Showing papers by "Robert A. Rosenheck published in 2017"
01 Jan 2017
TL;DR: In this paper, the authors examined the effect of the Department of Veterans Affairs compensated work therapy program (CWT) on non-vocational outcomes and found that patients in the CWT program were more likely to initiate outpatient addictions treatment, experience fewer drug and alcohol problems, report fewer physical symptoms related to substance use, avoid further loss of physical functioning, and have fewer episodes of homelessness.
Abstract: BACKGROUND
Little is known about the health outcomes of clinician-supervised, performance-based, abstinence-contingent therapeutic work programs on homeless persons with addiction disorders. This study examined the effect of the Department of Veterans Affairs compensated work therapy program (CWT) on nonvocational outcomes. With mandatory urine screenings and adherence to addiction treatment schedules, CWT provided work opportunities (wages, hours, and responsibilities) with jobs created from Veterans Affairs contracts competitively obtained from private industry.
METHODS
Homeless, substance-dependent veterans (N = 142) from 4 Department of Veterans Affairs medical centers were randomized, assessed at baseline, and reassessed at 3-month intervals for 1 year. Both CWT and control groups had access to comprehensive rehabilitation, addictions, psychiatric, and medical services. Data were analyzed to determine an immediate CWT effect after treatment and rates of change during 1 year.
RESULTS
Compared with control subjects, patients in the CWT program were more likely to (1) initiate outpatient addictions treatment, (2) experience fewer drug and alcohol problems, (3) report fewer physical symptoms related to substance use, (4) avoid further loss of physical functioning, and (5) have fewer episodes of homelessness and incarceration. No effect on psychiatric outcomes was found.
CONCLUSION
Work therapy can enhance nonvocational outcomes of addiction treatment for homeless persons, although long-term gains remain unknown.
82 citations
TL;DR: A comprehensive, team-based FEP treatment approach was associated with greater improvement in work or school participation, and this effect appears to be mediated, in part, by participation in SEE.
74 citations
TL;DR: Veterans with PSUD have more severe problems along several dimensions and use more numerous and varied services than those with 1 SUD, and this distinctive clinical profile warrants research to develop and evaluate methods for treating patients with complex multimorbid disorders.
Abstract: Objective While research on substance abuse has largely focused on people who have a single substance use disorder (SUD), many people abuse multiple substances. Studies have yet to examine the distinctive characteristics of patients diagnosed with more than 1 SUD and how those with polysubstance use disorder (PSUD) differ from those with a single SUD. Methods National Veterans Health Administration data from fiscal year 2012 were used to compare veterans diagnosed 1 SUD to veterans diagnosed with 2-3, and >3 SUDs on demographic characteristics, psychiatric and medical diagnoses, medical and psychiatric service utilization, and psychotropic medication fills. Comparisons of the 3 groups were based on bivariate and multiple logistic regression analyses. Results Of the 472,624 veterans with at least 1 diagnosed SUD, 346,329 (73.2%) had 1 disorder, 113,598 (24.0%) had 2-3, and 12,715 (2.7%) had >3 SUDs. Veterans with higher levels of PSUD were more likely to be black and homeless, were more likely to have hepatic disease as well as schizophrenia, bipolar disorder, major depressive disorder, and personality disorders. Higher levels of PSUD were associated with greater use of psychiatric inpatient care, residential and rehabilitative treatment, and with multiple psychotropic medication prescription fills. Conclusions Veterans with PSUD have more severe problems along several dimensions and use more numerous and varied services than those with 1 SUD. This distinctive clinical profile warrants research to develop and evaluate methods for treating patients with complex multimorbid disorders that involve interactions between medical morbidity and psychosocial dysfunction.
70 citations
Mental Health Services1, Dartmouth College2, Boston University3, University of Massachusetts Boston4, University of Minnesota5, Yale University6, Harvard University7, SUNY Downstate Medical Center8, University of North Carolina at Chapel Hill9, University of Calgary10, University of California, Los Angeles11, Nathan Kline Institute for Psychiatric Research12
TL;DR: Half of first episode psychosis patients have co-occurring substance use disorders, which are associated with both more severe symptoms and greater perceptions of stigma.
