Dialectical Behavior Therapy (DBT) is an evidence-based psychotherapy (EBP) for repeated suicidal and nonsuicidal self-injury and Borderline Personality Disorder. There has been little research on ...the effectiveness or implementation of DBT via telehealth. However, literature has demonstrated that other EBPs delivered via telehealth are just as effective as in person. DBT differs from these EBPs in complexity, inclusion of group sessions, length of treatment, and focus on individuals at high risk for suicide. The coronavirus disease 2019 (COVID-19) pandemic caused mental health care services across the country and Department of Veterans Affairs (VA) to transition to telehealth to reduce infection risk for patients and providers. This transition offered an opportunity to learn about implementing DBT via telehealth on a national scale. We conducted a survey of DBT team points of contact in VA (N = 32) to gather information about how DBT via telehealth was being implemented, challenges and solutions, and provider perceptions. The majority reported that their site continued offering the modes of DBT via telehealth that they had offered in person. The predominant types of challenges in transitioning to telehealth were related to technology on the provider and patient side. Despite challenges, most providers reported their experience was better than expected and had positive perceptions of patient acceptability. Skills group was the more difficult mode to provide via telehealth. Providers endorsed needing additional tools (e.g., means to get diary card data electronically). Multiple benefits of DBT via telehealth were identified, such as addressing barriers to care including distance, transportation issues, and caregiving and work responsibilities.
Impact Statement
The transition to telehealth during the coronavirus disease 2019 (COVID-19) pandemic offered an opportunity to learn about implementing Dialectical Behavior Therapy (DBT) via telehealth on a national scale in the Department of Veterans Affairs. In a survey of DBT team points of contact (N = 32), the predominant challenges were related to technology, most reported their experience was better than expected, and they had positive perceptions of patient acceptability. Multiple benefits of DBT via telehealth were identified, such as addressing barriers to care including distance, transportation issues, and caregiving and work responsibilities.
Lung cancer screening (LCS) can reduce lung cancer mortality with close follow-up and adherence to management recommendations. Little is known about factors associated with adherence to LCS in ...real-world practice, with data limited to case series from selected LCS programs.
To analyze adherence to follow-up based on standardized follow-up recommendations in a national cohort and to identify factors associated with delayed or absent follow-up.
This retrospective cohort study was conducted in Veterans Health Administration (VHA) facilities across the US. Veterans were screened for lung cancer between 2015 to 2019 with sufficient follow-up time to receive recommended evaluation. Patient- and facility-level logistic regression analyses were performed. Data were analyzed from November 26, 2019, to December 16, 2020.
Receipt of the recommended next step after initial LCS according to Lung CT Screening Reporting & Data System (Lung-RADS) category, as captured in VHA or Medicare claims.
Of 28 294 veterans (26 835 94.8% men; 21 969 individuals 77.6% were White; mean SD age, 65.2 5.5 years) who had an initial LCS examination, 17 863 veterans (63.1%) underwent recommended follow-up within the expected timeframe, whereas 3696 veterans (13.1%) underwent late evaluation, and 4439 veterans (15.7%) had no apparent evaluation. Facility-level differences were associated with 9.2% of the observed variation in rates of late or absent evaluation. In multivariable-adjusted models, Black veterans (odds ratio OR, 1.19 95% CI, 1.10-1.29), veterans with posttraumatic stress disorder (OR, 1.13 95% CI, 1.03-1.23), veterans with substance use disorders (OR, 1.11 95% CI, 1.01-1.22), veterans with lower income (OR, 0.88 95% CI, 0.79-0.98), and those living at a greater distance from a VHA facility (OR, 1.06 95% CI, 1.02-1.10) were more likely to experience delayed or no follow-up; veterans with higher risk findings (Lung-RADS category 4 vs Lung-RADS category 1: OR, 0.35 95% CI, 0.28-0.43) and those screened in high LCS volume facilities (OR, 0.38 95% CI, 0.21-0.67) or academic facilities (OR, 0.86 95% CI, 0.80-0.92) were less likely to experience delayed or no follow-up. In sensitivity analyses, varying how stringently adherence was defined, expected evaluation ranged from 14 486 veterans (49.7%) under stringent definitions to 20 578 veterans (78.8%) under liberal definitions.
In this cohort study that captured follow-up care from the integrated VHA health care system and Medicare, less than two-thirds of patients received timely recommended follow-up after initial LCS, with higher risk of delayed or absent follow-up among marginalized populations, such as Black individuals, individuals with mental health disorders, and individuals with low income, that have long experienced disparities in lung cancer outcomes. Future work should focus on identifying facilities that promote high adherence and disseminating successful strategies to promote equity in LCS among marginalized populations.
