PMCC PMCC

Search tips
Search criteria

Advanced
Results 1-25 (1908368)

Clipboard (0)
None

Related Articles

1.  Characteristics of Veterans Accessing the Veterans Affairs Telephone Triage Who Have Depression or Suicidal Ideation: Opportunities for Intervention 
Objective
To characterize Veterans who call telephone triage because of suicidal ideation (SI) or depression and to identify opportunities for suicide prevention efforts among these telephone triage users using a biosurveillance application.
Introduction
Veterans accessing Veterans Affairs (VA) health care have higher suicide rates and more characteristics associated with suicide risk, including being male, having multiple medical and psychiatric comorbidities, and being an older age, compared with the general U.S. population. The Veterans Crisis Line is a telephone hotline available to Veterans with urgent mental health concerns; however, not all Veterans are aware of this resource. By contrast, telephone triage is a national telephone-based triage system used by the VA to assess and triage all Veterans with acute medical or mental health complaints.
Methods
The VA Electronic Surveillance System for Early Notification of Community-based Epidemics (ESSENCE) was queried for telephone triage calls during January 1–June 30, 2012. Calls were classified as SI or depression when the triage nurse selected SI or depression as the Veteran’s chief complaint from a set of fixed options. Demographic and recommended follow-up time and location information was reviewed. A random sample of 20 SI calls and 50 depression calls were selected for chart review to determine whether Veterans were examined in a clinic or followed up by a clinician by telephone within 2 weeks of the veteran’s call.
Results
During January 1–June 30, 2012, 253,573 total calls were placed to telephone triage. Among these calls, 2,460 unique Veterans placed 417 calls for SI and 2,290 calls for depression. This represents 1% (2,707/253,573) of all calls placed during the period. All encounter information is available in the surveillance application within 24 hours of the call being placed. Median age of callers was 55 years (range: 19–94); 86% were male; and 6% placed repeat calls. The median number of repeat calls was 2 (range: 2–10). Among the 2,707 calls for SI or depression, 1,286 (48%) were made after routine business hours (5:00 p.m.–8:00 a.m.), and 646 (24%) were made on weekends. The greatest proportion of calls were from Wisconsin and Northern Illinois (17%) and the Southeastern United States (14%). Among the 2,290 calls for depression, 1,401 callers (61%) were recommended for urgent follow up or within 24 hours. 771 (34%) were assigned a follow up location of an emergency department; 117 (5%) an urgent care; 1,332 (58%) a physician’s office or clinic; 52 (2%) self-care at home; and 18 (1%) were unspecified. Among the 417 calls for SI, callers 410 (98%) were recommended for urgent follow-up or within 24 hours. 330 (79%) were assigned a follow-up location of an emergency department; 38 (9%) an urgent care; 43 (10%) a physician’s office or clinic; 3 (1%) self-care at home; and 3 (1%) unspecified. Among the 20 SI and 50 depression calls for which the charts were reviewed, 1 (5%) SI call and 6 (12%) depression calls had no documented follow-up by telephone or in person with a clinician within 2 weeks of initial call.
Conclusions
Telephone triage represents an additional data source available to surveillance applications. Although telephone triage is not the traditional method provided by the VA for triage of urgent mental health concerns, >2,000 Veterans called it with acute symptoms of SI or depression during January–June 2012. Training for suicide prevention should be prioritized for operators working during the high-volume periods of off-hours and weekends when approximately half and one-quarter of calls were received, respectively. We recommend standard notification of suicide prevention coordinators regarding calls to telephone triage for SI or depression to prevent loss to follow-up among Veterans at risk for suicide. Further investigation into reasons for increased call burden in identified geographic areas also is recommended.
PMCID: PMC3692783
Surveillance; Veterans; Suicide Risk
2.  Age-Related Concerns of Male Veteran Callers to a Suicide Crisis Line 
In July 2007, the United States Department of Veterans Affairs (VA) partnered with the Department of Health and Human Services’ Substance Abuse and Mental Health Service Administration (SAMHSA) to create the Veterans Crisis Line (VCL) in order to meet the unique needs of Veterans in distress. The current study utilized a mixed methods design to examine characteristics of male callers to the VCL. Results from qualitative analyses demonstrated that the majority of callers between April 1 and August 31, 2008 contacted the VCL with concerns related to mental health issues, suicide ideation, and substance abuse issues. Quantitative analyses demonstrated age differences associated with concerns presented by callers such that middle-aged and older callers were more likely to present with loneliness and younger callers were more likely to present with mental health concerns. The results of this study will help to inform future research designed to optimize the effectiveness of the VCL for suicide prevention in Veterans.
doi:10.1080/13811118.2013.824842
PMCID: PMC4386687  PMID: 24810270
suicide; veterans; crisis line; hotline
3.  Influences on call outcomes among Veteran callers to the National Veterans Crisis Line 
This evaluation examined the association of caller and call characteristics with proximal outcomes of Veterans Crisis Line calls. From October 1-7, 2010, 665 Veterans with recent suicidal ideation or a history of attempted suicide called the Veterans Crisis Line, 646 had complete data and were included in the analyses. A multivariable multinomial logistic regression was conducted to identify correlates of a favorable outcome, either a resolution or a referral, when compared to an unfavorable outcome, no resolution or referral. A multivariable logistic regression was used to identify correlates of responder-rated caller risk in a subset of calls. Approximately 84% of calls ended with a favorable outcome, 25% with a resolution and 59% with a referral to a local health care provider. Calls from high-risk callers had greater odds of ending with a referral than without a resolution or referral, as did weekday calls (6:00 am to 5:59 pm EST, Monday through Friday). Responders used caller intent to die and the absence of future plans to determine caller risk. Findings suggest that the Veterans Crisis Line is a useful mechanism for generating referrals for high-risk Veteran callers. Responders appeared to use known risk and protective factors to determine caller risk.
doi:10.1111/sltb.12033
PMCID: PMC5064431  PMID: 23611446
4.  Military Sexual Trauma Among Homeless Veterans 
Journal of General Internal Medicine  2013;28(Suppl 2):536-541.
ABSTRACT
BACKGROUND
Military sexual trauma (MST) is the Veteran Health Administration’s (VHA) term for sexual assault and/or sexual harassment that occurs during military service. The experience of MST is associated with a variety of mental health conditions. Preliminary research suggests that MST may be associated with homelessness among female Veterans, although to date MST has not been examined in a national study of both female and male homeless Veterans.
OBJECTIVE
To estimate the prevalence of MST, examine the association between MST and mental health conditions, and describe mental health utilization among homeless women and men.
DESIGN AND PARTICIPANTS
National, cross-sectional study of 126,598 homeless Veterans who used VHA outpatient care in fiscal year 2010.
MAIN MEASURES
All variables were obtained from VHA administrative databases, including MST screening status, ICD-9-CM codes to determine mental health diagnoses, and VHA utilization.
KEY RESULTS
Of homeless Veterans in VHA, 39.7 % of females and 3.3 % of males experienced MST. Homeless Veterans who experienced MST demonstrated a significantly higher likelihood of almost all mental health conditions examined as compared to other homeless women and men, including depression, posttraumatic stress disorder, other anxiety disorders, substance use disorders, bipolar disorders, personality disorders, suicide, and, among men only, schizophrenia and psychotic disorders. Nearly all homeless Veterans had at least one mental health visit and Veterans who experienced MST utilized significantly more mental health visits compared to Veterans who did not experience MST.
