Heather Walters

Predictors of Suicide in Patient Charts Among Patients With Depression in the Veterans Health Administration Health System: Importance of Prescription Drug and Alcohol Abuse

OBJECTIVE To identify factors recorded in electronic medical chart progress notes associated with suicide among patients who had received treatment for depression. METHOD The retrospective study sample consisted of 324 randomly selected US Veterans Health Administration (VHA) patients treated for depression who died by suicide from April 1, 1999, to September 30, 2004, stratified by geographic region, gender, and year of depression cohort entry and 312 control patients with depression who were alive on the date of suicide death (index date) and were from the same stratum as the matched suicide patient. In addition to constructing variables from administrative data, variables were abstracted from electronic medical chart notes in the year prior to the index date in 5 categories: clinical symptoms and diagnoses, substance use, life stressors, behavioral/ideation measures (eg, suicide attempts), and treatments received. Logistic regression was used to assess the associations. RESULTS Even after we adjusted for administratively available data, suicidal behaviors and substance-related variables were the strongest independent predictors of suicide. Prescription drug misuse had an odds ratio (OR) of 6.8 (95% CI, 2.5-18.5); history of suicide attempts, 6.6 (95% CI, 1.7-26.4); and alcohol abuse/dependence, 3.3 (95% CI, 1.9-5.7). Difficulty with access to health care was a predictor of suicide (OR = 2.9; 95% CI, 1.3-6.3). Receipt of VHA substance abuse treatment was protective (OR = 0.4; 95% CI, 0.1-0.9). CONCLUSIONS Prescription drug and alcohol misuse assessments should be prioritized in suicide assessments among depressed patients. Additionally, behavioral measures noted in electronic chart records may be useful in health system monitoring and surveillance and can potentially be accessed using word search or natural language processing approaches.

Reported barriers to mental health care in three samples of U.S. Army National Guard soldiers at three time points.

The military community and its partners have made vigorous efforts to address treatment barriers and increase appropriate mental health services use among returning National Guard soldiers. We assessed whether there were differences in reports of treatment barriers in 3 categories (stigma, logistics, or negative beliefs about treatment) in sequential cross-sectional samples of U.S. soldiers from a Midwestern Army National Guard Organization who were returning from overseas deployments. Data were collected during 3 time periods: September 2007-August 2008 (n = 333), March 2009-March 2010 (n = 884), and August 2011-August 2012 (n = 737). In analyses using discretized time periods and in trend analyses, the percentages of soldiers endorsing negative beliefs about treatment declined significantly across the 3 sequential samples (19.1%, 13.9%, and 11.1%). The percentages endorsing stigma barriers (37.8%, 35.2%, 31.8%) decreased significantly only in trend analyses. Within the stigma category, endorsement of individual barriers regarding negative reactions to a soldier seeking treatment declined, but barriers related to concerns about career advancement did not. Negative treatment beliefs were associated with reduced services use (OR = 0.57; 95% CI [0.33, 0.97]).

Treatment of Veterans with depression who died by suicide: timing and quality of care at last Veterans Health Administration visit

OBJECTIVE To examine the recency and quality of the last Veterans Health Administration (VHA) visit for patients with depression who died by suicide. METHOD We obtained services and pharmacy data for all 1,843 VHA patients with diagnosed depressive disorders (DSM-IV criteria) who died by suicide from April 1999 through September 2004. We ascertained the location and timing of their final VHA visit. For visits occurring within 30 days of suicide, we examined 3 quality indicators: (1) evidence that mental illness was a focus of the final visit, (2) adequacy of antidepressant dosage, and (3) recent receipt of mental health services. RESULTS Just over half of the patients (51%) with depression diagnoses had a VHA visit within 30 days of suicide. A minority of these patients (43%) died by suicide within 30 days of a final visit with mental health services, although 64% had received such services within 91 days of their suicide. Among the 57% of patients who died by suicide within 30 days and who were seen in non-mental health settings for their final visit, only 34% had a mental health condition coded at the final visit, and only 41% were receiving adequate dosages of antidepressant (versus 55% for those last seen by mental health services) (P < .0005). CONCLUSIONS Veterans Health Administration patients with depression who died by suicide within 30 days of their final visit received relatively high rates of mental health services, but most final visits still occurred in non-mental health settings. Increased referrals to mental health services, attention to mental health issues in non-mental health settings, and focus on antidepressant treatment adequacy by all providers might have reduced suicide risks for these patients.

