nation's veterans, enhanced by their involvement in clinical research supporting that care. From the development of new mental health care programs following World War II to their role in today's polytrauma centers caring for severely wounded veterans, VA psychologists have not only provided distinguished service to veterans but also provided insights for the entire profession in the care of veterans. This article highlights some of their contributions to practice and research as VA psychology and its training program celebrate their 60th anniversary. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Effects of childhood abuse on relapse in a recently homeless substance-dependent veteran population.

The impact of childhood abuse, both childhood sexual abuse (CSA) and childhood physical abuse (CPA), is well documented. Both CSA and CPA have been associated with a number of mental health difficulties, including substance dependence. Though the association between abuse and mental health problems is well documented, what has received little attention is the impact that abuse histories may have on the ability to complete treatment for these problems. This study evaluates the association between abuse and failure to complete treatment due to substance relapse in 70 substance-dependent homeless men served by a Veterans Affairs Domiciliary Residential Rehabilitation and Treatment Program. Demographic and mental health variables were compared with incident rates of sexual and physical abuse as well as with rates of relapse prior to program completion. Contrary to predictions, results found that physical abuse, not sexual abuse, was associated with higher relapse rates. Limitations, implications, and future directions are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The SAFE Program: A family psychoeducational curriculum developed in a Veterans Affairs medical center.

One of the unintended positive consequences of deinstitutionalization and managed care restrictions has been an increased awareness of the impact of serious mental illness on the family. The Support and Family Education (SAFE) Program: Mental Health Facts for Families is a 14-session curriculum of monthly workshops for caregivers. In contrast to similar programs, the SAFE Program is facilitated by mental health professionals, is not diagnostic specific, and includes attention to posttraumatic stress disorder. Three years of outcome data reveal that program attendance is related to increased understanding of mental illness and enhanced awareness of Veterans Affairs resources. Workshop attendance is positively correlated with improvements in participants' self-care. The entire SAFE Program manual is available free of charge on the Internet (http://w3.ouhsc.edu/safeprogram). (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

James Grier Miller (1916-2002).

Obituary for James Grier Miller (1916-2002). A psychologist, psychiatrist, and educator, his work had a profound impact in several disciplines. He left a legacy of multidisciplinary achievements, including involvement with the clinical psychology section of the Veterans Administration, coining the term 'behavioral science' to describe an integrative multidisciplinary approach for the development of a broad theoretical framework for the biological and social sciences, leadership in several mental health centers, and publishing many scholarly publications. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Award for Distinguished Early Career Contributions to Psychology in the Public Interest: Keith Humphreys.

Keith Humphreys, recipient of the Award for Distinguished Early Career Contributions to Psychology in the Public Interest, is cited for creatively combining a scientist’s commitment to rigor, a clinician’s emphasis on high-quality mental health care, and a policy analyst’s understanding of how to address and resolve social problems. His work as a program evaluator and policy analyst has informed important legislation that has enhanced access to and quality of mental health services for U.S. veterans within the Department of Veterans Affairs. Moreover, he has been a prime mover in shaping the Iraqi Ministry of Health’s effort to create a modern and equitable system of mental health care for the Iraqi community. A biography and selected bibliography of Humphreys' works are provided. In addition, Humphreys' paper, entitled "Responding to the psychological impact of war on the Iraqi people and U.S. veterans: Mixing icing, praying for cake," a version of which Hymphreys delivered at the American Psychological Association's annual convention, is presented. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A multidimensional wellness group therapy program for veterans with comorbid psychiatric and medical conditions.