CONCLUSIONS
A substantial proportion of homeless Veterans using VHA services have experienced MST, and those who experienced MST had increased odds of mental health diagnoses. Homeless Veterans who had experienced MST had higher intensity of mental health care utilization and high rates of MST-related mental health care. This study highlights the importance of trauma-informed care among homeless Veterans and the success of VHA homeless programs in providing mental health care to homeless Veterans.
doi:10.1007/s11606-013-2341-4
PMCID: PMC3695264  PMID: 23807062
Veterans; homelessness; sexual assault; mental health
5.  Experiences with VHA care: a qualitative study of U.S. women veterans with self-reported trauma histories 
BMC Women's Health  2017;17:38.
Background
Women veterans in the United States, particularly those with posttraumatic stress disorder (PTSD) or a history of military sexual assault, have unique health care needs, but their minority status in the US Veterans Health Administration (VHA) has led to documented healthcare disparities when compared to men. This study’s objective was to obtain a richer understanding of the challenges and successes encountered by women veterans with self-reported service-related trauma histories (particularly those with a history of military sexual assault and/or posttraumatic stress symptomology) receiving VHA care.
Methods
Thirty-seven female Vietnam and post-Vietnam (1975–1998) era veterans were randomly selected from a cohort of PTSD disability benefit applicants to complete semi-structured interviews in 2011–2012. Grounded-theory informed procedures were used to identify interview themes; differences between veterans with and without a history of military sexual assault were examined through constant comparison.
Results
At the time of the interviews, many women believed that VHA was falling short of meeting women veterans’ needs (e.g., lack of women-only mental health programming). Also common, but particularly among those with a military sexual assault history, was the perception that VHA’s environment was unwelcoming; being “surrounded by men” yielded emotions ranging from discomfort and mistrust to severe anxiety. A few veterans reported recent positive changes and offered additional suggestions for improvement.
Conclusions
Findings suggest that while at the time of the interviews gains had been made in the delivery of gender-sensitive outpatient medical care, women veterans with a history of military sexual assault and/or posttraumatic stress symptomology perceived that they were not receiving the same quality of care as male veterans.
doi:10.1186/s12905-017-0395-x
PMCID: PMC5450063  PMID: 28558740
Women; Veterans; Qualitative research; Patient satisfaction; Posttraumatic stress disorder; Military sexual assault
6.  Suicide after Leaving the UK Armed Forces —A Cohort Study 
PLoS Medicine  2009;6(3):e1000026.
Background
Few studies have examined suicide risk in individuals once they have left the military. We aimed to investigate the rate, timing, and risk factors for suicide in all those who had left the UK Armed Forces (1996–2005).
Methods and Findings
We carried out a cohort study of ex-Armed Forces personnel by linking national databases of discharged personnel and suicide deaths (which included deaths receiving either a suicide or undetermined verdict). Comparisons were made with both general and serving populations. During the study period 233,803 individuals left the Armed Forces and 224 died by suicide. Although the overall rate of suicide was not greater than that in the general population, the risk of suicide in men aged 24 y and younger who had left the Armed Forces was approximately two to three times higher than the risk for the same age groups in the general and serving populations (age-specific rate ratios ranging from 170 to 290). The risk of suicide for men aged 30–49 y was lower than that in the general population. The risk was persistent but may have been at its highest in the first 2 y following discharge. The risk of suicide was greatest in males, those who had served in the Army, those with a short length of service, and those of lower rank. The rate of contact with specialist mental health was lowest in the age groups at greatest risk of suicide (14% for those aged under 20 y, 20% for those aged 20–24 y).
Conclusions
Young men who leave the UK Armed Forces were at increased risk of suicide. This may reflect preservice vulnerabilities rather than factors related to service experiences or discharge. Preventive strategies might include practical and psychological preparation for discharge and encouraging appropriate help-seeking behaviour once individuals have left the services.
Navneet Kapur and colleagues find that young men who leave the United Kingdom Armed Forces are at increased risk of suicide.
Editors' Summary
Background.
Leaving any job can be hard but for people leaving the armed forces the adjustment to their new circumstances can sometimes be particularly difficult. For example, ex-military personnel may face obstacles to getting a new job, particularly if they were injured in action. Some become homeless. Others turn to alcohol or drugs or suffer mental illnesses such as depression. These things probably aren't common but those who leave the armed forces might also be at higher risk of suicide than the general population.
Why Was This Study Done?
Serving members of the UK Armed Forces (the British Army, the Naval Service, and the Royal Air Force) have a lower rate of suicide than the general UK population. The lower rate is probably due to “the healthy worker effect” (i.e., workers tend to be healthier than the general population, since the latter includes people unable to work due to illness or disability). However, there are anecdotal reports that ex-military personnel are more likely to die by suicide than are members of the general population. If these reports are correct, then measures should be put into place to prepare people for leaving the Armed Forces and to provide more support for them once they have left the military. The authors of this new study say that no previous studies had systematically examined suicide risk in individuals leaving the Armed Forces. In this new study, therefore, the researchers examine the suicide rate, timing, and risk factors for suicide in a large group (cohort) of former members of the UK Armed Forces.
What Did the Researchers Do and Find?
The researchers linked data on everyone who left the UK Armed Forces between 1996 and 2005 with information on suicides collected by the National Confidential Inquiry into Suicide and Homicide. Since 1996, the Inquiry has been collecting information about all suicides (defined as cases where the coroner has given a verdict of suicide or of “undetermined death”) in the UK, including information about whether the deceased used mental health services in the year before they died. The aim of the Inquiry is to reduce the risk of suicides (and homicides) in the UK by improving the country's mental health services. Between 1996 and 2005, 233,803 people left the Armed Forces and 224 (nearly all men) died by suicide. The researchers' statistical analysis of these data indicates that the overall suicide rate in the ex-military personnel was similar to that in the general population. However, the risk of suicide in men aged 24 y or younger who had left the military was 2–3 times greater than that in the same age group in both the general male population and in men serving in the Armed Forces. The risk of dying by suicide was highest in the first 2 y after leaving the military but remained raised for several years. Risk factors for suicide among ex-military personnel included being male, serving in the Army, having a short length of service, and being of lower rank. Only a fifth of the ex-military personnel who committed suicide had been in contact with mental health services in the year before they died, and the rate of contact with these services was lowest among individuals in the age groups at the highest risk of suicide.
What Do These Findings Mean?
These findings indicate that young men leaving the UK Armed Forces are at increased risk of suicide, particularly shortly after leaving. The study was not able to prove the reason for this increased risk, but the authors suggest three main possibilities: (1) the stress of transitioning to civilian life, (2) exposure to adverse experiences while in the military, or (3) a vulnerability to suicide before entering the military. The study provides some evidence to support the third hypothesis—untrained personnel with short lengths of service have a particularly high risk of dying by suicide after leaving the military, suggesting that the increased suicide risk may reflect a pre-military vulnerability. The researchers suggest that practical and psychological preparation might be helpful for people leaving the Armed Forces and that appropriate help-seeking behavior could be encouraged in these individuals. In the UK, the National Health Service is currently piloting a community-based mental health service for military veterans, characterized by regional clinical networks involving partnerships of relevant experts.
Additional Information.
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1000026.
