Suicide Risk Documented During Veterans' Last Veterans Affairs Health Care Contacts Prior to Suicide

A total of 295 veterans who died by suicide in 2009 across 11 states and received Veterans Affairs (VA) health care in the 6 months prior to death were identified. The suicide risk factors documented and the care received at these veterans' last VA contacts are described, and the study explores whether veterans present differently to VA care (i.e., different risk factors documented or different care settings accessed) based on the proximity of their last contact to suicide. Many veterans were seen in primary care (n = 136; 46%) for routine follow‐up (n = 168; 57%). Fifty‐three (18%) were assessed for suicidal thoughts; 20 (38%) of whom endorsed such thoughts. Although higher frequencies of some risk factors at last contacts more proximal to suicide compared to those more distal were observed, findings overall highlight the challenges clinicians face detecting enhanced risk prior to suicide.     

Improving Mental Health Treatment Utilization in Military Veterans: Examining the Effects of Perceived Need for Care and Social Support

Many veterans with mental health problems do not adequately utilize needed care. Research has focused on identifying barriers to mental health care in veterans. The current study adds to existing literature by examining whether perceived need for treatment and social support affect treatment utilization in a national longitudinal survey of Iraq and Afghanistan veterans (n = 1,090). The Health Beliefs Model (HBM) postulates that a key reason why patients fail to obtain needed care is their belief “it’s up to me to handle my own problems.” This view was endorsed by 42% in the current national sample of veterans and was found in multivariate analysis to predict less treatment seeking in the next year. Mediation analysis revealed that veterans with higher ratings of social support were less likely to believe they needed to solve mental health problems on their own, indirectly equating to higher odds of treatment use. Simultaneously, findings indicated that posttraumatic stress disorder (PTSD) had a direct effect on more mental health visits but was also associated with higher endorsement that one needed to handle one’s own problems and thus had an indirect effect of reducing mental health visits. Both social support and PTSD affected veterans’ perceptions of needing to solve one’s own problems, significantly predicted follow-up with mental health care. As a result, the findings indicate that clinicians’ should explore veterans’ belief systems about perceived treatment need as well as investigate the role of social support to improve mental health treatment utilization.     

Managing Behavioral Health Needs of Veterans with Traumatic brain injury (TBI) in Primary Care

Traumatic brain injury (TBI) is a frequent occurrence in the United States, and has been given particular attention in the veteran population. Recent accounts have estimated TBI incidence rates as high as 20 % among US veterans who served in Afghanistan or Iraq, and many of these veterans experience a host of co-morbid concerns, including psychiatric complaints (such as depression and post-traumatic stress disorder), sleep disturbance, and substance abuse which may warrant referral to behavioral health specialists working in primary care settings. This paper reviews many common behavioral health concerns co-morbid with TBI, and suggests areas in which behavioral health specialists may assess, intervene, and help to facilitate holistic patient care beyond the acute phase of injury. The primary focus is on sequelae common to mild and moderate TBI which may more readily present in primary care clinics.     

Behavioral Health Services Influence Medical Treatment Utilization Among Primary Care Patients with Comorbid Substance Use and Depression

Although research has shown benefits of integrating psychological care in primary care settings, it is unclear how this form of treatment impacts individuals with comorbid substance use and depression. The findings are also mixed concerning how frequently this comorbid population seeks primary care services. This study examined the associations between substance use, depression, and medical treatment utilization among 224 primary care patients. The aim of the investigation was twofold. First, to determine if depression increases medical treatment utilization among patients with substance use disorders; second, to evaluate if behavioral health treatment reduces medical service utilization. A moderated mediation model with bootstrapping analyses revealed that depression strengthened the relationship between substance use and primary care treatment utilization (both medical and behavioral health). The model also indicated that behavioral health services were associated with fewer primary care visits for individuals with comorbid substance use and depression. Clinical and social implications are discussed.     