Objective: Posttraumatic stress disorder (PTSD) is positively associated with involvement in the criminal justice system among veterans. Research that examines whether this association is confounded ...by risk factors ("criminogenic needs") from the risk-need-responsivity model of correctional rehabilitation can inform risk management with this population. Hypotheses: We hypothesized that (a) veterans with probable PTSD would score higher on all criminogenic needs than veterans without PTSD and (b) probable PTSD would be associated with criminal history but not after accounting for criminogenic needs. Method: We conducted secondary analyses of data from 341 veterans (95.3% male; 57.8% White/non-Hispanic/Latinx; Mage = 46.2 years) with a history of criminal justice system involvement who were admitted to mental health residential treatment. At treatment entry, participants completed interviews to assess criminal history, risk-need-responsivity-based criminogenic needs, and PTSD symptom severity. Cross-sectional analyses tested for differences between participants with and without probable PTSD on criminogenic needs and criminal history, and a multiple regression model examined the unique contributions of probable PTSD and criminogenic needs on criminal history. Results: The majority of the sample (74%, n = 251) met probable criteria for PTSD. Compared with veterans without PTSD, those with probable PTSD scored significantly higher on criminogenic needs of antisocial personality patterns, antisocial cognitions, antisocial associates, substance use, and family/marital dysfunction but did not differ on multiple indices of criminal history (Cohen's ds = 0.60-0.86). In the regression model, higher age (β = 0.52, p < .001) and higher scores on measures of antisocial personality patterns (β = 0.19, p = .04) and antisocial cognitions (β = 0.22, p = .02) were significantly associated with higher scores on a criminal history index. Conclusions: The findings suggest that veterans with probable PTSD may score higher on a number of criminogenic needs that are known to be drivers of recidivism. An approach that integrates trauma-informed and risk-need-responsivity principles to address veterans' dynamic criminogenic and clinical needs may be critical to risk management in this population.
Public Significance Statement
In some prior research, involvement in the criminal justice system among veterans of the U.S. military has been linked to posttraumatic stress disorder (PTSD). This study found that veterans with PTSD and a history of criminal justice system involvement are likely to have other risk factors for justice system involvement, but that PTSD by itself does not increase the likelihood of a criminal history. Risk management for justice-involved veterans should consider both the mental health needs of these veterans as well as risk factors for criminal justice system involvement that are typically monitored by correctional system staff.
Psychologists are integral to the care of transgender individuals. This article details the many roles for psychologists in transgender-specific care, including diagnosing and treating gender ...dysphoria; providing treatment for comorbid conditions; referring to medical services such as gender confirmation surgeries, voice modification, and cross-sex hormone therapies; serving as consultants within health care systems; and advocating for addressing barriers in systems in which transgender individuals live and work. Transgender veterans have unique experiences and vulnerabilities related to their military service that are detailed from a review of the literature, and we make the case that Veterans Health Administration (VHA) and community psychologists are well-positioned to provide care to transgender veterans (trans-vets). In this article, the authors describe the experiences that many trans-vets have faced, identify the importance of treatment for gender dysphoria (and draw the distinction between gender identity disorder and gender dysphoria) as well as psychologists' roles, and clarify which transgender-related services are available to eligible veterans though VHA per policy and how VHA providers have access to training to provide that care. In addition, we describe how veterans can connect to the VHA, even if they have (and want to continue working with) non-VHA psychologists or other community providers.
ABSTRACT
BACKGROUND
Posttraumatic Stress Disorder (PTSD) is associated with increased health care utilization, medical morbidity, and tobacco and alcohol use. Consequently, screening for PTSD has ...become increasingly common in primary care clinics, especially in Veteran healthcare settings where trauma exposure among patients is common.
OBJECTIVE
The objective of this study was to revise the Primary Care PTSD screen (PC-PTSD) to reflect the new Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria for PTSD (PC-PTSD-5) and to examine both the diagnostic accuracy and the patient acceptability of the revised measure.
DESIGN
We compared the PC-PTSD-5 results with those from a brief psychiatric interview for PTSD. Participants also rated screening preferences and acceptability of the PC-PTSD-5.
PARTICIPANTS
A convenience sample of 398 Veterans participated in the study (response rate = 41 %). Most of the participants were male, in their 60s, and the majority identified as non-Hispanic White.
MEASURES
The PC-PTSD-5 was used as the screening measure, a modified version of the PTSD module of the MINI-International Neuropsychiatric Interview was used to diagnose DSM-5 PTSD, and five brief survey items were used to assess acceptability and preferences.