This study is further discussed in a PLoS Medicine Perspective by Jitender Sareen and Shay-Lee Belik
The Manchester University Centre for Suicide Prevention provides information about the National Confidential Inquiry into Suicide and Homicide and about other research into suicide, and a list of useful Web sites and help lines for people going through crises
A recent article in the Observer newspaper by Mark Townsend discusses the problems facing UK military personnel when they leave the Armed Forces
Information about suicides among serving members of the UK Armed Forces is published by the Defence Analytical Services Agency
The UK National Health Service provides information about suicide, including statistics about suicide in the UK and links to other resources
MedlinePlus also provides links to further information and advice about suicide
The World Health Organization provides information on the global burden of suicide
doi:10.1371/journal.pmed.1000026
PMCID: PMC2650723  PMID: 19260757
7.  Pharmacy use by dual-eligible non-elderly veterans with private healthcare insurance 
Background
Utilization of private sector healthcare services among dual enrolled veterans with private healthcare insurance plans (PHIP) has not been well-characterized. Concurrent use of Veterans Health Administration (VHA) and non-VHA pharmacies may increase risk for adverse outcomes. Thus, the objectives of this study were to determine the extent to which dual VHA-PHIP enrollees obtain medications through VHA and non-VHA pharmacies and to characterize medications obtained through non-VHA pharmacies.
Methods
This observational study used merged administrative data from VHA and a predominant regional PHIP to select veterans < 65 years of age, residing in two Midwestern US states, and simultaneously enrolled in both VHA and the PHIP during fiscal years (FY) 2001–2010. Primary outcome measures included counts of prescriptions dispensed from VHA and non-VHA pharmacies, and frequencies of medications dispensed by non-VHA pharmacies based on PHIP claims.
Results
Of 5783 veterans who filled ≥ 1 prescription in FY10, 2935 (50.8 %) used non-VHA pharmacies exclusively, 1165 (20.2 %) used VHA pharmacies exclusively and 1683 (29.1 %) were dual users. Health services utilization was higher for dual users compared to exclusive users of either VHA or non-VHA pharmacies across multiple measures, including total prescriptions, outpatient encounters, and inpatient admissions. The most common medications dispensed by non-VHA pharmacies, by proportion of veterans treated, were hydrocodone (20.9 %), amoxicillin (18.5 %), simvastatin (17.5 %), azithromycin (17.4 %), and lisinopril (15.1 %). Antidepressants comprised 3 of 10 most common medications dispensed by VHA, but none of the most common medications dispensed to exclusive non-VHA pharmacy users.
Conclusions
Our findings align with VHA-Medicare dual enrolled veterans where only a minority of veterans used VHA services exclusively. Younger veterans relied disproportionately on VHA for mental health medications.
doi:10.1186/s12913-016-1773-z
PMCID: PMC5035463  PMID: 27664059
Access to care; Veterans; Drugs; Health insurance
8.  Use of outpatient care in VA and Medicare among disability-eligible and age-eligible veteran patients 
Background
More than half of veterans who use Veterans Health Administration (VA) care are also eligible for Medicare via disability or age, but no prior studies have examined variation in use of outpatient services by Medicare-eligible veterans across health system, type of care or time.
Objectives
To examine differences in use of VA and Medicare outpatient services by disability-eligible or age-eligible veterans among veterans who used VA primary care services and were also eligible for Medicare.
Methods
A retrospective cohort study of 4,704 disability- and 10,816 age-eligible veterans who used VA primary care services in fiscal year (FY) 2000. We tracked their outpatient utilization from FY2001 to FY2004 using VA administrative and Medicare claims data. We examined utilization differences for primary care, specialty care, and mental health outpatient visits using generalized estimating equations.
Results
Among Medicare-eligible veterans who used VA primary care, disability-eligible veterans had more VA primary care visits (p < 0.001) and more VA specialty care visits (p < 0.001) than age-eligible veterans. They were more likely to have mental health visits in VA (p < 0.01) and Medicare-reimbursed visits (p < 0.01). Disability-eligible veterans also had more total (VA+Medicare) visits for primary care (p < 0.01) and specialty care (p < 0.01), controlling for patient characteristics.
Conclusions
Greater use of primary care and specialty care visits by disability-eligible veterans is most likely related to greater health needs not captured by the patient characteristics we employed and eligibility for VA care at no cost. Outpatient care patterns of disability-eligible veterans may foreshadow care patterns of veterans returning from Afghanistan and Iraq wars, who are entering the system in growing numbers. This study provides an important baseline for future research assessing utilizations among returning veterans who use both VA and Medicare systems. Establishing effective care coordination protocols between VA and Medicare providers can help ensure efficient use of taxpayer resources and high quality care for disabled veterans.
doi:10.1186/1472-6963-12-51
PMCID: PMC3359202  PMID: 22390389
Outpatient; Utilization; Primary care; Veterans; Medicare
9.  A Novel Brief Therapy for Patients Who Attempt Suicide: A 24-months Follow-Up Randomized Controlled Study of the Attempted Suicide Short Intervention Program (ASSIP) 
PLoS Medicine  2016;13(3):e1001968.
Background
Attempted suicide is the main risk factor for suicide and repeated suicide attempts. However, the evidence for follow-up treatments reducing suicidal behavior in these patients is limited. The objective of the present study was to evaluate the efficacy of the Attempted Suicide Short Intervention Program (ASSIP) in reducing suicidal behavior. ASSIP is a novel brief therapy based on a patient-centered model of suicidal behavior, with an emphasis on early therapeutic alliance.
Methods and Findings
Patients who had recently attempted suicide were randomly allocated to treatment as usual (n = 60) or treatment as usual plus ASSIP (n = 60). ASSIP participants received three therapy sessions followed by regular contact through personalized letters over 24 months. Participants considered to be at high risk of suicide were included, 63% were diagnosed with an affective disorder, and 50% had a history of prior suicide attempts. Clinical exclusion criteria were habitual self-harm, serious cognitive impairment, and psychotic disorder. Study participants completed a set of psychosocial and clinical questionnaires every 6 months over a 24-month follow-up period.
The study represents a real-world clinical setting at an outpatient clinic of a university hospital of psychiatry. The primary outcome measure was repeat suicide attempts during the 24-month follow-up period. Secondary outcome measures were suicidal ideation, depression, and health-care utilization. Furthermore, effects of prior suicide attempts, depression at baseline, diagnosis, and therapeutic alliance on outcome were investigated.
During the 24-month follow-up period, five repeat suicide attempts were recorded in the ASSIP group and 41 attempts in the control group. The rates of participants reattempting suicide at least once were 8.3% (n = 5) and 26.7% (n = 16). ASSIP was associated with an approximately 80% reduced risk of participants making at least one repeat suicide attempt (Wald χ21 = 13.1, 95% CI 12.4–13.7, p < 0.001). ASSIP participants spent 72% fewer days in the hospital during follow-up (ASSIP: 29 d; control group: 105 d; W = 94.5, p = 0.038). Higher scores of patient-rated therapeutic alliance in the ASSIP group were associated with a lower rate of repeat suicide attempts. Prior suicide attempts, depression, and a diagnosis of personality disorder at baseline did not significantly affect outcome. Participants with a diagnosis of borderline personality disorder (n = 20) had more previous suicide attempts and a higher number of reattempts.
Key study limitations were missing data and dropout rates. Although both were generally low, they increased during follow-up. At 24 months, the group difference in dropout rate was significant: ASSIP, 7% (n = 4); control, 22% (n = 13). A further limitation is that we do not have detailed information of the co-active follow-up treatment apart from participant self-reports every 6 months on the setting and the duration of the co-active treatment.