61 citations
TL;DR: Buprenorphine retention was substantial among veterans treated in VHA, but few individual characteristics correlated with retention, and further research is required to help devise interventions to improve treatment continuation.
Abstract: Background
Buprenorphine has become the major treatment for opioid use disorder (OUD) but data on long treatment term retention and its correlates are sparse.
Methods
All veterans with OUD treated in Veterans Health Administration (VHA) facilities nationally in fiscal year (FY) 2012, and who began treatment with buprenorphine as indicated by a first prescription after the first 60 days of the year were identified with the date of and their last prescription from FY 2012–2015. Veterans were classified into four groups based on time from first to last prescription: (0–30 days, 31–365 days; 1–3 years; and more than 3 years). These groups were compared on socio-demographic, diagnoses and service, and psychotropic drug use. Kaplan-Meier curves and Cox proportional hazards models were used to identify variables independently associated with retention in buprenorphine treatment.
Results
Veterans newly started on buprenorphine (n = 3,151) were retained in treatment for a mean duration of 1.68 years (standard deviation [SD] 1.23), with 61.60% (n = 1,941) retained for more than a year and 31.83% (n = 1,003) for more than 3 years. Cox proportion hazards model showed that only black race (Hazards ratio [HR] 1.26; standard error [SE] .06; p.0003), the Charlson index (HR 1.03; SE .01; p.0132) and emergency room visits during FY 2012 (HR 1.03; SE .01; p < .0001) were the only available variables independently associated higher odds of buprenorphine discontinuation.
Conclusions
Buprenorphine retention was substantial among veterans treated in VHA, but few individual characteristics correlated with retention.
Scientific Significance
Future research focused on identifying further correlates of treatment retention is required to help devise interventions to improve treatment continuation. (Am J Addict 2017;XX:1–9)
61 citations
TL;DR: "Left-behind" children are at higher risk for PLEs and suffer more traumatic events than other Chinese children, and interventions that reduce trauma risk and improve relationships with caregivers may be helpful, especially for older "left- Behind" children.
50 citations
TL;DR: Sociocultural influences and personal experience withmental illness have a greater effect than medical education on attitudes toward people with mental illness, and psychiatric education appears to have a small but significant effect on student attitudes regarding treatment efficacy.
Abstract: Stigma among health care providers toward people with mental illness is a worldwide problem. This study at a large US university examined medical student attitudes toward mental illness and its causes, and whether student attitudes change as they progress in their education. An electronic questionnaire focusing on attitudes toward people with mental illness, causes of mental illness, and treatment efficacy was used to survey medical students at all levels of training. Exploratory factor analysis was used to establish attitudinal factors, and analysis of variance was used to identify differences in student attitudes among these factors. Independent-samples t tests were used to assess attitudes toward efficacy of treatments for six common psychiatric and medical conditions. The study response rate was 42.6 % (n = 289). Exploratory factor analysis identified three factors reflecting social acceptance of mental illness, belief in supernatural causes, and belief in biopsychosocial causes. Stages of student education did not differ across these factors. Students who had completed the psychiatry clerkship were more likely to believe that anxiety disorders and diabetes could be treated effectively. Students reporting personal experiences with mental illness showed significantly more social acceptance, and people born outside the USA were more likely to endorse supernatural causes of mental illness. Sociocultural influences and personal experience with mental illness have a greater effect than medical education on attitudes toward people with mental illness. Psychiatric education appears to have a small but significant effect on student attitudes regarding treatment efficacy.
38 citations
TL;DR: Veterans who received more partnership services showed greater improvements in housing and mental health than those who received fewer services, and those who achieved their predefined legal goals showed greater improved in housing status and community integration than Those who did not.