Development of a healthy lifestyle is an important aspect of mental health that is infrequently targeted in outpatient mental health settings. Although the interrelationship of psychological and physical factors has often been noted, interventions frequently focus on just one aspect of functioning. This project demonstrated the feasibility of a multidimensional weekly wellness group program focused on the overall health behaviors of patients in a Veterans Affairs mental health clinic. The modal participant was a male in his mid-50s, living alone, not employed, depressed, obese, and with many chronic medical problems. Eighty-three patients participated in a 15-week program promoting changes in such areas as stress management (abdominal breathing, muscle relaxation, visualization, and mindfulness), physical health care (exercise, nutrition, sleep routine, and substance use), and behavioral activation (activity scheduling, social affiliation, and use of community resources). Substantial improvement was found for most patients, in both psychosocial and physical functioning domains, and was maintained over time. The melding of psychoeducational and skills training into a positive psychology orientation appears to have been beneficial. In addition, the group process was quite effective in encouraging change in these highly comorbid, chronically ill veterans. The feasibility and importance of integrating psychosocial and physical interventions is underscored by this study. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Facilitating practice changes in mental health clinics: A guide for implementation development in health care systems.

For more than a decade, health care systems have attempted to implement evidence-based practices and guidelines. These efforts have demonstrated the difficulty in making practice changes in complex systems of care. Many health care systems, including the Department of Veterans Affairs (VA) and state community mental health systems, have made adoption of evidence-based treatments, especially psychotherapies, a priority. Psychologists, as behavioral change experts and clinical leaders, are positioned to aid local implementation efforts but may have limited knowledge of the “implementation science” literature. This article provides a brief introduction to the implementation literature and offers a guide for developing an implementation plan to adopt evidence-based psychotherapies in local health care settings illustrated by a hypothetical example. Challenges to implementation are discussed. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

The impact of the Veterans Health Administration (VHA) reorganization on psychology programs: A survey of VHA psychology leaders.

Because the Veterans Health Administration (VHA) is the nation's largest health care system and employer and trainer of psychologists, changes in VHA psychology have implications for the rest of the profession. A national survey of 127 VHA psychology leaders (91% response rate) documented that many psychologists now are managed by a psychiatrist, deliver more outpatient services, and do less personality testing. In the context of a 10% reduction in psychology staffing, morale is rated lower than 2 years earlier. Diversified professional roles are associated with higher status of psychology and management support for mental health programs. Psychologists need to understand and respond adaptively to the organizational and economic forces affecting their practice. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Utilization of mental health services by women in a male-dominated environment: the VA experience

OBJECTIVE: The study examined whether women in the Veterans Affairs system use mental health services at a lower rate than men because the system is geared to treat a mostly male population. METHODS: Data were obtained on a national cohort of patients utilizing specialty mental health services in the VA during a two-week period in fiscal year 1991 (N = 70,979). Analyses included comparison of the proportion of women among treated veterans with the age-adjusted proportion of women among all veterans, comparison across gender of the likelihood of use of any general psychiatric services or substance abuse care in 1991, comparison of the intensity of services used (inpatient days and outpatient contacts) by service users in 1991, and comparison of the likelihood of receiving care and the intensity of mental health services received two years later. RESULTS: Overall, 3.95 percent of veterans who used VA mental health specialty services were women; 4.02 percent of all veterans were women. No significant differences between genders were found in use of general psychiatric services, either in the likelihood of any use or the intensity of services used. However, women were significantly less likely to receive substance abuse care (16.3 percent of women versus 71.2 percent of men); once receiving care, they used a similar intensity of substance abuse services. CONCLUSIONS: Being a woman does not appear to have a substantial effect on overall access to VA mental health services or use of general psychiatric services; however, women use VA substance abuse treatment services at a lower rate than men.     

Selected characteristics of psychologists and psychological assessment in five settings: 1959–1982.

Surveyed 458 psychologists in psychiatric hospitals, community mental health centers and clinics, centers for the developmentally disabled and mentally retarded, counseling centers, and Veterans Administration medical centers to determine if the pattern of psychological service delivery has changed since B. Lubin and A. W. Lubin's (1972) national survey. Results reveal changes in areas such as the assessment function of psychologists, referral questions, and referral sources and support Lubin and Lubin's conclusion that surveys of psychological assessment should report individual rather than composite results for these 5 settings. (6 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)