Conclusions
ASSIP, a manual-based brief therapy for patients who have recently attempted suicide, administered in addition to the usual clinical treatment, was efficacious in reducing suicidal behavior in a real-world clinical setting. ASSIP fulfills the need for an easy-to-administer low-cost intervention. Large pragmatic trials will be needed to conclusively establish the efficacy of ASSIP and replicate our findings in other clinical settings.
Trial registration
ClinicalTrials.gov NCT02505373
In a randomized controlled trial, Konrad Michel and colleagues test the efficacy of a manual-based therapy intended to prevent repeat suicide attempts.
Editors' Summary
Background
Suicide is a serious public health problem. Over 800,000 people worldwide die by suicide every year. In the US, one suicide death occurs approximately every 12 minutes. While the causes of suicide are complex, the goals of suicide prevention are simple—reduce factors that increase risk, and increase factors that promote resilience or coping. Factors that increase suicide risk include family history of suicide, family history of child abuse, previous suicide attempts, history of mental disorders (particularly depression), history of alcohol and substance abuse, and access to lethal means. Factors that are protective against suicide include effective clinical care for mental, physical, and substance abuse disorders; connectedness to family and community; and problem solving and conflict resolution skills. A previous suicide attempt is the main risk factor for repeat attempts and for completed suicide. Fifteen to 25 percent of people who attempt suicide make another attempt, and five to ten percent eventually die by suicide.
Why Was This Study Done?
A number of suicide prevention treatments have been developed. Most of them involve therapy sessions and personal follow-up. While some of them have been shown to work in clinical trials—often with participants who have made a previous suicide attempt—few interventions have proven to be effective consistently in different settings. For this study, the researchers developed a treatment called Attempted Suicide Short Intervention Program (ASSIP) composed of three therapy sessions shortly after the suicide attempt and follow-up over two years with personalized mailed letters. They wanted the therapy part to be short, in order to provide a treatment that would allow a psychiatric service to cope with the large number of patients seen in the emergency department after a suicide attempt. The therapeutic elements of the treatment emphasized building an early therapeutic alliance, which would then serve as a basis (“anchoring”) for long-term outreach contact through regular letters. The therapy sessions and letters follow a detailed script, which the researchers developed into a manual that includes a step-by-step description of the highly structured treatment, checklists, handouts, and standardized letters for use by health professionals in various clinical settings. This study was done to test whether ASSIP can reduce suicidal behavior in addition to routine treatment.
What Did the Researchers Do and Find?
The researchers carried out a randomized clinical trial testing ASSIP in people who had attempted suicide (the majority by intentional overdosing) and been admitted to the emergency department of the Bern University General Hospital in Switzerland. Participants were randomly assigned to two groups. The treatment group received ASSIP in addition to treatment as usual (inpatient, day patient, and outpatient care as deemed appropriate by the hospital clinicians); the control group received a single structured assessment interview plus treatment as usual. The study objective was to evaluate—with follow-up questionnaires and health-care data—whether ASSIP can reduce the rate of repeated suicide attempt in the 24 months after a suicide attempt. The researchers also compared suicidal ideation (i.e., whether and how often participants had suicidal thoughts), levels of depression, and how often people were hospitalized between the two groups.
A total of 120 patients who had recently attempted suicide were randomly allocated to treatment as usual or treatment as usual plus ASSIP. The 60 ASSIP participants received three therapy sessions followed by regular contact over 24 months. During the first therapy session, the patient was prompted to tell the story of how he or she had reached the point of attempting suicide. Narrative interviewing is a key element of ASSIP’s patient-centered collaborative approach. The first session was videotaped, and parts were watched and discussed by patient and therapist during the second session, to recreate the experience of psychological pain and analyze how stress developed into suicidal action. During the final session, therapist and patient developed a list of long-term goals, warning signs, and safety strategies. These were printed and given to the patient in a credit-card-sized folded leaflet along with a list of telephone help numbers. Patients were told to carry both items at all times and to use them in the event of an emotional crisis. Over the subsequent two years, patients received six letters from their therapist reminding them of the risk of future suicidal crises and the importance of the collaboratively developed safety strategies.
During the 24 months of follow-up, one death by suicide occurred in each group, five repeat suicide attempts were recorded in the ASSIP group, and 41 repeat suicide attempts were recorded in the control group. ASSIP was associated with an approximately 80% reduced risk of repeat suicide attempt. In addition, ASSIP participants spent 72% fewer days in the hospital during follow-up. There was no difference in patient-reported suicidal ideation or in levels of depression.
What Do these Findings Mean?
The results show that ASSIP, administered in addition to the usual clinical treatment, was able to reduce suicidal behavior over 24 months in patients who had recently attempted suicide. The addition of ASSIP to usual treatment directly or its effect on repeat attempts might also reduce health care costs. The absence of effects on suicidal thoughts and depression is consistent with ASSIP’s objective to help people cope with crises as opposed to eliminating them. The study’s findings in a real-world clinical setting (a university hospital in the Swiss capital) are promising. They justify further testing in large clinical trials and diverse settings to answer conclusively whether and where ASSIP can reduce repeat suicide attempts, prevent deaths from suicide, and reduce health-care costs.
Additional Information
This list of resources contains links that can be accessed when viewing the PDF on a device or via the online version of the article at http://dx.doi.org/10.1371/journal.pmed.1001968.
National Action Alliance for Suicide Prevention has information on research prioritization for suicide prevention
There is also a supplemental issue of the American Journal of Preventive Medicine focused on research about suicide prevention
More information about suicide is available from ZEROSuicide http://zerosuicide.sprc.org/ and the Suicide Prevention Resource Center http://www.sprc.org/
The US Centers for Disease Control and Prevention has information on suicide
The UK Mental Health Foundation also has information on suicide
The page “About Suicide” from the American Foundation for Suicide Prevention has information on warning signs, risk factors, and statistics
The US National Suicide Prevention Lifeline offers help and information
The Bern University Hospital of Psychiatry has a page describing ASSIP for patients (in German)
The Finnish Association for Mental Health has a page describing ASSIP (in English)
doi:10.1371/journal.pmed.1001968
PMCID: PMC4773217  PMID: 26930055
10.  Mental Health Diagnoses and Utilization of VA Non-Mental Health Medical Services Among Returning Iraq and Afghanistan Veterans 
BACKGROUND
Over 35% of returned Iraq and Afghanistan veterans in VA care have received mental health diagnoses; the most prevalent is post-traumatic stress disorder (PTSD). Little is known about these patients’ use of non-mental health medical services and the impact of mental disorders on utilization.
OBJECTIVE
To compare utilization across three groups of Iraq and Afghanistan veterans: those without mental disorders, those with mental disorders other than PTSD, and those with PTSD.
DESIGN AND PARTICIPANTS
National, descriptive study of 249,440 veterans newly utilizing VA healthcare between October 7, 2001 and March 31, 2007, followed until March 31, 2008.
MEASUREMENTS
We used ICD9-CM diagnostic codes to classify mental health status. We compared utilization of outpatient non-mental health services, primary care, medical subspecialty, ancillary services, laboratory tests/diagnostic procedures, emergency services, and hospitalizations during veterans’ first year in VA care. Results were adjusted for demographics and military service and VA facility characteristics.
MAIN RESULTS
Veterans with mental disorders had 42–146% greater utilization than those without mental disorders, depending on the service category (all P < 0.001). Those with PTSD had the highest utilization in all categories: 71–170% greater utilization than those without mental disorders (all P < 0.001). In adjusted analyses, compared with veterans without mental disorders, those with mental disorders other than PTSD had 55% higher utilization of all non-mental health outpatient services; those with PTSD had 91% higher utilization. Female sex and lower rank were also independently associated with greater utilization.