Abstract: Medical-legal partnerships—collaborations between legal professionals and health care providers that help patients address civil legal problems that can affect health and well-being—have been implemented at several Veterans Affairs (VA) medical centers to serve homeless and low-income veterans with mental illness. We describe the outcomes of veterans who accessed legal services at four partnership sites in Connecticut and New York in the period 2014–16. The partnerships served 950 veterans, who collectively had 1,384 legal issues; on average, the issues took 5.4 hours’ worth of legal services to resolve. The most common problems were related to VA benefits, housing, family issues, and consumer issues. Among a subsample of 148 veterans who were followed for one year, we observed significant improvements in housing, income, and mental health. Veterans who received more partnership services showed greater improvements in housing and mental health than those who received fewer services, and those who achieved...
34 citations
TL;DR: Overall, the findings indicate that PWB and mental health recovery can improve in FEP, are related to yet distinct from quality of life, and that DUP may play a role in certain facets of these constructs.
32 citations
TL;DR: It is concluded that patients with PTSD and co-morbid SUD have been largely neglected in PTSD RCTs; thus findings may not be fully applicable to those meeting criteria for both conditions.
25 citations
TL;DR: The NAVIGATE intervention improved quality of life, symptoms, and employment but did not significantly reduce the likelihood of receiving SSA disability benefits, and providing income supports without impeding recovery remains an important policy challenge.
Abstract: Objective:Social Security Administration (SSA) disability benefits are an important source of income for people with psychoses and confer eligibility for health insurance. The authors examined the impact of coordinated specialty care on receipt of such benefits in first-episode psychosis, along with the correlates and consequences of receiving them.Method:The Recovery After an Initial Schizophrenia Episode–Early Treatment Program (RAISE-ETP) study, a 34-site cluster-randomized trial, compared NAVIGATE, a coordinated specialty care program, to usual community care over 2 years. Receipt of SSA benefits and clinical outcomes were assessed at program entry and every 6 months for 2 years. Piecewise regression analysis was used to identify relative change in outcome trajectories after receipt of disability benefits.Results:Among 399 RAISE-ETP participants, 36 (9%) were receiving SSA disability benefits at baseline; of the remainder, 124 (34.1%) obtained benefits during the 2-year study period. The NAVIGATE inte...
TL;DR: Sustained engagement in treatment is vital, particularly in the first “golden month” of the new year, according to the National Institute for Health and Care Excellence (NICE).
Abstract: Sustained engagement in treatment is vital, particularly in the first “golden month”
Deaths related to the “epidemic” of opioid use disorder are inescapable realities in communities across North America, with tags like “the American Carnage” and “this generations’ AIDS crisis” in the lay press. Prescription opioids, heroin, and, more recently, fentanyl have all contributed to a precipitous rise in deaths related to opioid overdose.1 The global burden of opioid use disorder also continues to rise. Opioid substitution treatment (or the preferred term opioid agonist treatment2) with long acting opioids such as methadone or buprenorphine, the most effective evidence based approach, has emerged as the prominent tool in response to this public health challenge.3 Long term treatment of opioid use disorder with another opioid might evoke skepticism and concern among policymakers, patients, families, communities, and even physicians, potentially limiting participation in treatment and posing a challenge to public health.
In a linked paper, Sordo and colleagues (doi:10.1136/bmj.j1550) aggregated data on the mortality benefits of engagement with opioid substitution treatment and the harms associated with disengagement.4 Their well conducted systematic review includes …
TL;DR: Participation in a psychiatric clerkship was associated with greater social acceptance but not with improvement on other attitudinal factors, which may reflect ceiling effects in responses before the clerkship concerning supernatural and bio-psychosocial beliefs about causes of mental illness that left little room for change.
Abstract: The authors evaluated whether a psychiatric clerkship reduces stigmatized attitudes towards people with mental illness among medical students. A 56-item questionnaire was used to assess the attitudes of medical students towards patients with mental illness and their beliefs about its causes before and after their participation in their psychiatric clerkship at a major medical school in Rio de Janeiro. Exploratory factor analysis identified four factors, reflecting “social acceptance of people with mental illness,” “normalizing roles for people with mental illness in society,” “non-belief in supernatural causes for mental illness,” and “belief in bio-psychosocial causes for mental illness.” Analysis of variance was used to evaluate changes in these factors before and after the clerkship. One significant difference was identified with a higher score on the factor representing social acceptance after as compared to before the clerkship (p = 0.0074). No significant differences were observed on the other factors. Participation in a psychiatric clerkship was associated with greater social acceptance but not with improvement on other attitudinal factors. This may reflect ceiling effects in responses before the clerkship concerning supernatural and bio-psychosocial beliefs about causes of mental illness that left little room for change.
