Veterans In Primary Care Research Articles

Home-based primary care providers' perspectives on the unique challenges of working with late life posttraumatic stress disorder within their population of Veterans.

Posttraumatic stress disorder (PTSD) is more prevalent in medically ill older Veterans in Home-Based Primary Care (HBPC) settings than in the general population, raising unique considerations. The aim of this qualitative project was to explore HBPC mental health providers' perceptions of the presentation and treatment of PTSD and trauma-related symptoms in this population of older Veterans, many of whom face additional barriers to treatment due to living in rural settings. Five focus groups and one one-on-one interview were conducted with 23 HBPC mental health providers serving rural or rural/urban mixed communities across the United States. We applied qualitative content analysis to the data. Three themes were found: (1) Presentation of Trauma-Related Symptoms and PTSD in HBPC Population; (2) Treatment Challenges in HBPC; and (3) PTSD Treatment Strategies. Each theme had multiple subthemes which illustrate unique issues in this population. Results of this project contribute to key insights surrounding the unique presentation of PTSD and trauma-related processes and treatment considerations in a medically, cognitively, and psychosocially complex group of veterans. Efforts to improve access to care should consider the specific needs of veterans who are homebound, live in rural settings and identify with rural cultural norms, and have difficulty engaging in specialized PTSD treatment due to the convergence of these factors. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Preliminary Investigation Into the Effectiveness of Group webSTAIR for Trauma-exposed Veterans in Primary Care.

A substantial number of trauma-exposed veterans seen in primary care report significant symptoms of PTSD and depression. While primary care mental health integration (PCMHI) providers have been successful in delivering brief mental health treatments in primary care, few studies have evaluated interventions that combine mobile health resources with PCMHI groups. This pilot study assessed the potential benefits of webSTAIR, a 10-module transdiagnostic treatment for trauma-exposed individuals, supported by 5 biweekly group sessions delivered via telehealth. The transdiagnostic and mobile health nature of the treatment, as well as the therapist and peer support provided through group sessions, may offer an innovative approach to increasing access to patient-centered and trauma-informed treatment in primary care settings. Thirty-nine male and female veterans with trauma-related symptoms (i.e., PTSD and/or depression) participated in group webSTAIR. Mixed effects analyses were conducted to assess changes in PTSD and depression at pre-, mid-, and post-treatment. Baseline symptom severity was assessed as a predictor of module completion and group attendance. The project was part of a VHA quality improvement project, and IRB approval was waived by the affiliated university. Analyses revealed significant pre-to-post improvement in both PTSD and depression outcomes with a large effect size for PTSD (Hedges' gav = 0.88) and medium to large for depression (Hedges' gav = 0.73). Of participants who completed the baseline assessment, 90% began webSTAIR; of those, 71% completed the program. Baseline symptoms of PTSD and depression did not predict group attendance or module completion. Good outcomes and a satisfactory retention rate suggest that group webSTAIR may provide easily accessible, high-quality, and effective treatment for patients presenting with trauma-related problems without increasing therapist or system burdens. The results suggest the value of conducting a randomized controlled trial to test the effectiveness of group webSTAIR relative to PCMHI usual care or other evidence-based, disorder-specific (e.g., PTSD) treatments for trauma-exposed individuals in PCMHI.

Integrating stakeholder feedback into the design of a peer-delivered primary care wellness program: A rapid qualitative study

BackgroundIndividuals seen in Primary Care with behavioral health concerns who decline behavioral health treatment may benefit from the support of peers (consumers in recovery from behavioral health concerns employed to support other consumers). Whole Health STEPS is a new intervention for Veterans in Primary Care with behavioral health concerns which combines essential elements of peers’ role and the Whole Health model using a stepped-care design. We incorporated stakeholder feedback in the Whole Health STEPS design to improve fit with Veterans, peers, and primary care settings.MethodsWe conducted semi-structured qualitative interviews with VA staff using questions derived from the Consolidated Framework for Implementation Research (CFIR). Participants were recruited via a maximum variation strategy across a national sample and interviewed between January 2021-April 2021. The analytic design was a rapid qualitative analysis. Interviews addressed design decisions and potential barriers and facilitators to future implementation. Then, we made adaptations to Whole Health STEPS and catalogued changes using the Framework for Adaptations and Modifications-Enhanced (FRAME). A VA peer conducted the interviews, participated in analyses, assisted with design modifications, and co-wrote this paper.ResultsSixteen staff members from 9 VA primary care peer programs participated (8 peers and 8 supervisors/administrators). Feedback themes included: capitalizing on peer skills (e.g., navigation), ensuring patient-centered and flexible design, and making it easy and efficient (e.g., reducing session length). Understanding the structure of primary care peers’ roles and their interactions with other programs helped us identify role conflicts (e.g., overlap with Whole Health Coaches and Health Behavior Coordinators), which led to design modifications to carve out a unique role for Whole Health STEPS. Staff also made recommendations about marketing materials and training tools to support Whole Health STEPS roll out.ConclusionsFeedback from frontline staff, including peers, in the design process was crucial to identifying essential modifications that would not have been possible after initial trials without re-evaluating efficacy due to the extent of the changes. Whole Health STEPS was adapted to fit within a range of program structures, emphasize peers’ unique contributions, and streamline delivery. Lessons learned can be applied to other interventions.