Telephone-based mutual peer support for depression: a pilot study.

Objectives: To evaluate the acceptability, feasibility and depression-related outcomes of a telephone-based mutual peer support intervention for individuals with continued depressive symptoms in specialty mental health treatment. Methods: Participants were depressed patients with continued symptoms or functional impairment treated at one of the three outpatient mental health clinics. Participants were partnered with another patient, provided with basic communication skills training, and asked to call their partner at least once a week using a telephone platform that recorded call initiation, frequency and duration. Depression symptoms, quality of life, disability, self-efficacy, overall mental and physical health and qualitative feedback were collected at enrolment, 6 weeks and 12 weeks. Results: Fifty-four participants enroled in the 12-week intervention and 32 participants (59.3%) completed the intervention. Participants completing the study averaged 10.3 calls, with a mean call length of 26.8 min. The mean change in BDI-II score from baseline to study completion was -4.2 (95% CI: -7.6, -0.8; p<0.02). Measures of disability, quality of life and psychological health also improved. Qualitative assessments indicated that participants found meaning and support through interactions with their partners. Discussion: Telephone-based mutual peer support is a feasible and acceptable adjunct to specialty depression care. Larger trials are needed to determine efficacy and effectiveness of this intervention.

Student and Nonstudent National Guard Service Members/Veterans and Their Use of Services for Mental Health Symptoms.

Abstract. Objective: To compare mental health symptoms and service utilization among returning student and nonstudent service members/veterans (SM/Vs). Participants: SM/Vs (N = 1,439) were predominately white (83%) men (92%), half were over age 30 (48%), and 24% were students. Methods: SM/Vs completed surveys 6 months post deployment (October 2011–July 2013). Results: Students and nonstudent SM/Vs did not differ in positive screens for depression, anxiety, hazardous drinking, or posttraumatic stress disorder. Students (n = 81) and nonstudents (n = 265) with mental health symptoms had low levels of mental health service use (eg, Department of Veterans Affairs [VA], civilian, or military facilities), at 47% and 57%. respectively. Fewer students used VA mental health services. Common barriers to treatment seeking included not wanting treatment on military records and embarrassment. Conclusions: Like other returning SM/Vs, student SM/Vs have unmet mental health needs. The discrepancy between potential need and treatment seeking suggests that colleges might be helpful in further facilitating mental health service use for student SM/Vs.

Integration of peer support and computer-based CBT for veterans with depression

Depressive disorders are a serious public health concern and treatment priority for the Veterans Health Administration. Computer-based Cognitive Behavioral Therapy (cCBT) is an effective intervention for patients with major depressive disorders; however, rates of program completion are an area of concern, which may be improved through the assistance of peers. This pilot study investigated the feasibility of a Veteran-peer assisted cCBT intervention. Participants were patients diagnosed with depression at an Outpatient Mental Health (OMH) or Primary Care Mental Health (PCMH) clinic at a single VHA facility. Participants were paired with a Veteran-peer and given access to a widely used cCBT program via the Internet. Measures of depressive symptoms were obtained at baseline, 4-, and 8-weeks follow-up. Completion rates and program satisfaction were also assessed. At 8weeks, symptom reductions and completion rates were comparable to study results of brief individual, group CBT, and staff assisted computerized CBT interventions. Significant reductions in depressive symptoms were observed in patients from both clinics, although ratings of program usefulness, relevance, and ease of use were higher for individuals recruited from the PCMH clinic. Peer-assisted cCBT for depression is feasible but further research is needed to determine the clinical efficacy of this approach.

