Bridget B. Matarazzo

Prevalence and screening of traumatic brain injury among veterans seeking mental health services.

Objectives:To assess the prevalence of traumatic brain injury (TBI) among Veterans seeking mental health services using a 4-item tool, the Traumatic Brain Injury–4 (TBI-4), and to establish the classification accuracy of the TBI-4 using the Ohio State University TBI-Identification Method as the criterion standard. Study Design:Archival and observational data collected from individuals seeking care at a Mountain State VA Medical Center. Participants:The sample for the archival study was 1810. Three hundred sixteen Veterans completed observational study measures. Main Measures:For the archival study, TBI-4 and demographic data extracted from electronic medical records. For the observational study, the Ohio State University TBI-Identification Method and a demographic questionnaire were used. TBI-4 data were also obtained from electronic medical records. Results:The prevalence of probable TBI among those seeking VA MH treatment was 45%. Sensitivity and specificity of the TBI-4 were 0.74 and 0.56, respectively. Veterans with all levels of TBI severity sought care within this VA mental health setting. Conclusions:The prevalence of TBI in this VA mental health treatment population was higher than expected. Additional research is required to assess the clinical utility of screening for TBI among this population of Veterans.

Therapeutic risk management of the suicidal patient: stratifying risk in terms of severity and temporality.

This column is the third in a series describing a model for therapeutic risk management of the suicidal patient. In the preceding column, we described augmenting clinical suicide risk assessment with structured instruments. In this column, we describe how clinicians can use the totality of available clinical data to offer a two-dimensional risk stratification that qualifies risk in terms of both severity and temporality. By offering two separate designations that reflect severity for both acute and chronic risk, conceptualizing and communicating a patients risk for suicide is accomplished in a more nuanced way, providing the level of detail necessary when working with high risk individuals, especially those struggling with chronic suicidal ideation. Formulations reflecting suicide risk need to be accurate and facilitate good clinical decision-making in order to optimally balance the principles of autonomy, non-maleficence, and beneficence. Stratifying risk in terms of both severity and temporality helps identify situations in which involuntary hospitalization is warranted, while also helping to minimize unnecessary admissions. Hence, two-dimensional risk stratification that addresses both acute and chronic risk for suicide is an essential component of therapeutic risk management of the suicidal patient.

A model for therapeutic risk management of the suicidal patient.

While the practice of psychiatry involves many challenges, few scenarios are as clinically and emotionally demanding as managing the patient who is at high risk for suicide. Risk management is a reality of psychiatric practice, and this necessitates practicing and documenting thoughtful suicide risk assessment and management. Therapeutic risk management is based on clinical risk management that is patient-centered, supportive of the treatment process, and maintains the therapeutic alliance. In this article, the authors present a broad overview of a model for achieving therapeutic risk management of the suicidal patient that involves augmenting clinical risk assessment with structured instruments, stratifying risk in terms of both severity and temporality, and developing and documenting a safety plan. These elements are readily accessible to and deployable by mental health clinicians in most disciplines and treatment settings, and they collectively yield a suicide risk assessment and management process (and attendant documentation) that should withstand the scrutiny that often occurs in the wake of a patient suicide or suicide attempt.

Therapeutic risk management of the suicidal patient: safety planning.

This column is the fourth in a series describing a model for therapeutic risk management of the suicidal patient. Previous columns presented an overview of the therapeutic risk management model, provided recommendations for how to augment risk assessment using structured assessments, and discussed the importance of risk stratification in terms of both severity and temporality. This final column in the series discusses the safety planning intervention as a critical component of therapeutic risk management of suicide risk. We first present concerns related to the relatively common practice of using no-suicide contracts to manage risk. We then present the safety planning intervention as an alternative approach and provide recommendations for how to use this innovative strategy to therapeutically mitigate risk in the suicidal patient.

Therapeutic risk management of the suicidal patient: augmenting clinical suicide risk assessment with structured instruments.

This column is the second in a series presenting a model for therapeutic risk management of the suicidal patient. As discussed in the first part of the series, the model involves several elements including augmenting clinical risk assessment with structured instruments, stratifying risk in terms of both severity and temporality, and developing and documenting a safety plan. This column explores in more detail how to augment clinical risk assessment with structured instruments. Unstructured clinical interviews have the potential to miss important aspects of suicide risk assessment. By augmenting the free-form clinical interview with structured instruments that demonstrate reliability and validity, a more nuanced and multifaceted approach to suicide risk assessment is achieved. Incorporating structured instruments into practice also serves a medicolegal function, since these instruments may become a living part of the medical record, establishing baseline levels of suicidal thoughts and behaviors and facilitating future clinical determinations regarding safety needs. We describe several instruments used in a multidisciplinary suicide consultation service, each of which has demonstrated relevance to suicide risk assessment and screening, ease of administration, and strong psychometric properties. In addition, we emphasize the importance of viewing suicide risk assessment as an ongoing process rather than as a singular event. Finally, we discuss special considerations in the evolving practice of risk assessment.

Evaluating the psychometric properties of the Interpersonal Needs Questionnaire and the Acquired Capability for Suicide Scale in military veterans.