TL;DR: It is suggested that becoming housed is a key driver of reduced ED utilization and that efforts to provide housing for homeless adults may result in significantly decreased ED use.
Abstract: Homeless adults use emergency department (ED) services more frequently than other adults, but the relationships between homelessness, health status, outpatient service use, and ED utilization are poorly understood. Data from the Collaborative Initiative to Help End Chronic Homelessness (CICH) were used to compare ED use among chronically homeless adults receiving comprehensive housing, case management, mental health, addiction, and primary care services through CICH at 5 U.S. sites (n = 274) and ED use among comparison group clients receiving generally available community services (n = 116) at the same sites. Multiple imputation was used to account for missing data and differential rates of attrition between the cohorts. Longitudinal models were constructed to compare ED use between the 2 groups during the first year after initiation of CICH services. A mediation analysis was performed to determine the relative contributions of being housed, the receipt of outpatient services, and health status to group differences in ED utilization. Participants receiving CICH services were significantly less likely to report ED use (odds ratio = 0.78, 95% confidence interval [0.65, 0.93]) in the year after program entry. Decreased ED use was primarily mediated by decreased homelessness-not by increased access to other services or health status. This suggests that becoming housed is a key driver of reduced ED utilization and that efforts to provide housing for homeless adults may result in significantly decreased ED use. Further research is needed to determine the long-term effects of housing on health status and to develop services to improve health outcomes. (PsycINFO Database Record
TL;DR: The development and operations of MLPs at four VHA medical centers that serve veterans who are homeless or who have serious mental illness are described and they offer opportunities to expand VHA-community partnerships to address social determinants of health.
Abstract: Medical-legal partnerships (MLPs) represent an innovative service model in which lawyers are integrated into health care teams to address diverse legal problems that affect vulnerable populations. The Veterans Health Administration (VHA) operates the largest safety-net health care system in the country and serves many low-income and disabled veterans who could benefit from MLP services. In this column, the authors describe the development and operations of MLPs at four VHA medical centers that serve veterans who are homeless or who have serious mental illness. The authors also briefly report on the characteristics of 700 veterans served by these MLPs from 2014 to 2016. MLPs can fit within the interdisciplinary, comprehensive system of care provided by VHA, and they offer opportunities to expand VHA-community partnerships to address social determinants of health.
TL;DR: Patients attending pain specialty clinics have more difficult-to-treat pain conditions and comorbid psychiatric disorders that are independent of major medical diagnoses, use more outpatient services, and receive a greater number of opioid prescriptions.
Abstract: Objective Chronic pain management is a growing focus of attention, in part because of concern over excessive use of opioids for treatment of chronic noncancer pain. In the Veterans Health Administration (VHA), pain specialty clinics have been established to address the needs of patients with challenging pain issues. The current study identified characteristics of such patients in a national sample of VHA service users in fiscal year 2012. Design Bivariate analyses compared patients diagnosed with pain who visited a pain specialty clinic with those who did not on sociodemographic characteristics, medical, pain, and psychiatric diagnoses, health service use, and opioid and psychotropic drug use. Logistic regression identified variables that independently differentiated pain clinic users from nonusers. Results Altogether, 122,240 of 2,025,765 patients with pain diagnoses (5.79%) attended pain specialty clinics. Pain clinic users had higher rates of muscle spasms, neuralgia, neuritis, radiculitis, and fibromyalgia, as well as major depression and personality disorders. Further, a fibromyalgia diagnosis was the strongest independent correlate of pain clinic attendance, along with the number of medical-surgical clinic visits. Veterans attending a pain clinic also received more opioids than those not attending (10.4 vs 6.7 prescriptions, respectively), but there were no substantial differences in other factors. Conclusions Patients attending pain specialty clinics have more difficult-to-treat pain conditions and comorbid psychiatric disorders that are independent of major medical diagnoses, use more outpatient services, and receive a greater number of opioid prescriptions. These data support the inclusion of mental health care in the specialized treatment of chronic pain.
