Michael R. Kauth

Prevalence of Gender Identity Disorder and Suicide Risk Among Transgender Veterans Utilizing Veterans Health Administration Care

OBJECTIVES We estimated the prevalence and incidence of gender identity disorder (GID) diagnoses among veterans in the Veterans Health Administration (VHA) health care system and examined suicide risk among veterans with a GID diagnosis. METHODS We examined VHA electronic medical records from 2000 through 2011 for 2 official ICD-9 diagnosis codes that indicate transgender status. We generated annual period prevalence estimates and calculated incidence using the prevalence of GID at 2000 as the baseline year. We cross-referenced GID cases with available data (2009-2011) of suicide-related events among all VHA users to examine suicide risk. RESULTS GID prevalence in the VHA is higher (22.9/100 000 persons) than are previous estimates of GID in the general US population (4.3/100 000 persons). The rate of suicide-related events among GID-diagnosed VHA veterans was more than 20 times higher than were rates for the general VHA population. CONCLUSIONS The prevalence of GID diagnosis nearly doubled over 10 years among VHA veterans. Research is needed to examine suicide risk among transgender veterans and how their VHA utilization may be enhanced by new VA initiatives on transgender care.

Access to Care for Transgender Veterans in the Veterans Health Administration: 2006–2013

A 2011 Veterans Health Administration directive mandated medically necessary care for transgender veterans. Internal education efforts informed staff of the directive and promoted greater access to care. For fiscal years 2006 through 2013, we identified 2662 unique individuals with International Classification of Diseases, Ninth Revision diagnoses related to transgender status in Veterans Health Administration medical records, with 40% of new cases in the 2 years following the directive. A bottom-up push for services by veterans and top-down education likely worked synergistically to speed implementation of the new policy and increase access to care.

Communication between VA providers and sexual and gender minority veterans: a pilot study.

Approximately one million gay and lesbian Americans are veterans, and rates of engagement in the Veterans Affairs (VA) health care system may be increasing for both sexual and gender minority veterans. Very little research has examined the experience of these veterans when receiving care at VA health care facilities. The purpose of this study was to explore the experiences, beliefs, and preferences of lesbian, gay, bisexual, or transgender (LGBT) veterans in their communication with VA health care providers. LGBT veterans (n = 58) participated in focus groups or individual interviews and completed self-report measures at two southern VA hospitals. Approximately 2/3 of veterans report that none of their VA providers have specifically asked about their sexual orientation, and 24% of the veterans indicate that they have not disclosed their orientation to any VA provider. Although some veterans want providers to initiate these discussions, veterans also expressed fears about disclosure and its possible negative consequences. Similarly, LGBT veterans report varied opinions about the appropriateness of routine assessment of minority status. Only 28% of these veterans experience VA as welcoming to them as LGBT veterans. Systematic training is needed for all VA providers about the rationale for assessing sexual and gender orientation. Staff education should include specific skills for initiating these assessments, and ways of responding to veteran concerns about discussing this topic in the VA health care system.

Sexual Dysfunction among Male Veterans Returning from Iraq and Afghanistan: Prevalence and Correlates

INTRODUCTION Sexual dysfunction (SD) is not well described in the Iraq/Afghanistan veteran population despite high prevalence of multiple risk factors for this issue. AIM To estimate the prevalence and examine the association of various sociodemographic, mental health, comorbid conditions and life style factors with sexual dysfunction in Iraq/Afghanistan veterans. METHODS This exploratory cross-sectional study was conducted using data from the VA administrative database. A total of 4,755 Iraq/Afghanistan veterans were identified who sought treatment from the Michael E. DeBakey Veterans Affairs Medical Center inpatient and outpatient clinic between September 2007 and August 2009. MAIN OUTCOME MEASURES Sexual dysfunction was determined by ICD9-CM codes related to sexual health issues and/or by specific medications, primarily phosphodiesterase-5 inhibitors (PDE5i), prescribed for erectile dysfunction. RESULTS The overall prevalence of sexual dysfunction was 5.5% (N = 265). By age category, it was 3.6% (N = 145) for Iraq/Afghanistan veterans aged 18-40 years and 15.7% (N = 120) for Iraq/Afghanistan veterans aged > 40 years, respectively. A multivariate logistic-regression model revealed that annual income, marital status, post-traumatic stress disorder, and hypertension were significant risk factors of SD (all P < 0.05) among younger Iraq/Afghanistan veterans, whereas among the older Iraq/Afghanistan veterans, being African American and having PTSD and hypertension were significant risk factors of SD (all P < 0.05). There was marked discrepancy between documented erectile dysfunction and prescription of a PDE5i. CONCLUSIONS These data demonstrate that a significant proportion of Iraq/Afghanistan veterans have SD and that the risk factors differ between younger and older veterans. Our findings also suggest that SD is likely under-coded. To better identify the scope of the problem, systematic screening for sexual dysfunction may be appropriate perhaps as part of an initial post-deployment health evaluation.