Joiners (2005) interpersonal-psychological theory of suicide (IPTS) has become one of the most frequently studied in the field. Currently there are 2 primary measures designed to assess the 3 main constructs of the theory-the Interpersonal Needs Questionnaire (INQ; Van Orden, Witte, Gordon, Bender, & Joiner, 2008) and the Acquired Capability for Suicide Scale (ACSS; Van Orden et al., 2008). The psychometric properties of these 2 measures were evaluated in a sample of 477 U.S. military veterans. It was determined that the factor structure for both measures is consistent with the underlying theory and that all internal consistency reliability estimates are good. Acceptable convergent validity was found for the INQ, but not for the ACSS. Recommendations for refining the ACSS based on the results of the current analyses are provided. Comparisons of scale performance were made with data from participants with and without a history of 1 or more suicide attempts. Burdensomeness alone and the interaction between thwarted belongingness and burdensomeness were associated with prior suicide attempts. In conclusion, although some refinement may improve performance of the ACSS, both measures are appropriate and psychometrically sound for use in research and clinical applications with veterans of the U.S. military. (PsycINFO Database Record

Balancing patient care and confidentiality: considerations in obtaining collateral information.

Collateral information facilitates comprehensive mental health care and is consistent with recovery-oriented models of care. But providers are often faced with complex decisions about obtaining collateral information, particularly when patients do not consent to communication with third parties for information gathering. Such situations require a thoughtful balance of best clinical practices, legal and ethical responsibilities, and patient safety concerns. This column offers an overview of the clinical utility of collateral information as well as the ethical and legal regulations concerning confidentiality that guide the process of obtaining collateral information. The risk-benefit analysis process related to obtaining collateral information without patient permission is illustrated. Recommendations about clinical consultation and documentation that facilitate optimal and ethical patient care are offered.

responses to Traumatic Brain injury screening Questions and suicide attempts among Those seeking Veterans health administration Mental health services

Background Psychometrically sound screening tools available to aid in the identification of lifetime history of traumatic brain injury (TBI) are limited. As such, the Traumatic Brain Injury-4 (TBI-4) was developed and implemented in a Veterans Health Administration (VHA) mental health clinic. To provide information regarding both the predictive validity and clinical utility of the TBI-4, the relationship between screening results and future suicide attempts was evaluated. Objective The aim of this study was to determine whether a positive screen on the TBI-4 was associated with increased risk for suicide attempt within 1-year post screening. Methods The TBI-4 was administered to 1,097 Veterans at the time of mental health intake. Follow-up data regarding suicide attempts for the year post-mental health intake were obtained from suicide behavior reports (SBRs) in Veteran electronic medical records (EMRs). Fisher’s exact tests were used to determine the proportion of suicide attempts by TBI-4 status. Results In the year post TBI-4 screening, significantly more Veterans who screened positive had a documented suicide attempt as compared to those who screened negative (p = 0.003). Conclusion Those with a positive TBI screen at mental health intake had a higher proportion of SBRs than those who screened negative for TBI. Findings provided further psychometric support for the TBI-4. Moreover, results suggest the inclusion of this screen could prove to be helpful in identifying those who may be at risk for future suicide attempt within 1-year post screening.

Delivering Mental Health Services to OEF/OIF Veterans: A VHA Qualitative Study.

Purpose: Veterans Health Administration (VHA) mental health (MH) professionals are providing care to increasing numbers of veterans who served in Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF). This study aimed to describe MH clinicians’ views of OEF/OIF veteran needs and how providers meet those needs within a large system of care. Design: Qualitative research methodology, specifically qualitative description, was used to explore VHA MH clinicians’ experiences providing MH services to OEF/OIF veterans. Methods: Thirteen VA MH providers participated in semistructured interviews, which included questions regarding the following areas: psychiatric needs of OEF/OIF veterans; collaboration and referral; needs and resources; and the personal/professional impact of providing services to this cohort. Findings: Themes emerged which highlighted complex challenges faced by OEF/OIF veterans, barriers associated with matching the unique needs of these veterans with existing treatments, and the challenges and rewards associated with providing care to members of this population. Conclusions: Capturing provider perspectives within MH services suggest potential areas for innovation aimed at providing patient-centered care to this cohort of veterans. Results may also inform future work aimed at meeting the needs of both OEF/OIF veterans and MH providers.

Cross-cultural adaptation of the Window to Hope: A psychological intervention to reduce hopelessness among US Veterans with traumatic brain injury

Abstract Primary objective: To conduct a cross-cultural adaptation of Window to Hope (WtoH), a treatment to reduce hopelessness after traumatic brain injury (TBI), from the Australian civilian context to that of US Veterans. Research design: Three-stage mixed-methods approach. Methods: Stage 1: Consensus conference with stakeholders to revise the manual. Stage 2: Pilot study of the revised manual with US Veterans to examine acceptability, feasibility and fidelity. Stage 3: Review of results with consensus conference attendees and further revisions. Results: Stage 1: Conference attendees reached 100% consensus regarding changes made to the manual. Stage 2: Qualitative results yielded themes that suggest that participants benefitted from the intervention and that multiple factors contributed to successful implementation (Narrative Evaluation of Intervention Interview, User Feedback Survey-Modified, Post-Treatment Interviews). Therapists achieved 100% treatment fidelity. Quantitative results from the Client Satisfaction Questionnaire-8 suggest that the intervention was acceptable. Stage 3: The culturally adapted manual was finalized. Conclusions: Results of this study suggest that the revised WtoH manual is acceptable and feasible. US therapists exhibited adherence to the protocol. The three-stage methodology was successfully employed to cross-culturally adapt an intervention that is well-suited for a Phase II randomized controlled trial among US military Veterans.