Identifying Unmet Mental Health Needs in Children of Formerly Homeless Mothers Living in a Supportive Housing Community Sector of Care

This study reports psychosocial characteristics of a sample of 111 children (K to 2nd grade) and their mothers who were living in urban supportive housings. The aim of this study was to document the various types and degree of risk endemic to this population. First, we describe the psychosocial characteristics of this homeless sample. Second, we compared this homeless sample with a grade-matched, high-risk, school-based sample of children (n = 146) who were identified as showing early symptoms of disruptive behaviors. Third, we compared the parents in both samples on mental health, parenting practices, and service utilization. Results showed that children living in supportive housing were in the at-risk range and had comparable levels of externalizing problems, internalizing problems, school problems and emotional strengths with the school-based risk sample receiving prevention services at a family support community agency. Mothers in supportive housing reported significantly higher psychological distress, less optimal parenting practices and greater service utilization. These findings are among the first to provide empircal support for the need to deliver prevention interventions in community sectors of care.     

The Effect of Racial and Ethnic Diversity on the Delivery of Mental Health Services in Pediatric Primary Care

The effects of racial and ethnic diversity on the detection and management of behavioral and emotional problems in pediatric primary care are addressed. Service access and utilization as a function of race and culture are initially examined. Important barriers within pediatric training including minimal emphases on behavioral training and the limited supply of minority physicians are underscored. The impact of ethnicity on the development and maintenance of the clinical relationship that is critical to accurately and sensitively identifying and managing behavioral and developmental problems is briefly addressed. Recommendations for further integration of racial/ethnic issues into mental health service provision within the pediatric primary care arena are presented.     

Co-Occurring Traumatic Brain Injury,PTSD Symptoms,and Alcohol Use in Veterans

Traumatic brain injury (TBI) has been identified as a significant health problem among veterans. Recent research demonstrates the potential interaction and magnification of symptoms of posttraumatic stress disorder (PTSD) and substance use disorders (SUD) in veterans with a history of TBI; however, there is very limited research on the co-occurrence of the three conditions. Veterans (N = 115) with comorbid PTSD and SUD completed a baseline assessment for enrollment into a larger treatment study. As part of that assessment, participants completed a TBI screener as well as self-report measures for pain and physical health, affective symptoms, and substance use. Almost half of the sample (48 %) endorsed a history of a previous head trauma with loss of consciousness (LOC). Participants with and without head trauma with LOC were compared across various measures of functioning. Increased severity of physical health complaints and affective symptoms were reported by the TBI group compared to controls. However, the increases in affective symptoms were relatively small. No group differences were observed for alcohol use. Together, the findings suggest that treatment-seeking veterans with a history of head trauma with LOC may present with roughly equivalent symptoms of PTSD and SUD to those without said history.     

The Starting Early Starting Smart Integrated Services Model: Improving Access to Behavioral Health Services in the Pediatric Health Care Setting for At-Risk Families with Young Children

We evaluated the Starting Early Starting Smart (SESS) national initiative to integrate behavioral health services (parenting, mental health, and drug treatment) into the pediatric health care setting for families with young children. Data are presented from five pediatric care (PC) sites, drawing from families at risk due to demographic and behavioral health factors, with infants less than 12 months of age (n = 612). Families were randomly assigned to either the SESS program or a standard care Comparison group. We utilized longitudinal analyses to estimate differences in utilization rates for parenting, mental health, and drug treatment over 6 follow-up time points (3, 6, 9, 12, 15 and 18 months). Our findings indicate that SESS caregiver participants were 4.6 times (p < 0.001; CI = 3.33–6.26) more likely to receive parenting services, 2.1 times (p < 0.001; CI = 1.48–2.86) more likely to receive outpatient mental health treatment, and 1.8 times (p = 0.025; CI = 1.08–3.14) more likely to receive drug treatment than Comparison group participants. Our results demonstrate the success of the SESS program in coordinating and improving access to behavioral health services for high-risk caregivers within the pediatric health care setting and highlight the importance of continuing to focus public health policy on the behavioral health care needs of families with young children.     