CONCLUSIONS
Veterans with mental health diagnoses, particularly PTSD, utilize significantly more VA non-mental health medical services. As more veterans return home, we must ensure resources are allocated to meet their outpatient, inpatient, and emergency needs.
doi:10.1007/s11606-009-1117-3
PMCID: PMC2811589  PMID: 19787409
veterans; post-traumatic stress disorder; psychiatry; health services research; utilization
11.  Changes in characteristics of veterans using the VHA health care system between 1996 and 1999 
Background
The Department of Veterans Affairs' Veterans Health Administration (VHA) provides a health care safety net to veterans. This study examined changes in characteristics of veterans using the VHA health care system between 1996 and 1999 when VHA implemented major organizational changes to improve access of ambulatory care and to provide care to more veterans.
Methods
The study used two cross-sectional samples of the Medical Expenditures Panel Survey (MEPS), a national representative survey, in 1996 and 1999. The 1996 MEPS survey included 1,944 veterans and the 1999 MEPS survey included 1,974 veterans. There were 534 veterans and 740 veterans who used VHA services in 1996 and 1999, respectively.
Results
The proportion of veterans using the VHA system increased from 12.4% in 1996 to 14.6% in 1999. In both years, veterans were more likely to use VHA care if they were older, male, less educated, uninsured, unemployed, and in fair or poor health status. Only two variables, marital status and income, were different between the two years. Married veterans were more likely to use VHA care in 1999, but not in 1996. Veterans with higher incomes had greater odds of using VHA care in 1996, but there was no significant association between income and VHA use in 1999.
Conclusion
Characteristics of VHA users did not fundamentally change despite the reorganization of VHA health care delivery system and changes in eligibility and enrollment policy. The VHA system maintains its safety net mission while attracting more veterans.
doi:10.1186/1478-4505-3-5
PMCID: PMC1090608  PMID: 15836789
12.  Military service and other socioecological factors influencing weight and health behavior change in overweight and obese Veterans: a qualitative study to inform intervention development within primary care at the United States Veterans Health Administration 
BMC obesity  2016;3:5.
Background
Obesity affects 37 % of patients at Veterans Health Administration (VHA) medical centers. The VHA offers an intensive weight management program (MOVE!) but less than 10 % of eligible patients ever attend. However, VHA patients see their primary care provider about 3.6 times per year, supporting the development of primary care-based weight management interventions. To address gaps in the literature regarding Veterans’ experiences with weight management and determine whether and how to develop a primary care-based weight management intervention to both improve obesity counseling and increase attendance to MOVE!, we conducted a qualitative study to assess: 1) Veterans’ personal experiences with healthy weight-related behavior change (including barriers and facilitators to behavior change and experiences with primary care providers, staff, and the MOVE! program), and 2) potential new approaches to improve weight management within primary care at the VHA including goal setting and technology.
Methods
Overweight/obese VHA patients (aged 18–75, BMI greater than 30 or greater than 25 with at least 1 co-morbidity) were recruited for focus group sessions stratified by gender, MOVE! referral, and attendance. Each session was facilitated by a trained moderator, audio-recorded, and professionally transcribed. Using an iterative coding approach, two coders separately reviewed and coded transcripts, and met frequently to negotiate codes and synthesize emerging themes.
Results
Of 161 eligible patients, 54 attended one of 6 focus groups (2 female, 4 male, 9–11 participants per session): 63 % were male, 46 % identified as African-American, 32 % White/Caucasian, 74 % were college-educated or higher, and 61 % reported having attended MOVE!. We identified two major themes: Impact of Military Service and Promotion and Sustainability of Healthy Behaviors. After service in a highly structured military environment, Veterans had difficulty maintaining weight on their own. They perceived physical activity as having more impact than diet, but chronic pain was a barrier. We identified individual/interpersonal-, community/environment-, and healthcare system-related factors affecting healthy behaviors. We also received input about Veteran’s preferences and experiences with technology and setting health goals.
Conclusions
Unique factors influence weight management in Veterans. Findings will inform development of a technology-assisted weight management intervention with tailored counseling and goal-setting within primary care at the VHA.
doi:10.1186/s40608-016-0087-3
PMCID: PMC4736653  PMID: 26855786
Obesity; Primary care; Veterans; Weight management; Focus groups; Qualitative
13.  A Break-Even Analysis for Dementia Care Collaboration: Partners in Dementia Care 
Background
Dementia is a costly disease. People with dementia, their families, and their friends are affected on personal, emotional, and financial levels. Prior work has shown that the “Partners in Dementia Care” (PDC) intervention addresses unmet needs and improves psychosocial outcomes and satisfaction with care.
Objective
We examined whether PDC reduced direct Veterans Health Administration (VHA) health care costs compared with usual care.
Design
This study was a cost analysis of the PDC intervention in a 30-month trial involving five VHA medical centers.
Participants
Study subjects were veterans (N = 434) 50 years of age and older with dementia and their caregivers at two intervention (N = 269) and three comparison sites (N = 165).
Interventions
PDC is a telephone-based care coordination and support service for veterans with dementia and their caregivers, delivered through partnerships between VHA medical centers and local Alzheimer’s Association chapters.
Main Measures
We tested for differences in total VHA health care costs, including hospital, emergency department, nursing home, outpatient, and pharmacy costs, as well as program costs for intervention participants. Covariates included caregiver reports of veterans’ cognitive impairment, behavior problems, and personal care dependencies. We used linear mixed model regression to model change in log total cost post-baseline over a 1-year follow-up period.
Key Results
Intervention participants showed higher VHA costs than usual-care participants both before and after the intervention but did not differ significantly regarding change in log costs from pre- to post-baseline periods. Pre-baseline log cost (p ≤ 0.001), baseline cognitive impairment (p ≤ 0.05), number of personal care dependencies (p ≤ 0.01), and VA service priority (p ≤ 0.01) all predicted change in log total cost.
Conclusions
These analyses show that PDC meets veterans’ needs without significantly increasing VHA health care costs. PDC addresses the priority area of care coordination in the National Plan to Address Alzheimer’s Disease, offering a low-cost, structured, protocol-driven, evidence-based method for effectively delivering care coordination.
doi:10.1007/s11606-015-3205-x
PMCID: PMC4441671  PMID: 25666216
costs and cost analysis; dementia; veterans
14.  Pregnancy and Mental Health Among Women Veterans Returning from Iraq and Afghanistan 
Journal of Women's Health  2010;19(12):2159-2166.
Abstract
Background
Veterans of Operations Enduring Freedom and Iraqi Freedom (OEF/OIF) may experience significant stress during military service that can have lingering effects. Little is known about mental health problems or treatment among pregnant OEF/OIF women veterans. The aim of this study was to determine the prevalence of mental health problems among veterans who received pregnancy-related care in the Veterans Health Administration (VHA) system.
Methods
Data from the Defense Manpower Data Center (DMDC) deployment roster of military discharges from October 1, 2001, through April 30, 2008, were used to assemble an administrative cohort of female OEF/OIF veterans enrolled in care at the VHA (n = 43,078). Pregnancy and mental health conditions were quantified according to ICD-9-CM codes and specifications. Mental healthcare use and prenatal care were assessed by analyzing VHA stop codes.