TL;DR: This national study identifies sociodemographic characteristics, comorbidities, and service utilization patterns associated with WNDT and DT, a potentially life-threatening condition for adults with multiple chronic conditions and long-term service models are needed.
Abstract: Background and Objectives
Alcohol withdrawal—especially delirium tremens (DT)—is a potentially life-threatening condition. While short-term treatment regimens and factors that predispose to more severe symptomatology have been extensively studied, little attention has been paid to the clinical epidemiology and long-term care of the chronic medical, addictive, psychiatric, and psychosocial problems faced by these patients.
Methods
National Veterans Health Administration data from fiscal year 2012 were examined to identify veterans diagnosed with DT; with withdrawal but not DT (WNDT); and with Alcohol Use Disorder (AUD) but neither DT nor WNDT. They were compared on sociodemographic characteristics, psychiatric and medical co-morbidities, and health service and psychotropic medication use, first with bivariate analyses and then multiple logistic regression.
Results
Among the 345,297 veterans diagnosed with AUD, 2,341 (0.7%) were diagnosed with DT and 6,738 (2.0%) with WNDT. Veterans diagnosed with either WNDT or DT were more likely to have been homeless, had more comorbid medical and psychiatric disorders, were more likely to be diagnosed with drug use disorders, utilized more health services, received more psychotropic medications, and were more likely to receive naltrexone. They were more likely to receive specialized legal, housing, vocational, and psychosocial rehabilitation services, as well as intensive case management.
Conclusions
Adults with WNDT and DT suffer from multiple chronic conditions and long-term service models are needed to coordinate the work of multiple specialists and to assure continuity of care.
Scientific Significance
This national study identifies sociodemographic characteristics, comorbidities, and service utilization patterns associated with WNDT and DT.(Am J Addict 2017;XX:1–9)
TL;DR: Investigation of the rate and clinical correlates of complete medication discontinuation in the year after hospital discharge found interventions that strengthen patient engagement in treatment through insurance coverage and insight, fostered through psychoeducational intervention, may increase medication compliance.
Abstract: Medication discontinuation is a major risk factor for relapse in schizophrenic patients. The present study investigated the rate and clinical correlates of complete medication discontinuation in the year after hospital discharge. Data collected from 236 schizophrenia patients who were prescribed anti-psychotics documented socio-demographic characteristics, symptom severity, insight, and attitudes towards medication in the week before their discharge and the experience of caregiver burden for their primary caregiver as recorded at the time of hospitalization. Follow-up telephones call one-year after discharge documented whether they were regularly taking prescribed psychotropic medication or not. Logistic regression analysis was used to investigate factors that were independently associated with medication discontinuation. Altogether 25.8% of the sample discontinued medication in the one-year after discharge. Logistic regression analysis showed that shorter duration of illness, lack of health insurance, and poor insight at the time of discharge were significantly associated with complete discontinuation of medication (p<0.05). Patients discontinued their medication within a year after psychiatric hospitalization which was associated with a lack of insurance coverage, less insight into their illness and shorter duration of illness. Interventions that strengthen patient engagement in treatment through insurance coverage and insight, fostered through psychoeducational intervention, may increase medication compliance.
TL;DR: In this paper, the authors examined social network structure and function among a sample of 460 homeless veterans who participated in an experimental trial of the Housing and Urban Development-Veterans Affairs Supported Housing (HUD-VASH) program.