Health-Related Outcomes Associated with Patterns of Risk Factors in Primary Care Patients

It is important to find ways to identify prevalent co-occurring health risk factors to help facilitate treatment programming. One method is to use electronic medical record (EMR) data. Funderburk et al. (J Behav Med 31:525–535, 2008) used such data and latent class analysis to identify three classes of individuals based on standard health screens administered in Veterans Affairs primary care clinics. The present study extended these results by examining the health-related outcomes for each of these identified classes. Follow-up data were collected from a subgroup of the original sample (N = 4,132). Analyses showed that class assignment predicted number of diagnoses associated with the diseases that the health screens target and number of primary care behavioral health, and emergency room encounters. The findings illustrate one way an EMR can be used to identify clusters of individuals presenting with multiple health risk factors and where the healthcare system comes in contact with them.     

Delivering Parent Management Training in an Integrated Primary Care Setting: Description and Preliminary Outcome Data

This paper describes how behavioral health consultants (BHCs) in an integrated primary care setting use evidence-based principles that underlie parent management training (PMT) to assist caregivers of youth with externalizing behavior problems. Illustrated is the decision-making process that BHCs utilize from the moment they receive a patient referral from a primary care provider to how interventions are selected and delivered. When delivering PMT in integrated care, operant-based learning principles underlying PMT are often selected based on a combination of factors, including match with presenting problem, caregiver efficacy, caregiver beliefs about the causes and maintaining factors, and feasibility of implementation. We further present preliminary outcome data on the effectiveness of BHCs’ efforts to use PMT principles in a primary care setting. Participants were 21 caregivers and their children (M_age = 7.76 years, 38.1% female; 66.7% Hispanic) seen for an average of 2.38 visits. Pre-post data provided by caregivers (for youth 11 years or younger) and adolescents (self-report of patients 12–17 years of age) taken at the time of first and last sessions revealed significant reductions in global distress scores and high levels of satisfaction with services received. Findings support the viability of providing brief, focused PMT interventions for pediatric populations seen in primary care.     

Primary Care Medical Provider Attitudes Regarding Mental Health and Behavioral Medicine in Integrated and Non-integrated Primary Care Practice Settings

Primary care medical providers (PCPs) have become de facto providers of services for the management of both mental and chronic illnesses. Although some reports suggest that PCPs favor having Behavioral Health colleagues provide behavioral health services in primary care, others demonstrate this view is necessarily not universal. We examined attitudes regarding behavioral health services among PCPs in practices that offer such services via onsite behavioral health providers (n = 31) and those that do not (n = 62). We compared referral rates and perceived need for and helpfulness of behavioral health colleagues in treating mental health/behavioral medicine issues. In both samples, perceived need was variable (5?C100%), as were PCPs?? views of their own competence in mental health/behavioral medicine diagnosis and treatment. Interestingly, neither sample rated perceived access to behavioral health providers exceptionally high. Referral rates and views about the helpfulness of behavioral health services, except in relation to depression and anxiety, were lower than expected. These results suggest a need for increased collaboration with and education of PCPs about the roles and skills of behavioral health professionals.     

Social anxiety disorder in veterans affairs primary care clinics

To examine the prevalence and correlates of social anxiety disorder (SAD) in veterans, 733 veterans from four VA primary care clinics were evaluated using self-report questionnaires, telephone interviews, and a 12-month retrospective review of primary care charts. We also tested the concordance between primary care providers’ detection of anxiety problems and diagnoses of SAD from psychiatric interviews. For the multi-site sample, 3.6% met criteria for SAD. A greater rate of SAD was found in veterans with than without post-traumatic stress disorder (PTSD) (22.0% vs. 1.1%), and primary care providers detected anxiety problems in only 58% of veterans with SAD. The elevated rate of comorbid psychiatric diagnoses and suicidal risk associated with SAD was not attributable to PTSD symptom severity. Moreover, even after controlling for the presence of major depressive disorder, SAD retained unique, adverse effects on PTSD diagnoses and severity, the presence of other psychiatric conditions, and suicidal risk. These results attest to strong relations between SAD and PTSD, the inadequate recognition of SAD in primary care settings, and the significant distress and impairment associated with SAD in veterans.     