Results
During the study period, 2966 (7%) women received at least one episode of pregnancy-related care, and 32% of veterans with a pregnancy and 21% without a pregnancy received one or more mental health diagnoses (p < 0.0001). Veterans with a pregnancy were twice as likely to have a diagnosis of depression, anxiety, posttraumatic stress disorder (PTSD), bipolar disorder, or schizophrenia as those without a pregnancy.
Conclusions
Women OEF/OIF veterans commonly experience mental health problems after military service. The burden of mental health conditions is higher among women with an identified instance of pregnancy than among those without. Because women do not receive pregnancy care at the VHA, however, little is known about ongoing concomitant prenatal and mental healthcare or about pregnancy outcomes among these women veterans.
doi:10.1089/jwh.2009.1892
PMCID: PMC3052271  PMID: 21039234
15.  Association between health literacy and medical care costs in an integrated healthcare system: a regional population based study 
Background
Low health literacy is associated with higher health care utilization and costs; however, no large-scale studies have demonstrated this in the Veterans Health Administration (VHA). This research evaluated the association between veterans’ health literacy and their subsequent VHA health care costs across a three-year period.
Methods
This retrospective study used a Generalized Linear Model to estimate the relative association between a patient’s health literacy and VHA medical costs, adjusting for covariates. Secondary data sources included electronic health records and administrative data in the VHA (e.g., Medical and DCG SAS Datasets and DSS-National Data Extracts). Health literacy assessments and identifiers were electronically retrieved from the originating health system. Demographic and cost data were retrieved from the VHA centralized databases for the corresponding patients who had VHA use in all three years.
Results
In a study of 92,749 veterans with service utilization from 2007–2009, average per patient cost for those with inadequate and marginal health literacy was significantly higher ($31,581 [95 % CI: $30,186 - $32,975]; $23,508 [95 % CI: $22,749 - $24,268]) than adequate health literacy ($17,033 [95 % CI: $16,810 - $17,255]). Estimated three-year cost associated with veterans’ with marginal and inadequate health literacy was $143 million dollars more than those with adequate health literacy.
Conclusions
Analyses suggest when controlling for other person-level factors within the VHA integrated healthcare system, lower health literacy is a significant independent factor associated with increased health care utilization and costs. This study confirms the association of lower health literacy with higher medical service utilization and pharmacy costs for veterans enrolled in the VHA. Confirmation of higher costs of care associated with lower health literacy suggests that interventions might be designed to remediate health literacy needs and reduce expenditures. These analyses suggest 17.2 % (inadequate & marginal) of the Veterans in this population account for almost one-quarter (24 %) of VA medical and pharmacy cost for this 3-year period. Meeting the needs of those with marginal and inadequate health literacy could produce potential economic savings of approximately 8 % of total costs for this population.
doi:10.1186/s12913-015-0887-z
PMCID: PMC4482196  PMID: 26113118
Retrospective; Health care costs; VA health care system
16.  Fit to Serve? Exploring Mental and Physical Health and Well-Being Among Transgender Active-Duty Service Members and Veterans in the U.S. Military 
Transgender Health  2016;1(1):4-11.
Abstract
Purpose: Although transgender people are currently excluded from enlistment and discharged from service based on medical and psychological fitness policies, the current mental and physical health of transgender active-duty U.S. military personnel and veterans is poorly understood. The purpose of the current study was to investigate the military histories, lifetime mental and physical health diagnoses, and transgender transition-related health of transgender active-duty service members (ADSM) and veterans.
Methods: Participants were recruited through private LGBT military and veteran organizational listservs, snowball sampling, and in-person recruitment to complete an anonymous and confidential self-administered online questionnaire.
Results: A total of 106 transgender ADSM (n=55) and veterans (n=51) completed the questionnaire. Transgender veterans were significantly older (44 mean years vs. 29.5 mean years, t=−6.23, p<0.001). A greater percentage of veterans than ADSM reported depression (64.6% vs. 30.9%, χ2=11.68, p=0.001) and anxiety (41.3% vs. 18.2%, χ2=6.54, p=0.011). In addition, 15.9% of veterans versus 1.8% of ADSM (χ2=6.53, p=0.011) had been diagnosed with a substance abuse disorder. There were no significant differences in lifetime physical health conditions; however, veterans reported a higher body–mass index than ADSM (28.4 vs. 24.9, t=−3.85, p<0.001). For both groups, mental and physical health problems were positively correlated with age and years of military service (r=0.37–0.84, p<0.01). There were no significant differences between groups in transgender transition-related health.
Conclusion: Our data represent the first descriptive statistics of lifetime mental and physical health issues among transgender ADSM and veterans. Data indicate that transgender ADSM report fewer lifetime mental and physical health problems than transgender veterans. Taken together, our findings suggest that more research, specifically among transgender ADSM, is needed to challenge the exclusion of transgender persons from U.S. military service based on the presumption of poor mental or physical health.
doi:10.1089/trgh.2015.0002
PMCID: PMC5685248
mental health; military/Department of Defense; physical health; transgender; transgender health
17.  A two-state comparative implementation of peer-support intervention to link veterans to health-related services after incarceration: a study protocol 
Background
Approximately 600,000 persons are released from prison annually in the United States. Relatively few receive sufficient re-entry services and are at risk for unemployment, homelessness, poverty, substance abuse relapse and recidivism. Persons leaving prison who have a mental illness and/or a substance use disorder are particularly challenged. This project aims to create a peer mentor program to extend the reach and effectiveness of reentry services provided by the Department of Veterans’ Affairs (VA). We will implement a peer support for reentry veterans sequentially in two states. Our outcome measures are 1) fidelity of the intervention, 2) linkage to VA health care and, 3) continued engagement in health care.
The aims for this project are as follows: (1) Conduct contextual analysis to identify VA and community reentry resources, and describe how reentry veterans use them. (2) Implement peer-support, in one state, to link reentry veterans to Veterans’ Health Administration (VHA) primary care, mental health, and SUD services. (3) Port the peer-support intervention to another, geographically, and contextually different state.
Design
This intervention involves a 2-state sequential implementation study (Massachusetts, followed by Pennsylvania) using a Facilitation Implementation strategy. We will conduct formative and summative analyses, including assessment of fidelity, and a matched comparison group to evaluate the intervention’s outcomes of veteran linkage and engagement in VHA health care (using health care utilization measures). The study proceeds in 3 phases.
Discussion
We anticipate that a peer support program will be effective at improving the reentry process for veterans, particularly in linking them to health, mental health, and SUD services and helping them to stay engaged in those services. It will fill a gap by providing veterans with access to a trusted individual, who understands their experience as a veteran and who has experienced justice involvement. The outputs from this project, including training materials, peer guidebooks, and implementation strategies can be adapted by other states and regions that wish to enhance services for veterans (or other populations) leaving incarceration. A larger cluster-randomized implementation-effectiveness study is planned.
Trial registration
This protocol is registered with clinicaltrials.gov on November 4, 2016 and was assigned the number NCT02964897.
Electronic supplementary material
The online version of this article (10.1186/s12913-017-2572-x) contains supplementary material, which is available to authorized users.
doi:10.1186/s12913-017-2572-x
PMCID: PMC5596492  PMID: 28899394
Facilitation; Vulnerable populations; Process mapping; Peer-support
18.  Dual Medicare and Veteran Health Administration Use and Ambulatory Care Sensitive Hospitalizations 
Journal of General Internal Medicine  2011;26(Suppl 2):669-675.