EFFECTIVENESS OF A DEPRESSION DISEASE MANAGEMENT PROGRAM IN IMPROVING DEPRESSION AND WORK FUNCTION—A PILOT STUDY*

Objective: We examined whether there were differences in depression and work function outcomes among primary care and specialty mental health patients treated by the Michigan Depression Outreach and Collaborative Care (M-DOCC), a depression care management program, developed by the University of Michigan Depression Center. In addition, we examined the relationship between depressive symptoms and workplace functioning among M-DOCC enrollees over time. Method: We used mixed model and logistic regression analyses. Results: Despite baseline differences in patient characteristics between primary care and specialty care patients, the location of treatment setting was not a significant predictor of depression or work function outcomes over time among patients enrolled in a depression care management program. Patients in both treatment settings showed significant decreases in depressive and functional impairment over time, with improvements in these symptoms occurring concurrently. Patients with greater case severity were less likely to demonstrate depression and work function improvements over time, and more severe side effects were associated with fewer depression symptom improvements over time. Conclusions: Both depression and work function outcomes improved over time among patients enrolled in a depression care management program, and this improvement did not differ based on whether a patient was treated in a primary or specialty care setting.

Factors Associated With Civilian Employment, Work Satisfaction, and Performance Among National Guard Members

OBJECTIVE Employment is a vital part of the postdeployment return to civilian life. This study investigated factors associated with employment-related outcomes (employment status, self-reported work performance, and self-reported work satisfaction) among National Guard members returning from Operation Enduring Freedom, Operation Iraqi Freedom, or Operation New Dawn deployments. METHODS The sample consisted of 1,151 National Guard service members who had returned from overseas deployments approximately six months earlier. Bivariate and multivariable analyses were performed to examine associations between predictors and employment-related outcome variables. RESULTS Higher-risk alcohol use was associated with reduced odds of being employed as well as with lower ratings of work satisfaction, whereas psychiatric symptom load was associated with lower self-reported work performance and work satisfaction ratings. Perceived social resources were associated with higher self-reported work performance and work satisfaction, whereas better physical functioning was associated with better self-reported work performance. CONCLUSIONS Policy makers and clinicians may need to consider and assess alcohol use among unemployed National Guard members. They may also need to consider psychiatric symptom load and physical functioning among employed service members who perceive poor work performance and have low work satisfaction. Further research is needed on causal links between these predictors and employment outcomes.

Psychometric analysis of the mental health recovery measure in a sample of veterans with depression

Using data from a sample of 398 veterans diagnosed with depression, the present study used principal components analysis to shorten the Mental Health Recovery Measure (MHRM) to a 10-item instrument. Results indicated the 10-item MHRM had excellent internal reliability. Construct validity for the 10-item MHRM was evidenced by correlations with measures of depression coping self-efficacy, social adjustment, hopelessness, and depression. The 10-item MHRM derived in the present study was compared with a 10-item version of the MHRM that was previously empirically derived in a sample of veterans with schizophrenia (Armstrong, Cohen, Hellemann, Reist, & Young, 2014). Results suggest that similar items represent the underlying construct of recovery for veterans with depression and veterans with schizophrenia. Veterans with depression reported lower average levels of recovery than veterans with schizophrenia. Study limitations, directions for future investigations, and the implications of routine assessment of mental health recovery in public mental health systems are discussed. (PsycINFO Database Record

Veteran Mental Health and Employment: The Nexus and Beyond

In the armed forces, “service” denotes a willingness to “work for” your country, wages, personal recognition of accomplishment, your brothers/sisters in arms, and references the importance of work in the identity of these individuals. Veteran employment and mental health are intricately connected and at times dependent upon each other. As such, focusing on one in isolation is not recommended. To help veterans successfully integrate back into their communities and move toward mental health recovery when needed, a more integrated approach is warranted. In this chapter, we review the state of the literature concerning veteran employment, effects of mental illness on veteran employment, and examine current employment services for veterans. This chapter concludes with a discussion of approaches that show promise for addressing the nexus of employment and mental health in veterans, as well as identifying future directions for research to help better mitigate the needs of our veterans.