Nonsuicidal Self‐Injury among Adolescents: A Training Priority for Primary Care Providers

Primary care providers were surveyed to determine how prepared they feel to address nonsuicidal self‐injury (NSSI) among adolescents, their interest in training on NSSI, and factors associated with routinely asking about NSSI when providing health supervision. Participants included family medicine physicians (n = 260), pediatricians (n = 127), family nurse practitioners (n = 96), and pediatric nurse practitioners (n = 54). Almost 50% felt unprepared to address NSSI, and over 70% wanted training in this area. Overall, relative to other areas of mental health care, clinicians felt least prepared to address and wanted more training on NSSI. Just 27% reported they routinely inquired about NSSI during health supervision. Factors associated with routinely asking about NSSI were identifying as female (OR = 2.37; 95% CI = 1.25–4.49), feeling better prepared to address NSSI (OR = 1.51; 95% CI = 1.04–2.20), and more frequently using a psychosocial interview to identify adolescents in distress (OR = 1.23; 95% CI = 1.02–1.48). Teaching clinicians to assess NSSI within a psychosocial interview may increase screening for and identification of the behavior among adolescents in primary care.     

Behavioral Health Consultation and Primary Care: Lessons Learned

This article provides an overview of 20 years of professional experiences with developing and implementing a model for integrating behavioral health services into primary care. The Primary Care Behavioral Health (PCBH) model is designed to provide immediate access to behavioral care for a large number of primary care patients by positioning a behavioral health consultant in the exam room area to function as a core member of the primary care team. In an initial era of discovery, the authors were directly involved in developing and testing a variety of new approaches to providing behavioral health services in general medicine. In a second era focused on feasibility, the authors worked with Kaiser Permanente, the United States Air Force and Navy, the Veteran’s Administration, and the Bureau of Primary Care to system test this innovative model of integrated care. Now in an era devoted to dissemination, the authors review the various roles formal research, system level quality improvement initiatives and stakeholder analysis play in promoting integrated care. The authors also describe current efforts to (1) create a tool that helps systems develop integration targets and (2) use the PCBH model as a platform for teaching medical residents and behavioral health providers to work together in a redesigned primary care team model.     

Factor Structure of the PTSD Checklist in a Sample of OEF/OIF Veterans Presenting to Primary Care: Specific and Nonspecific Aspects of Dysphoria

Although DSM-IV-TR diagnostic criteria for posttraumatic stress disorder (PTSD) include three primary symptom clusters, recent evidence from confirmatory factor analyses suggest that the latent structure of PTSD is better represented by four factors, which will likely be reflected in the upcoming DSM-5. Given this likely transition from three to four clusters, the present study sought to examine specific and non-specific aspects of dysphoria in the factor structure of PTSD symptoms in a sample of OEF/OIF combat veterans presenting to a Veterans Affairs primary care clinic. PTSD symptoms were assessed using the PCL-M (Weathers et al. 1993). Results from confirmatory factor analyses suggested that a dysphoria factor involving a number of non-specific distress symptoms may be an important part of the PTSD symptom profile. After controlling for variance due to general psychological distress, we further found that factor loadings on the dysphoria factor were attenuated but continued to significantly load onto the factor, suggesting that dysphoria may be a specific part of the PTSD symptom constellation.     

Meta‐Analysis of Integrated Primary and Behavioral Health Care Interventions for Treating Substance Use Among Adults

This meta‐analysis detected low effects in reducing substance use (Hedges's g = –0.11) in favor of using integrated primary and behavioral health care (IPBH) compared with treatment‐as‐usual approaches for adult patients with substance use. The impact of IPBH was limited.     