ABSTRACT
OBJECTIVE
The objective of the study is to examine the association between ambulatory care sensitive hospitalizations (ACSH) and dual Medicare/Veteran Health Administration use.
PARTICIPANTS
A nationally representative sample of Medicare beneficiaries, who participated in the Medicare Current Beneficiary Survey (MCBS).
DESIGN/MEASUREMENTS
Cross-sectional analyses (N = 44,988) of linked fee-for-service Medicare claims and survey data from multiple years of the MCBS (2001–2005). Any ACSH and specific types of ACSH were measured using the list of prevention quality indicators developed by the Agency for Healthcare Research and Quality. Among veterans, dual Medicare/VHA use was defined as having inpatient or outpatient visits paid by VHA and consisted of three categories: 1) predominant-VHA use; 2) some VHA use and no VHA use. Unadjusted group differences in any ACSH were tested using chi-square tests. Logistic regressions were used to analyze the association between dual Medicare/VHA use and ACSH after controlling for demographic, socio-economic status, health status, functional status, smoking status and obesity. All analyses accounted for the complex design of the MCBS.
RESULTS
Among inpatient users, 10.1% had ACSH events for acute conditions and 15.8% for chronic conditions. Among all survey respondents, 5% had any ACSH event. Among predominant-VHA users the rate was 4.9% and among veterans with some VHA use it was 3.7%. In bivariate and multivariate analyses, dual Medicare/VHA use was not significantly associated with any ACSH.
CONCLUSION
In a representative sample of Medicare beneficiaries, despite low income and health status, veterans with dual Medicare/VHA use were as likely as veterans without dual use to have any ACSH, perhaps due to expanded healthcare access and emphasis on primary care in the VHA system.
doi:10.1007/s11606-011-1788-4
PMCID: PMC3191226  PMID: 21989620
dual utilization; ACSH; veterans; care coordination
19.  Reducing Barriers to Mental Health and Social Services for Iraq and Afghanistan Veterans: Outcomes of an Integrated Primary Care Clinic 
Journal of General Internal Medicine  2011;26(10):1160-1167.
ABSTRACT
BACKGROUND
Despite high rates of post-deployment psychosocial problems in Iraq and Afghanistan veterans, mental health and social services are under-utilized.
OBJECTIVE
To evaluate whether a Department of Veterans Affairs (VA) integrated care (IC) clinic (established in April 2007), offering an initial three-part primary care, mental health and social services visit, improved psychosocial services utilization in Iraq and Afghanistan veterans compared to usual care (UC), a standard primary care visit with referral for psychosocial services as needed.
DESIGN
Retrospective cohort study using VA administrative data.
POPULATION
Five hundred and twenty-six Iraq and Afghanistan veterans initiating primary care at a VA medical center between April 1, 2005 and April 31, 2009.
MAIN MEASURES
Multivariable models compared the independent effects of primary care clinic type (IC versus UC) on mental health and social services utilization outcomes.
KEY RESULTS
After 2007, compared to UC, veterans presenting to the IC primary care clinic were significantly more likely to have had a within-30-day mental health evaluation (92% versus 59%, p < 0.001) and social services evaluation [77% (IC) versus 56% (UC), p < 0.001]. This exceeded background system-wide increases in mental health services utilization that occurred in the UC Clinic after 2007 compared to before 2007. In particular, female veterans, younger veterans, and those with positive mental health screens were independently more likely to have had mental health and social service evaluations if seen in the IC versus UC clinic. Among veterans who screened positive for ≥ 1 mental health disorder(s), there was a median of 1 follow-up specialty mental health visit within the first year in both clinics.
CONCLUSIONS
Among Iraq and Afghanistan veterans new to primary care, an integrated primary care visit further improved the likelihood of an initial mental health and social services evaluation over background increases, but did not improve retention in specialty mental health services.
doi:10.1007/s11606-011-1746-1
PMCID: PMC3181313  PMID: 21647750
veterans; mental health; health services utilization; primary care
20.  Mental health utilization among older Veterans with coexisting depression and dementia 
SAGE Open Medicine  2015;3:2050312114566488.
Objective:
We compared mental health service utilization among older, depressed Veterans (60 years or older) with and without coexisting dementia.
Methods:
This retrospective study examined data from the 2010 Veterans Health Administration National Patient Care Database outpatient treatment files of Veterans with a newly recognized diagnosis of depression (N = 177,710).
Results:
Approximately 48.84% with coexisting depression and dementia and 32.00% with depression only received mental health services within 12 months of diagnosis (p < .0001). Veterans with coexisting depression and dementia were more likely to receive medication-management appointments (33.40% vs 20.62%), individual therapy (13.39% vs 10.91%), and family therapy (3.77% vs 1.19%) than depressed Veterans without dementia.
Conclusion:
In general, Veterans with recently diagnosed depression are significantly underusing Veterans Affairs mental health treatment services. Those Veterans who have comorbid dementia are more likely than those with just depression to be enrolled in mental health treatments. Systemic improvements are needed to increase use of mental health services for older, depressed Veterans.
doi:10.1177/2050312114566488
PMCID: PMC4679217  PMID: 26770761
Mental health service utilization; dementia; depression; Veterans
21.  Use of the internet and an online personal health record system by US veterans: comparison of Veterans Affairs mental health service users and other veterans nationally 
Objective
The Department of Veterans Affairs (VA) operates one of the largest nationwide healthcare systems and is increasing use of internet technology, including development of an online personal health record system called My HealtheVet. This study examined internet use among veterans in general and particularly use of online health information among VA patients and specifically mental health service users.
Methods
A nationally representative sample of 7215 veterans from the 2010 National Survey of Veterans was used. Logistic regression was employed to examine background characteristics associated with internet use and My HealtheVet.
Results
71% of veterans reported using the internet and about a fifth reported using My HealtheVet. Veterans who were younger, more educated, white, married, and had higher incomes were more likely to use the internet. There was no association between background characteristics and use of My HealtheVet. Mental health service users were no less likely to use the internet or My HealtheVet than other veterans.
Discussion
Most veterans are willing to access VA information online, although many VA service users do not use My HealtheVet, suggesting more education and research is needed to reduce barriers to its use.
Conclusion
Although adoption of My HealtheVet has been slow, the majority of veterans, including mental health service users, use the internet and indicate a willingness to receive and interact with health information online.
doi:10.1136/amiajnl-2012-000971
PMCID: PMC3534469  PMID: 22847305
Internet; technology; mental health; military medicine; health services; electronic medical records; severe mental illness; homeless
22.  The mental health of UK Gulf war veterans: phase 2 of a two phase cohort study 
BMJ : British Medical Journal  2002;325(7364):576.
Objectives
To examine the prevalence of psychiatric disorders in veterans of the Gulf war with or without unexplained physical disability (a proxy measure of ill health) and in similarly disabled veterans who had not been deployed to the Gulf war (non-Gulf veterans).
Design
Two phase cohort study.
Setting
Current and ex-service UK military personnel.
Participants
Phase 1 consisted of three randomly selected samples of Gulf veterans, veterans of the 1992-7 Bosnia peacekeeping mission, and UK military personnel not deployed to the Gulf war (Era veterans) who had completed a postal health questionnaire. Phase 2 consisted of randomly selected subsamples from phase 1 of Gulf veterans who reported physical disability (n=111) or who did not report disability (n=98) and of Bosnia (n=54) and Era (n=79) veterans who reported physical disability.
Main outcome measure
Psychiatric disorders assessed by the schedule for clinical assessment in neuropsychiatry and classified by the Diagnostic and Statistical Manual of Mental Disorders, fourth edition.
