Nicholas W. Bowersox

Pain conditions among veterans with schizophrenia or bipolar disorder

OBJECTIVE The purpose of this study was to assess the rates of chronic, noncancer pain conditions in patients with schizophrenia or bipolar disorder within the Veterans Health Administration (VHA) System. METHOD This cross-sectional study used administrative data extracted from VHA treatment records of all individuals receiving VHA services in fiscal year 2008 (N=5,195,551). The associations between severe psychiatric disorders (schizophrenia and bipolar disorder) and chronic pain (arthritis, back pain, chronic pain, migraine, headache, psychogenic and neuropathic) were evaluated using a series of logistic regression analyses. RESULTS Veterans with schizophrenia [odds ratio (OR)=1.21] and bipolar disorder (OR=2.17) were significantly more likely to have chronic pain overall relative to veterans without these psychiatric conditions. These associations were slightly lower than for the association between depression and pain in this sample (OR=2.61). The highest associations between specific psychiatric diagnosis and pain condition were found with chronic pain, headache and psychogenic pain. CONCLUSIONS Noncancer pain conditions occur in elevated rates among patients with schizophrenia and bipolar disorder. Future research could further examine possible barriers to adequate pain treatment among people with serious mental illness, as well as the extent to which chronic pain might impact mental health recovery.

Does colocated care improve access to cardiometabolic screening for patients with serious mental illness

OBJECTIVE Individuals with serious mental illness (SMI; e.g., schizophrenia, bipolar disorder) experience disparities in mortality relative to the general population, mainly because of medical conditions (i.e., cardiometabolic disease).We assessed whether VA patients with SMI and receiving care from VA mental health facilities with colocated medical care were more likely to receive cardiometabolic risk assessments in accordance with clinical practice guidelines than patients from noncolocated facilities. METHODS Patients with SMI identified prescribed second-generation antipsychotic medications in fiscal year (FY) 2007 receiving care from VA mental health facilities completing the VA Mental Health Program Survey were included. VA administrative data were ascertained to assess receipt of the following tests every 6 months in FY 2007: body mass index (BMI), blood pressure, lipid profile and fasting glucose. RESULTS Out of 40,600 patients with SMI prescribed second-generation antipsychotics, 29% received all cardiometabolic tests (lipid, glucose, BMI and blood pressure). While 79% and 76% received blood pressure and BMI assessments, respectively, only 37% received a lipid test. Patients from colocated sites were more likely to receive all cardiometabolic tests (odds ratio=1.26, 95% confidence interval: 1.18-1.35, P<.001). CONCLUSIONS Colocated general medical providers in mental health clinics are more likely to provide cardiometabolic assessments for patients with SMI prescribed second-generation antipsychotics.

Design and rationale of a randomized controlled trial to reduce cardiovascular disease risk for patients with bipolar disorder

BACKGROUND Persons with bipolar disorder (BD) experience a disproportionate burden of medical comorbidity, notably cardiovascular disease (CVD), contributing to decreased function and premature mortality. We describe the design, rationale, and baseline findings for the Self-Management Addressing Heart Risk Trial (SMAHRT), a randomized controlled effectiveness trial of an intervention (Life Goals Collaborative Care; LGCC) designed to reduce CVD risk factors and improve physical and mental health outcomes in patients with BD. METHODS Patients with BD and at least one CVD risk factor were recruited from a VA healthcare system and randomized to either LGCC or usual care (UC). LGCC participants attended four weekly, group-based self-management sessions followed by monthly individual contacts supportive of health behavior change and ongoing medical care management. In contrast, UC participants received monthly wellness newsletters. Physiological and questionnaire assessments measured changes in CVD outcomes and quality of life (QOL) over 24 months. RESULTS Out of the 180 eligible patients, 134 patients were enrolled (74%) and 118 started the study protocols. At baseline (mean age=54, 17% female, 5% African American) participants had a high burden of clinical risk with nearly 70% reporting at least three CVD risk factors including, smoking (41%) and physical inactivity (57%). Mean mental and physical HRQOL scores were 1.5 SD below SF-12 population averages. CONCLUSION SMAHRT participants experienced substantial CVD morbidity and risk factors, poor symptom control, and decreased QOL. LGCC is the first integrated intervention for BD designed to mitigate suboptimal health outcomes by combining behavioral medicine and care management strategies.