Cognitive Behavioral Treatment for Insomnia in Veterans with Long-Standing Posttraumatic Stress Disorder: A Pilot Study

This uncontrolled pilot study assessed the effects of cognitive behavioral therapy for insomnia in veterans with long-standing posttraumatic stress disorder. Male veterans with current chronic insomnia and PTSD (n?=?8; M age = 58.6, SD?=?3.0; 87.5% African American, 12.5% European American; 87.5% Vietnam Veterans, 12.5% 1st Gulf War Veterans) reported a trauma related to their military service. Participants appeared for five weekly individual sessions of cognitive behavioral therapy for insomnia and completed one-week assessments of objective sleep (actigraphy) and subjective sleep (sleep diaries), the Insomnia Severity Index, and measures of functioning, posttraumatic stress disorder, and psychological distress both before and after treatment. Paired t tests revealed significant posttreatment improvements for various subjective assessments of sleep patterns but actigraphy-defined sleep was unchanged. Measures of functioning, nightmares, and posttraumatic stress disorder severity were also unchanged at posttreatment. Preliminary results were encouraging in improving subjective perceptions of sleep in individuals with posttraumatic stress disorder, warranting further study with more rigorous methodology.     

Emerging Adulthood and Leaving Foster Care: Settings Associated with Mental Health

The present study examined the role of contextual support on mental health during the transition to adulthood within a vulnerable group, adolescents leaving foster care because of their age. Participants were 265 19- to 23-year-olds who retrospectively reported on 3 main contexts of emerging adulthood: housing security, educational achievement, and employment attainment in the first 2 years after leaving foster care. Mental health measured self-reported emotional distress, substance abuse, and deviancy at the time of interview. Growth Mixture Modeling empirically identified 3 latent trajectory classes. Stable-Engaged (41%) experienced secure housing and increasing connections to education and employment over time. Stable-Disengaged (30%) maintained housing but reported decreasing rates of education and small increases in employment. Instable-Disengaged (29%) experienced chronic housing instability, declined connection to education, and failed to attain employment. Stable-Engaged and Stable-Disengaged classes reported better mental health compared to the Instable-Disengaged class, indicating the importance of housing in transitioning to adulthood.     

Psychological Functioning of Partners of Australian Combat Veterans: Contribution of Veterans' PTSD Symptoms and Partners' Caregiving Distress

Previous research has found posttraumatic stress disorder (PTSD) symptoms in combat veterans to be associated with impaired psychological functioning in their partners. However, little is known about possible mediators of this association. The present study investigated the mediational properties of six dimensions of the revised Partners of Veterans' Distress Scale (MacDonell, Marsh, Hine, & Bhullar, 2010). Participants were 181 female partners of Australian combat veterans, age ranging from 43 and 83 years (M = 60.47, SD = 4.96), who completed measures assessing their caregiving distress levels, dyadic adjustment, mental health, and satisfaction with life. The combat veterans also completed a scale measuring their PTSD symptoms. Our results indicated that higher scores of veterans' PTSD were associated with lower levels of dyadic adjustment, mental health, and satisfaction with life in their partners. Partners reported that distress related to exhaustion and intimacy problems significantly mediated the relationship between veterans' PTSD symptoms and their partners' satisfaction with life, whereas partners' distress associated with intimacy problems was the sole significant mediator for their dyadic adjustment, and exhaustion was the only significant mediator for partners' mental health. Implications for programmes designed to address the significant needs of the partners of combat veterans are discussed.     

Social Control of Health Behaviors in Marriage1

Married couples (N= 69) reported on their use of social control strategies in attempting to modify each other's health behaviors, as well as their affective and behavioral responses to experiencing health‐related social control. Experiencing more negative social control was associated with the tendency to engage in potentially health‐compromising behaviors, whereas experiencing positive social control was associated with attempts to engage in the desired behavior. Most associations between experiencing social control and the target's behavioral responses could be accounted for, at least partially, by the target's affective responses to the social control attempts. These results suggest that current conceptualizations of the health‐relevance of social control are in need of revision. Implications of these results for social control measurement and theory are discussed.