Results
Only 24% (n=27) of the disabled Gulf veterans had a formal psychiatric disorder (depression, anxiety, or alcohol related disorder). The prevalence of psychiatric disorders in non-disabled Gulf veterans was 12%. Disability and psychiatric disorders were weakly associated in the Gulf group when confounding was adjusted for (adjusted odds ratio 2.4, 99% confidence interval 0.8 to 7.2, P=0.04). The prevalence of psychiatric disorders was similar in disabled non-Gulf veterans and disabled Gulf veterans ( 19% v 24%; 1.3, 0.5 to 3.4). All groups had rates for post-traumatic stress disorder of between 1% and 3%.
Conclusions
Most disabled Gulf veterans do not have a formal psychiatric disorder. Post-traumatic stress disorder is not higher in Gulf veterans than in other veterans. Psychiatric disorders do not fully explain self reported ill health in Gulf veterans; alternative explanations for persistent ill health in Gulf veterans are needed.
What is already known on this topicGulf veterans report medically unexplained symptoms more often than non-Gulf veteransThe clinical characteristics of ill health in Gulf veterans are not well known, and factors associated with ill health in Gulf veterans are poorly understoodWhat this study addsMost ill Gulf veterans do not have a formal psychiatric disorderThe rates for post-traumatic stress disorder are lowPsychiatric morbidity is not strongly associated with ill health in Gulf veteransThe rates for somatoform disorders are three times greater in disabled Gulf veterans than they are in disabled non-Gulf veterans
PMCID: PMC124552  PMID: 12228134
23.  Role of the police in linking individuals experiencing mental health crises with mental health services 
BMC Psychiatry  2012;12:171.
Background
The police are considered frontline professionals in managing individuals experiencing mental health crises. This study examines the extent to which these individuals are disconnected from mental health services, and whether the police response has an influence on re-establishing contact.
Methods
Police records were searched for calls regarding individuals with acute mental health needs and police handling of these calls. Mental healthcare contact data were retrieved from a Psychiatric Case Register.
Results
The police were called upon for mental health crisis situations 492 times within the study year, involving 336 individuals (i.e. 1.7 per 1000 inhabitants per year). Half of these individuals (N=162) were disengaged from mental health services, lacking regular care contact in the year prior to the crisis (apart from contact for crisis intervention). In the month following the crisis, 21% of those who were previously disengaged from services had regular care contact, and this was more frequent (49%) if the police had contacted the mental health services during the crisis. The influence of police referral to the services was still present the following year. However, for the majority (58%) of disengaged individuals police did not contact the mental health services at the time of crisis.
Conclusions
The police deal with a substantial number of individuals experiencing a mental health crisis, half of whom are out of contact with mental health services, and police play an important role in linking these individuals to services. Training police officers to recognise and handle mental health crises, and implementing practical models of cooperation between the police and mental health services in dealing with such crises may further improve police referral of individuals disengaged from mental health services.
doi:10.1186/1471-244X-12-171
PMCID: PMC3511214  PMID: 23072687
Mental Health Services; Utilisation; Crisis intervention; Police
24.  Pathways into mental health care for UK veterans: a qualitative study 
ABSTRACT
Background: It is well established that veterans suffering from mental health difficulties under use mental health services.
Objective: This study aimed to understand more about the barriers that prevent veterans from seeking professional help and the enablers that assist veterans in seeking professional help. It also aimed to explore potential mechanisms to improve veterans’ help-seeking and pathways to care.
Method: The study employed a qualitative design whereby 17 veterans who had recently attended specialist veteran mental health services took part in semi-structured interviews. The resultant data were analysed using grounded theory.
Results: Participants described two distinct stages to their help-seeking: initial help-seeking and pathways through treatment. Specific barriers and enablers to help-seeking were identified at each stage. Initial barriers included recognizing that there is a problem, self-stigma and anticipated public stigma. Initial enablers included being in crisis, social support, motivation and the media. Treatment pathway barriers included practical factors and negative beliefs about health services and professionals. Treatment pathway enablers included having a diagnosis, being seen in a veteran-specific service and establishing a good therapeutic relationship. Participants provided some suggestions for interventions to improve veterans’ help-seeking in future; these focussed on enhancing both veterans and health professionals’ knowledge regarding mental health difficulties.
Conclusions: This study identified a number of barriers and enablers that may impact a veteran’s journey in seeking help from professional services for mental health difficulties. Enablers such as reaching a crisis point, social support, the media, having a diagnosis of PTSD and veteran-specific mental health services appeared to be important in opposing stigma-related beliefs and in supporting veterans to engage in help-seeking behaviours.
doi:10.1080/20008198.2017.1389207
PMCID: PMC5687804
Veterans; ex-service personnel; mental health; stigma; barriers; help-seeking; Veteranos; personal que ya no está de servicio; salud mental; estigma; barreras; búsqueda de ayuda; 老兵; 退役人员; 心理健康; 污名效应; 障碍; 寻求帮助; • This article aimed to understand why a vast majority of veterans suffering from mental health difficulties do not seek professional help. • Living with untreated mental health difficulties has significant negative implications for individuals, society and the economy. • During interviews with veterans suffering from mental health difficulties, we learned about a number of barriers which got in the way of them accessing help, and a number of enablers which allowed them to get the help that they required.
25.  Costs of treating patients with schizophrenia who have illness-related crisis events 
BMC Psychiatry  2008;8:72.
Background
Relatively little is known about the relationship between psychosocial crises and treatment costs for persons with schizophrenia. This naturalistic prospective study assessed the association of recent crises with mental health treatment costs among persons receiving treatment for schizophrenia.
Methods
Data were drawn from a large multi-site, non-interventional study of schizophrenia patients in the United States, conducted between 1997 and 2003. Participants were treated at mental health treatment systems, including the Department of Veterans Affairs (VA) hospitals, community mental health centers, community and state hospitals, and university health care service systems. Total costs over a 1-year period for mental health services and component costs (psychiatric hospitalizations, antipsychotic medications, other psychotropic medications, day treatment, emergency psychiatric services, psychosocial/rehabilitation group therapy, individual therapy, medication management, and case management) were calculated for 1557 patients with complete medical information. Direct mental health treatment costs for patients who had experienced 1 or more of 5 recent crisis events were compared to propensity-matched samples of persons who had not experienced a crisis event. The 5 non-mutually exclusive crisis event subgroups were: suicide attempt in the past 4 weeks (n = 18), psychiatric hospitalization in the past 6 months (n = 240), arrest in the past 6 months (n = 56), violent behaviors in the past 4 weeks (n = 62), and diagnosis of a co-occurring substance use disorder (n = 413).
Results
Across all 5 categories of crisis events, patients who had a recent crisis had higher average annual mental health treatment costs than patients in propensity-score matched comparison samples. Average annual mental health treatment costs were significantly higher for persons who attempted suicide ($46,024), followed by persons with psychiatric hospitalization in the past 6 months ($37,329), persons with prior arrests ($31,081), and persons with violent behaviors ($18,778). Total cost was not significantly higher for those with co-occurring substance use disorder ($19,034).
Conclusion
Recent crises, particularly suicide attempts, psychiatric hospitalizations, and criminal arrests, are predictive of higher mental health treatment costs in schizophrenia patients.
doi:10.1186/1471-244X-8-72
PMCID: PMC2533651  PMID: 18727831

Results 1-25 (1908368)