Reengaging Veterans With Serious Mental Illness Into Care: Preliminary Results From a National Randomized Trial

OBJECTIVE This study compared effectiveness of an enhanced versus standard implementation strategy (Replicating Effective Programs [REP]) on site-level uptake of Re-Engage, a national program for veterans with serious mental illness. METHODS Mental health providers at 158 Veterans Affairs (VA) facilities were given REP-based manuals and training in Re-Engage, which involved identifying veterans who had not been seen in VA care for at least one year, documenting their clinical status, and coordinating further health care. After six months, facilities not responding to REP (N=88) were randomized to receive six months of facilitation (enhanced REP) or continued standard REP. Site-level uptake was defined as percentage of patients (N=1,531) with updated documentation or with whom contact was attempted. RESULTS Rate of Re-Engage uptake was greater for enhanced REP sites compared with standard REP sites (41% versus 31%, p=.01). Total REP facilitation time was 7.3 hours per site for six months. CONCLUSIONS Added facilitation improved short-term uptake of a national mental health program.

Leading from the Middle: Replication of a Re-Engagement Program for Veterans with Mental Disorders Lost to Follow-Up Care

Objectives. Persons with mental disorders experience functional impairments and premature mortality. Limited continuity of care may contribute to disparities in this group. We describe the replication of an evidence-based outreach program (Re-Engage) to reconnect Veterans with mental disorders into care who have dropped out of services. Methods. Using the Enhanced Replicating Effective Programs framework, population-based registries were used to identify Veterans lost-to-care, and providers used this information to determine Veteran disposition and need for care. Providers recorded Veteran preferences, health status, and care utilization, and formative process data was collected to document implementation efforts. Results. Among Veterans who dropped out of care (n = 126), the mean age was 49 years, 10% were women, and 29% were African-American. Providers determined that 39% of Veterans identified for re-engagement were deceased, hospitalized, or ineligible for care. Of the remaining 68 Veterans, outreach efforts resulted in contact with 20, with 7 returning to care. Providers averaged 14.2 hours over 4 months conducting re-engagement services and reported that gaining facility leadership support and having service agreements for referrals were essential for program implementation. Conclusions. Population-level, panel management strategies to re-engage Veterans with mental disorders are potentially feasible if practices are identified to facilitate national rollout.

Preferences and Barriers to Care Following Psychiatric Hospitalization at Two Veterans Affairs Medical Centers: A Mixed Methods Study

Patient preferences and barriers to care may impact receipt of adequate mental health treatment following psychiatric hospitalization and could inform quality improvement initiatives. This study assessed preferences for a broad range of post-hospital services and barriers to counseling by surveying 291 patients and interviewing 25 patients who had recently been discharged from an inpatient psychiatric stay at one of the two Veterans Affairs Medical Centers. Individual counseling was the most frequently reported service that survey respondents preferred, but did not receive; whereas, open-ended survey responses and interviews also identified telephone follow-up “check-in” calls as a frequently preferred service. Difficulty with transportation was the most commonly cited barrier to counseling among survey respondents and in interviews; however, patients strongly preferred in-person counseling to telephone or internet-video alternatives. Increasing support from family and support from an individual Veteran peer were also perceived to be helpful in the majority of survey respondents.

Service Utilization Among Veterans With Schizophrenia and a Comorbid Anxiety Disorder

OBJECTIVE The objective was to assess the prevalence and impact of anxiety disorders on service utilization among Veterans Health Administration (VHA) patients with schizophrenia. METHODS This cross-sectional study examined diagnostic, utilization, and medication records included in the VHA National Psychosis Registry. Relationships between schizophrenia and anxiety disorders were evaluated along demographic and service utilization dimensions. RESULTS During fiscal year 2011, 23.8% (N=20,722) of 87,006 VHA patients with schizophrenia were diagnosed as having a comorbid anxiety disorder; 15.2% of the sample had a posttraumatic stress disorder (PTSD) diagnosis and 8.6% a non-PTSD anxiety disorder. Comorbid anxiety disorders were associated with increased psychiatric comorbidity (depression, personality disorder, and substance use disorder), higher rates of psychiatric and medical hospitalization, and increased utilization of outpatient mental health services. CONCLUSIONS Anxiety disorders are common among individuals with schizophrenia within the VHA and appeared in this study to convey additional disability in terms of psychiatric comorbidity and the need for increased psychiatric care. Future research should investigate ways to improve detection and enhance treatment provided to this population.