Translating clinical training into practice in complex mental health systems: Toward opening the 'Black Box' of implementation

BackgroundImplementing clinical training in a complex health care system is challenging. This report describes two successive trainings programs in one Veterans Affairs healthcare network and the lessons we drew from their success and failures. The first training experience led us to appreciate the value of careful implementation planning while the second suggested that use of an external facilitator might be an especially effective implementation component. We also describe a third training intervention in which we expect to more rigorously test our hypothesis regarding the value of external facilitation.ResultsOur experiences appear to be consonant with the implementation model proposed by Fixsen. In this paper we offer a modified version of the Fixsen model with separate components related to training and implementation.ConclusionThis report further reinforces what others have noted, namely that educational interventions intended to change clinical practice should employ a multilevel approach if patients are to truly benefit from new skills gained by clinicians. We utilize an implementation research model to illustrate how the aims of the second intervention were realized and sustained over the 12-month follow-up period, and to suggest directions for future implementation research. The present report attests to the validity of, and contributes to, the emerging literature on implementation research.

Brief cognitive behavioral therapy in primary care: a hybrid type 2 patient-randomized effectiveness-implementation design

BackgroundDespite the availability of evidence-based psychotherapies for depression and anxiety, they are underused in non-mental health specialty settings such as primary care. Hybrid effectiveness-implementation designs have the potential to evaluate clinical and implementation outcomes of evidence-based psychotherapies to improve their translation into routine clinical care practices.MethodsThis protocol article discusses the study methodology and implementation strategies employed in an ongoing, hybrid, type 2 randomized controlled trial with two primary aims: (1) to determine whether a brief, manualized cognitive behavioral therapy administered by Veterans Affairs Primary Care Mental Health Integration program clinicians is effective in treating depression and anxiety in a sample of medically ill (chronic cardiopulmonary diseases) primary care patients and (2) to examine the acceptability, feasibility, and preliminary outcomes of a focused implementation strategy on improving adoption and fidelity of brief cognitive behavioral therapy at two Primary Care-Mental Health Integration clinics. The study uses a hybrid type 2 effectiveness/implementation design to simultaneously test clinical effectiveness and to collect pilot data on a multifaceted implementation strategy that includes an online training program, audit and feedback of session content, and internal and external facilitation. Additionally, the study engages the participation of an advisory council consisting of stakeholders from Primary Care-Mental Health Integration, as well as regional and national mental health leaders within the Veterans Administration. It targets recruitment of 320 participants randomized to brief cognitive behavioral therapy (n = 200) or usual care (n = 120). Both effectiveness and implementation outcomes are being assessed using mixed methods, including quantitative evaluation (e.g., intent-to-treat analyses across multiple time points) and qualitative methods (e.g., focus interviews and surveys from patients and providers). Patient-effectiveness outcomes include measures of depression, anxiety, and physical health functioning using blinded independent evaluators. Implementation outcomes include patient engagement and adherence and clinician brief cognitive behavioral therapy adoption and fidelity.ConclusionsHybrid designs are needed to advance clinical effectiveness and implementation knowledge to improve healthcare practices. The current article describes the rationale and challenges associated with the use of a hybrid design for the study of brief cognitive behavioral therapy in primary care. Although trade-offs exist between scientific control and external validity, hybrid designs are part of an emerging approach that has the potential to rapidly advance both science and practice.Trial registrationNCT01149772 athttp://www.clinicaltrials.gov/ct2/show/NCT01149772

Understanding Health-Care Needs of Sexual and Gender Minority Veterans: How Targeted Research and Policy Can Improve Health

Given the size of the patient population of the Veterans Health Administration (VHA), it is likely the largest single provider of health care for sexual and gender minority (SGM) individuals in the United States, including lesbian, gay, bisexual, and transgender persons. However, current VHA demographic data-collection strategies limit the understanding of how many SGM veterans there are, thereby making a population-based understanding of the health needs of SGM veterans receiving care in VHA difficult. In this article, we summarize the emergent research findings about SGM veterans and the first initiatives that have been implemented by VHA to promote quality care. Though the research on SGM veterans is in its infancy, it suggests that SGM veterans share some of the health risks noted in veterans generally and also risks associated with SGM status. Some promising resiliency factors have also been identified. These findings have implications for both VHA and non-VHA systems in the treatment of SGM veterans. However, more research on the unique needs of SGM veterans is needed to fully understand their health risks and resiliencies in addition to health-care utilization patterns.