Abstract: Objective:This study examined social network structure and function among a sample of 460 homeless veterans who participated in an experimental trial of the Housing and Urban Development–Veterans Affairs Supported Housing (HUD-VASH) program.Methods:Participants were randomly assigned to HUD-VASH (housing subsidies and case management), case management only, or standard care. Mixed-model longitudinal analysis was used to compare treatment groups on social network outcomes over 18 months.Results:Veterans in HUD-VASH reported significantly greater increases in social support than veterans in the two other groups, as well as greater frequency of contacts, availability of tangible and emotional support, and satisfaction with nonkin relationships over time. These gains largely involved relationships with providers and other veterans encountered in treatment.Conclusions:Supported housing may play a pivotal role in fostering constructive new relationships with persons associated with service programs but may have...
TL;DR: The findings suggest that ECT is used as a treatment of last resort, although available evidence and guidelines recommend wider use.
Abstract: Objectives Little epidemiologic research has examined the practice of electroconvulsive therapy (ECT). We investigated sociodemographic and clinical characteristics, service use, and psychotropic medication prescription patterns associated with ECT use at a Veterans Health Administration Medical Center. Methods Among veterans receiving specialty mental health services, we compared those who received ECT with those who did not using bivariate χ and t tests and multivariate logistic regression. Results In fiscal year 2012, 11,117 veterans received specialty mental health services, of whom 50 received ECT (0.45%) in FY2012 or FY2013. Those who received ECT were more likely to be diagnosed with major depressive or bipolar disorders and had substantially higher levels of mental health service usage (Cohen d > 0.75) and psychotropic prescription fills, including antidepressants (Cohen d = 2.66), antipsychotics (Cohen d = 2.15), lithium (Cohen d = 1.34), mood stabilizers (Cohen d = 1.30), and anxiolytic/sedative/hypnotics (Cohen d = 1.34). Conclusions Our findings suggest that ECT is used as a treatment of last resort, although available evidence and guidelines recommend wider use.
TL;DR: Migrant workers appear to be at greater risk of hospitalization for schizophrenia than other residents of Hunan and showed more severe psychopathology, which may reflect specific lack of health insurance coverage for workers migrating to non-native provinces in China, thereby delaying access to treatment.
TL;DR: It is suggested that specific PTSD symptom clusters and impairment are associated with variable improvement in veterans with antidepressant-resistant PTSD, underscoring the importance of developing more effective and targeted pharmacotherapies for specific symptom clusters in this population.
Abstract: Background Posttraumatic stress disorder (PTSD) is a chronic and often difficult-to-treat condition that is prevalent among military veterans. First-line pharmacotherapy for this population typically involves antidepressants; however, veterans who do not improve are sometimes prescribed antipsychotics such as risperidone. A 2011 randomized controlled trial of adjunctive risperidone versus placebo for veterans with chronic, antidepressant-resistant, military service-related PTSD revealed no difference between groups. Hence, there is a need to examine predictors of nonimprovement for chronic, treatment-resistant PTSD. Methods We examined correlates of nonimprovement and delayed improvement (ie, ≥12 weeks) using data from 267 veterans with chronic, antidepressant-resistant PTSD who were prescribed adjunctive risperidone or a placebo. Veterans received 1 to 4 mg adjunctive risperidone (n = 133; mean dose, 2.74 mg) or a placebo daily (n = 134) in addition to their original treatment regimen over the 24-week trial. Results Greater severity of PTSD symptoms at baseline, specifically reexperiencing (ie, nightmares) and emotional numbing (ie, sense of foreshortened future), was independently associated with nonimprovement. Of the 194 veterans (72.7%) who did improve, 95 (49.0%) showed delayed improvement, taking 12 weeks or longer to demonstrate a 10-point reduction in Clinician-Administered PTSD Scale scores. Emotional difficulties affecting role functioning, as assessed using the Veterans RAND 36-item Health Survey, independently predicted nonimprovement. Conclusions While results are indicative of nonspecific pharmacotherapeutic effects, they suggest that specific PTSD symptom clusters and impairment are associated with variable improvement in veterans with antidepressant-resistant PTSD. They underscore the importance of developing more effective and targeted pharmacotherapies for specific symptom clusters in this population.
TL;DR: Analysis of data from a quasi-experimental demonstration reveals distinctive work-related challenges among homeless IPS participants, highlighting a potentially unique role of alcohol in job loss in veterans who were homeless.