KEY RESULTS
The PC-PTSD-5 demonstrated excellent diagnostic accuracy (AUC = 0.941; 95 %
C.I
.: 0.912– 0.969). Whereas a cut score of 3 maximized sensitivity (κ1) = 0.93; SE = .041; 95 %
C.I
.: 0.849–1.00), a cut score of 4 maximized efficiency (κ0.5 = 0.63; SE = 0.052; 95 %
C.I
.: 0.527–0.731), and a cut score of 5 maximized specificity (κ0 = 0.70; SE = 0.077; 95 %
C.I
.: 0.550–0.853). Patients found the screen acceptable and indicated a preference for administration by their primary care providers as opposed to by other providers or via self-report.
CONCLUSIONS
The PC-PTSD-5 demonstrated strong preliminary results for diagnostic accuracy, and was broadly acceptable to patients.
To examine associations between history of traumatic brain injury (TBI) diagnosis and death by suicide among individuals receiving care within the Veterans Health Administration (VHA).
Individuals ...who received care between fiscal years 2001 to 2006 were included in analyses. Cox proportional hazards survival models for time to suicide, with time-dependent covariates, were utilized. Covariance sandwich estimators were used to adjust for the clustered nature of the data, with patients nested within VHA facilities. Analyses included all patients with a history of TBI (n = 49626) plus a 5% random sample of patients without TBI (n = 389053). Of those with a history of TBI, 105 died by suicide. Models were adjusted for demographic and psychiatric covariates.
Veterans with a history of TBI were 1.55 (95% confidence interval CI, 1.24-1.92) times more likely to die by suicide than those without a history of TBI. Analyses by TBI severity were also conducted, and they suggested that in comparison to those without an injury history, those with (1) concussion/cranial fracture were 1.98 times more likely (95% CI, 1.39-2.82) to die by suicide and (2) cerebral contusion/traumatic intracranial hemorrhage were 1.34 times more likely (95% CI, 1.09-1.64) to die by suicide. This increased risk was not explained by the presence of psychiatric disorders or demographic factors.
Among VHA users, those with a diagnosis of TBI were at greater risk for suicide than those without this diagnosis. Further research is indicated to identify evidence-based means of assessment and treatment for those with TBI and suicidal behavior.
Abstract Demographic factors, characteristics of military service, PTSD, and depression were examined as predictors of alcohol misuse in Iraq and Afghanistan War Veterans ( N = 287) presenting for ...post-deployment Veteran Affairs (VA) health care. Results indicated that alcohol misuse was more common among younger male Veterans who served in the Army or Marine Corps. Accounting for demographic factors and characteristics of service, Veterans who screened positive for PTSD or depression were two times more likely to report alcohol misuse relative to Veterans who did not screen positive for these disorders. The examination of specific PTSD symptom clusters suggested that emotional numbing symptoms were most strongly associated with alcohol misuse. The implications for interventions for alcohol misuse in returning Veterans are discussed.
This qualitative study provides a platform for women veterans to inform our perspective of their experienced impacts following military sexual trauma (MST). We engaged 23 women veterans in ...semistructured interviews and used a grounded theory-informed thematic analytic approach, to interpret women's experiences. Women described negative impacts of their MST experiences across psychological, behavioral, and occupational domains. Less frequently, women discussed experiences of posttraumatic growth. These results aid our understanding of the complexities of women's posttrauma experiences and suggest that holistic intervention frameworks focused on a range of potential intervention targets are warranted in helping women veterans recover from MST.
In 2009 the Department of Veterans Affairs (VA) began a major, four-year investment in improving the quality of end-of-life care. The Comprehensive End of Life Care Initiative increased the numbers ...of VA medical center inpatient hospice units and palliative care staff members as well as the amount of palliative care training, quality monitoring, and community outreach. We divided male veterans ages sixty-six and older into categories based on their use of the VA and Medicare and examined whether the increases in their rates of hospice use in the last year of life differed from the concurrent increase among similar nonveterans enrolled in Medicare. After adjusting for age, race and ethnicity, diagnoses, nursing home use in the last year of life, census region, and urbanicity of a person's last residence, we found a 6.9-7.9-percentage-point increase in hospice use over time for the veteran categories, compared to a 5.6-percentage-point increase for nonveterans (the relative increases were 20-42 percent and 16 percent, respectively). The VA's substantial investment in palliative care appears to have resulted in greater hospice use by older male veterans enrolled in the VA, a critical step forward in caring for veterans with serious illnesses.
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