Coping mediates the relationship between disease severity and illness intrusiveness among chronically ill patients

Reducing perceptions of illness intrusiveness may improve quality of life and mental health among patients with cardiopulmonary disease. To better understand relationships between coping style, locus of control, perceived illness intrusiveness, and disease severity, we analyzed data from 227 older Veterans with chronic obstructive pulmonary disease or congestive heart failure. Regressions revealed illness intrusiveness to be associated with younger age and greater disease severity, less internal locus of control, and avoidant/emotion-focused coping. Avoidant/emotion-focused coping but not active coping mediated the relationship between illness severity and illness intrusiveness. Findings suggest that supportive psychological interventions may reduce illness intrusiveness by targeting an avoidant/emotion-focused coping style and associated behaviors.

Assessment and Documentation of Sexual Health Issues of Recent Combat Veterans Seeking VHA Care

INTRODUCTION Sexual health is an important aspect of human existence associated with disease and overall health. Despite these associations and the existence of medical treatments to improve sexual function, sexual health is often overlooked in health care. Recent combat veterans may be particularly vulnerable to sexual health issues due to their deployment-related health issues such as mental health conditions, prescription medications use, and psychosocial challenges. AIM This study assesses the sexual health issues of recent combat veterans seeking care at a Veterans Affairs Medical Center (VAMC) documented in the primary care and mental health notes from the first 6 months of care. MAIN OUTCOME MEASURES Documentation of sexual health issues in the progress notes (coded into categories), primary care vs. mental health care visit note, initial vs. follow-up visit notes, and templated vs. non-templated text. METHODS This is a retrospective chart review of the first 158 consecutive patients seen for an initial assessment in the VAMC post-deployment clinic. Medical records were reviewed and text of sexual health issues and relevant patient and care characteristics were abstracted and coded into variables. RESULTS Almost 25% of patients had documented sexual health issues in the first 6 months of care. We coded 52 separate sexual health issues into 13 distinct categories. Overall, most sexual health issues were documented in mental health care notes, in non-templated text, and at follow-up visits. The use of templated text appeared to drive the documentation of low libido (the most common sexual health issue) in mental health care notes. CONCLUSIONS Sexual health issues are prevalent in recent combat veterans seeking care at a VAMC, but patterns of documentation suggest that they may be under-reported or incompletely addressed. A more systematic and provider-initiated approach to assessment of sexual health may promote fuller discussion of sexual health issues and optimize management.

Multidisciplinary cognitive-behavioral therapy training for the veterans affairs primary care setting.

OBJECTIVE Current research highlights the need to embed evidence-based psychotherapies such as cognitive-behavioral therapy (CBT) within primary care settings. Few studies have examined CBT training procedures, and no studies have examined the impact of CBT training in the primary care setting. The current study sought to describe and assess the feasibility and effectiveness of a focused CBT training program for a diverse sample of primary care mental health providers in the Department of Veterans Affairs (VA). METHOD A multidisciplinary group of 28 mental health clinicians from 6 VA medical centers and 15 community-based outpatient clinics received an intensive 1½-day CBT workshop, held in Houston, Texas, in May 2008, including didactic presentations, expert modeling, and small-group role plays. CBT experts also provided biweekly follow-up group telephone consultation calls for participants over 12 weeks to aid in development of CBT skills. Participant program evaluation surveys and self-reported CBT knowledge, ability, and utilization were measured preworkshop, postworkshop, and 3 months postworkshop. Analyses compared mean change scores at baseline to those at 3-month follow-up. Wilcoxon signed rank tests were completed, and Cohen d effect-size calculations were also computed. RESULTS Statistical analyses found that participant self-reported CBT knowledge (P < .01, effect size [ES] = 0.49) was significantly improved postworkshop and maintained at 3-month follow-up. Self-reported abilities were also improved (P = .07, ES = 0.40). The potency of the training experience appeared to be enhanced by the multimodal nature of the program. CONCLUSION Although challenges exist, focused and intensive training in CBT appears feasible for multidisciplinary mental health practitioners in the primary care setting.