Abstract: Individual Placement and Support (IPS) improves competitive employment rates for those with serious mental illness (SMI) and is available through the Veterans Healthcare Administration (VHA). IPS clients often have difficulty maintaining jobs, and various reasons for job loss have been identified for those with SMI. No study has yet investigated IPS job loss in a homeless and largely substance-using population. An analysis of data from a quasi-experimental demonstration examined the association of various reasons for job loss with the duration of the first IPS job and with veteran characteristics. This study also examined the relationship of job duration and reasons for job loss with subsequent employment. Veterans’ most commonly identified reason for termination was drug/alcohol use; mental and/or physical health problems were uncommonly cited as reason for job loss. Those whose jobs ended due to drugs/alcohol were less likely to find subsequent employment. They also had greater scores on alcohol...
TL;DR: Data suggest that the short-term support, shelter, and asylum that formed part of intensive treatment are associated with reduced violent behavior and that such services play an important role in the spectrum of care for war-related PTSD.
Abstract: Objective:Posttraumatic stress disorder (PTSD) has been linked to violent behavior, especially among military personnel returning from service in a war zone. Little is known, however, about whether...
TL;DR: Comparison with previous studies suggests changes in certain characteristics of homeless veterans over the past few decades that may reflect the growing proportion of veterans from the all-volunteer force, initiated after the draft ended in 1975.
Abstract: The current study examined differences between urban homeless veterans and non-veterans on sociodemographics, housing, clinical characteristics, and psychosocial factors. We recruited a sample of 196 homeless men (101 veterans, 95 non-veterans) from the Omaha, Nebraska metropolitan area. Structured interviews were conducted by research staff. The results showed that the two groups were similar in most respects, though there were several notable differences. Homeless veterans were found to be older and more educated than non-veterans, more likely to have married, and reported having fewer non-adult children. Multivariable models controlling for age further showed that veterans reported a higher number of medical problems and were more likely to report being diagnosed with major depression or PTSD than non-veterans. Comparison with previous studies suggests changes in certain characteristics of homeless veterans over the past few decades that may reflect the growing proportion of veterans from the a...
TL;DR: Both OUD and OAT in VHA were positively and significantly correlated with state rates of opioid-related deaths, while indicators of OAT were significantly associated with higher state-level median income, health insurance coverage and levels of education.
Abstract: Purpose
Opioid use disorder (OUD) poses a national public health challenge including for the Veterans Health Administration (VHA). However, the responsiveness of VHA, as a centralized national health care system, to local conditions has not been studied. The purpose of this paper is to examine the correlation of measures of population-based OUD case identification and provision of opioid agonist treatment (OAT) in VHA and in local systems at the state level thus evaluating the responsiveness of VA as centralized health system to local conditions.
Design/methodology/approach
Correlation of VHA administrative data and local survey data reflecting OUD and OAT rates were evaluated with Pearson correlations. Further analyses examined the correlation of VHA and non-VHA OUD and OAT measures with state rates of opioid-related deaths, median income, health insurance coverage and education levels.
Findings
VHA rates of OUD and OAT at the state level were both significantly correlated with corresponding state data from the National Survey on Drug Use and Health (r=0.28, p=0.048 and r=0.71, p=0.002, respectively). Both OUD and OAT in VHA were positively and significantly correlated with state rates of opioid-related deaths, while indicators of OAT were significantly associated with higher state-level median income, health insurance coverage and levels of education.
Practical implications
Although centrally managed from Washington, D.C., VHA case identification and OAT service delivery appear to be correlated with relevant local measures.
Social implications
Significant associations with general population indicators point to underlying conditions that may shape both VHA and local health system performance.
Originality/value
Public health systems would benefit from performance evaluation data to examine responsiveness to local conditions.
TL;DR: A substantial proportion of people with TUD diagnosis despite concurrent smoking-related medical illnesses are also likely to have other comorbid SUDs, complicating efforts at smoking cessation, and requiring a broader approach than standard nicotine-dependence interventions.