Peer-supported mobile mental health for veterans in primary care: A pilot study.

One in four veteran primary care patients suffers from a mental health condition; however, most do not receive any treatment for these problems. Mobile health (mHealth) can overcome barriers to care access, but poor patient engagement limits the effectiveness and implementation of these tools. Peers may facilitate patient engagement with mHealth. We designed a protocol for peers to support implementation of mobile mental health tools in primary care and tested the feasibility, acceptability, and clinical utility of this approach. Thirty-nine patients across two Veterans Affairs sites who screened positive for depression during a primary care visit and were not currently in mental health treatment were enrolled. Participants were scheduled for four phone sessions with a peer over 8 weeks and introduced to five mobile apps for a range of transdiagnostic mental health issues (stress, low mood, sleep problems, anger, and trauma). Pre/post phone interviews using quantitative and qualitative approaches assessed participants' self-reported app use, satisfaction with the intervention, symptom change (stress, anxiety, depression, insomnia), and progress with personal health goals. On average, patients reported using 3.04 apps (SD = 1.46). Per the Client Satisfaction Questionnaire, global satisfaction with the intervention was high (M = 25.71 out of 32, SD = 3.95). Pre to post participants reported significant improvements in their level of stress, based on a quantitative measure (p = .008), and 87% reported progress on at least one personal health goal. Findings support the feasibility, acceptability, and clinical utility of peer-supported mobile mental health for veterans in primary care. A randomized controlled trial of an adaptive version of this intervention is recommended. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Impacts of COVID-19 on Health and Healthcare for Rural Veterans in Home-Based Primary Care.

This qualitative study explored the impact of COVID-19 on older rural-dwelling veterans and their caregivers enrolled in home-based primary care (HBPC) through the Birmingham VA Health Care System (BVAHCS). Phone interviews were conducted with 16 veterans and/or their caregivers and rapid qualitative analysis of interview notes was performed. Average age of veterans was 77 (range = 69-97) and 93.7% were white males. Despite a significant number of co-morbidities, 68.8% reported minimal adverse impacts of COVID-19 on overall physical and mental health. Like many healthcare teams, the inter-disciplinary VA HBPC team incorporated Telehealth during COVID-19. Telehealth utilization varied among the 16 participants, with 50% using telehealth independently, 37.5% needing assistance, and 12% lacking access. Our findings are consistent with prior research that identifies resilient characteristics as potentially protective in this high-risk older veteran population during the COVID-19 pandemic.

Pain and Hazardous Alcohol Use in Veterans in Primary Care: The Role of Affective Pain Interference and Alcohol Pain-Coping Perceptions

Chronic pain and unhealthy alcohol use commonly co-occur and are associated with negative health outcomes. Veterans may be particularly vulnerable to these conditions, yet limited research has examined factors involved in their co-occurrence. This cross-sectional study aimed to examine the role of affective pain interference and alcohol pain-coping perceptions in the relationship between pain and hazardous alcohol use. As informed by the catastrophizing, anxiety, negative urgency, and expectancy model, we hypothesized that the relationship between pain and hazardous alcohol consumption is mediated by affective pain interference and stronger among those with greater perceptions that alcohol helps cope with pain. Participants were 254 VA primary care patients (87.8% male, Mage = 64.03, 76.4% White) with a history of chronic musculoskeletal pain, past-year alcohol use, and past-week pain. Veterans completed a mailed survey including measures of pain, affective pain interference, alcohol pain-coping perceptions, and hazardous alcohol use. Hypotheses were tested with regression models and PROCESS macros. As hypothesized, affective pain interference mediated the pain-hazardous alcohol use association. Contrary to hypotheses, results showed no moderating effect of alcohol pain-coping perceptions. Findings partially support relationships among theorized constructs and suggest that for Veterans with co-occurring pain and alcohol use it may be important to target pain-related affective interference and perceptions that alcohol helps cope with pain. PerspectiveThis article presents a test of factors involved in the pain and alcohol relationship, as informed by the CANUE model. Findings suggest that for Veterans with co-occurring pain and past-year alcohol use, it may be important to target pain-related affective interference and perceptions that alcohol helps cope with pain.