Cause-specific mortality among Veterans with serious mental illness lost to follow-up

OBJECTIVE Although reduced care engagement has been linked to increased mortality for persons with serious mental illness (SMI), there have been limited investigations into specific mortality causes for this group. This study evaluates the effects of care disengagement on mortality cause and time until death in Veterans with SMI. METHOD A total of 3300 Veterans with SMI lost to Veterans Affairs care for more than 1 year were contacted by providers who attempted treatment reengagement. Fishers Exact Tests evaluated associations between mortality cause and reengagement status, and a Cox proportional hazard model evaluated the association between reengagement and survival. RESULTS During the study, 146 (4.6%) patients died. A lack of reengagement was associated with increased noninjury death [odds ratio (OR)=1.64], increased cancer-based mortality (OR=4.76) and an average of 97.4 fewer days of life. CONCLUSIONS Care reengagement may support medical care management and reduce preventable medical mortality for Veterans with SMI.

Associations Between Psychiatric Inpatient Bed Supply and the Prevalence of Serious Mental Illness in Veterans Affairs Nursing Homes

OBJECTIVES We assessed whether reductions in inpatient psychiatric beds resulted in transinstitutionalization to nursing home care of patients with serious mental illness (SMI) within the Veterans Health Administration (VHA). METHODS We assessed trends in national and site-level inpatient psychiatric beds and nursing home patient demographics, service use, and functioning from the VHA National Patient Care Database, VHA Service Support Center Bed Control, and VHA Minimum Data Set. We estimated nursing home admission appropriateness using propensity score analyses based on Michigan Medicaid Nursing Facility Level of Care Determinations ratings. RESULTS From 1999 to 2007, the number of VHA inpatient psychiatric beds declined (43,894-40,928), the average inpatient length of stay decreased (33.1-19.0 days), and the prevalence of SMI in nursing homes rose (29.4%-43.8%). At site level, psychiatric inpatient bed availability was unrelated to SMI prevalence in nursing home admissions. However, nursing home residents with SMI were more likely to be inappropriately admitted than were residents without SMI (4.0% vs 3.2%). CONCLUSIONS These results suggest the need for increased attention to the long-term care needs of individuals with SMI. Additional steps need to be taken to ensure that patients with SMI are offered appropriate alternatives to nursing home care and receive adequate screening before admission to nursing home treatment.

Innovating team-based outpatient mental health care in the Veterans Health Administration: Staff-perceived benefits and challenges to pilot implementation of the Behavioral Health Interdisciplinary Program (BHIP).

In the past decade, the demand for Veterans Health Administration (VHA) mental health care has increased rapidly. In response to the increased demand, the VHA developed the Behavioral Health Interdisciplinary Program (BHIP) team model as an innovative approach to transform VHA general outpatient mental health delivery. The present formative evaluation gathered information about pilot implementation of BHIP to understand the struggles and successes that staff experienced during facility transitions to the BHIP model. Using a purposive, nonrandom sampling approach, we conducted 1-on-1, semistructured interviews with 37 licensed and nonlicensed clinical providers and 13 clerical support staff assigned to BHIP teams in 21 facilities across the VHA. Interviews revealed that having actively involved facility mental health leaders, obtaining adequate staffing for teams to meet the requirements of the BHIP model, creating clear descriptions and expectations for team member roles within the BHIP framework, and allocating designated time for BHIP team meetings challenged many VHA sites but are crucial for successful BHIP implementation. Despite the challenges, staff reported that the transition to BHIP improved team work and improved patient care. Staff specifically highlighted the potential for the BHIP model to improve staff working relationships and enhance communication, collaboration, morale, and veteran treatment consistency. Future evaluations of the BHIP implementation process and BHIP team functioning focusing on patient outcomes, organizational outcomes, and staff functioning are recommended for fully understanding effects of transitioning to the BHIP model within VHA general mental health clinics and to identify best practices and areas for improvement. (PsycINFO Database Record