Abstract: Introduction Very little is known of the behavioral vulnerabilities of patients diagnosed with smoking-related chronic medical illness who continue to smoke, potentially worsening morbidity and mortality risks. This study explores the association of tobacco use disorder (TUD) among those with smoking-related chronic medical illnesses with other substance use disorders (SUDs) and risk factors. Methods Among veterans with smoking-related chronic medical illnesses identified from the National Veterans Health Administration administrative records from fiscal year 2012, we compared the characteristics of those with a diagnosis of TUD (International Classification of Diseases, 9th edition code 305.xx; n = 519,918), and those without such a diagnosis (n = 2,691,840). Using multiple logistic regression, we further explored the independent association of factors associated with TUD. Results SUD prevalence was markedly higher among those with TUD (24.9% vs 5.44%), including alcohol use disorder (20.4% vs 4.3%) and drug use disorder (13.5% vs 2.6%), compared with nonsmokers. On multiple logistic regression analyses, alcohol use disorder (odds ratio [OR] 2.94, 95% confidence interval [CI] 2.90-2.97) and drug use disorder (OR 1.97, 95% CI 1.94-1.99) were independently associated with current TUD diagnosis. Having any single SUD was associated with considerably high odds of having TUD (OR 3.32, 95% CI 3.29-2.36), and having multiple SUDs with even further increased risk (OR 4.09, 95% CI 4.02-4.16). Conclusions A substantial proportion of people with TUD diagnosis despite concurrent smoking-related medical illnesses are also likely to have other comorbid SUDs, complicating efforts at smoking cessation, and requiring a broader approach than standard nicotine-dependence interventions.
TL;DR: Evidence of the successful implementation of this program in VHA is provided and an efficient approach and a first step in the evaluation of peer support services is demonstrated.
Abstract: Peer support is an important component in the promotion of recovery for people with serious mental illness. The Veterans Health Administration (VHA) has implemented peer support services nationally. This study used a series of questions about the perceived acceptance of peer services at VA facilities and the Recovery Self-Assessment (RSA), a standard measure of recovery attitudes, to evaluate and compare responses of a convenience sample of peer support specialists (PSS) and local peer supervisors (LPS). The authors hypothesized that level of receptivity of program among PSS and LPS will be high and that the scores on the five RSA domains will be comparable. The level of perceived receptivity was quite high for PSS and LPS and it was strongly correlated with recovery attitudes. Moreover, PSS scored significantly higher than LPS, on the Receptivity measure and on several domains of the RSA. RSA scores in this study were slightly higher than, or similar to, those observed in other VHA and non-VHA sa...
TL;DR: This study demonstrates that future efforts should focus on increasing provider and veteran awareness of and accessibility to VHA intensive tobacco cessation counseling for veterans with PTSD.
Abstract: Purpose
Veterans with post-traumatic stress disorder (PTSD) have high lifetime rates of smoking and often have substantial difficulty quitting. However, relatively little research has focussed on the use of Veterans Health Administration (VHA) intensive tobacco cessation counseling services by veterans with PTSD and the characteristics of veterans with PTSD who do and do not use these services. The paper aims to discuss these issues.
Design/methodology/approach
The present study is an analysis of national VHA administrative data fiscal year 2012 that identified utilization rates of VHA intensive tobacco cessation counseling among veterans with diagnoses of both PTSD and tobacco use disorder (TUD) (N=144,990) and the correlates of tobacco cessation counseling use.
Findings
Altogether, 7,921 veterans with PTSD diagnosed with TUD used VHA tobacco cessation services (5.5 percent). Veterans with PTSD who used tobacco cessation counseling services were more likely to have been homeless, to have a comorbid drug use disorder, and had used other VHA services more frequently than their counterparts who did not access tobacco cessation counseling. The use of outpatient mental health and substance use services was the strongest correlate of tobacco cessation counseling use by veterans in this sample. Notably, veterans with PTSD, TUD and HIV were more likely to engage in tobacco cessation services.
Originality/value
This study demonstrates that future efforts should focus on increasing provider and veteran awareness of and accessibility to VHA intensive tobacco cessation counseling for veterans with PTSD.