Managing Social Isolation during the COVID-19 Pandemic: Perspectives from US Department of Veterans Affairs Home-Based Primary Care Veterans and Caregivers

The COVID-19 pandemic proved especially devastating for older adults who are primarily homebound, as well as their caregivers. The objective of this study was to describe how United States (US) Veterans—and their caregivers—who receive care from the US Department of Veterans Affairs (VA) Home Based Primary Care (HBPC) program managed increased social isolation due to the COVID-19 pandemic. We designed a qualitative study and conducted phone interviews with Veterans and their caregivers receiving VA HBPC care, interviewing N = 44 Veterans and caregivers from eight VA HBPC programs across the US. We audio recorded and transcribed all interview data and applied an inductive and deductive approach to thematic analysis to analysis. The following themes emerged illustrating how Veterans and caregivers managed increased isolation during the pandemic: 1) normalizing challenges; 2) caregivers struggling to manage isolation, as Veterans were accustomed to being homebound; 3) relying heavily on social support of family and/or friends and neighbors, and engaging in creative activities; and 4) those living in their own homes found increased isolation more manageable than those living in assisted living facilities. Results show HBPC Veterans & their caregivers with stronger social networks drew upon previously curated social capital to manage isolation and took a “we’re all in this together” attitude toward the pandemic. Results can inform community programs, healthcare systems, and policy makers to target efforts when creating supportive programs and policies for older adults and caregivers, especially those with smaller social support networks and those living in assisted living facilities.

Association of Diet Quality with Metabolic (Dysfunction) Associated Fatty Liver Disease in Veterans in Primary Care.

Diet is associated with metabolic (dysfunction)-associated fatty liver disease (MAFLD), but the dietary composition associated with MAFLD risk has not been well-examined. The purpose of this study was to assess the association of two healthy eating indices with the presence and severity of MAFLD in a sample of Veterans in a primary care setting. This was a single center cross-sectional study using a random stratified sample of Veterans enrolled in primary care. Participants underwent a Fibroscan and completed an interviewer-administered Diet History Questionnaire II from which we calculated the Healthy Eating Index-2015 and Alternate Mediterranean Diet Score. We used multivariable logistic regression models to assess associations of dietary quality with MAFLD. We analyzed data from 187 participants, 53.5% of whom were female. On average, participants were 50.2 years of age (SD, 12.3 years) with an average BMI of 31.7 kg/m2. MAFLD was detected in 78 (42%) and at least moderate fibrosis in 12 (6%) participants. We found that the Alternate Mediterranean Diet Score was inversely associated with MAFLD (adjusted OR = 0.85, 95%CI 0.72-1.00), but controlling for BMI and total energy intake attenuated the association (adjusted OR = 0.92, 95%CI 0.74-1.15). We found no statistically significant associations between the Healthy Eating Index-2015 and MAFLD or advanced fibrosis. We found that the Alternate Mediterranean Diet Score was significantly associated with lower MAFLD risk in Veterans; however, the association was mediated by BMI and total energy intake. A Mediterranean-style diet could potentially help reduce the risk of MAFLD, particularly if it helps control total energy intake and weight.

Development and Initial Testing of a Brief, Integrated Intervention Aimed at Reducing Heavy Alcohol Use and PTSD among Military Veterans in Primary Care.

There is a need for integrated treatment approaches that address heavy alcohol use and posttraumatic stress disorder (PTSD) concurrently among Veterans as interactions between heavy drinking and PTSD are frequent. Veteran engagement in specialty mental health services after referral is limited with poorer outcomes following empirically-supported, exposure-based PTSD treatments that do not explicitly address alcohol use. The current project aimed to incorporate two evidenced-based interventions: Brief Motivational Intervention (BMI) with Prolonged Exposure for Primary Care (PE-PC) for Veterans with heavy drinking and PTSD. Delphi methodology was applied to adapt an intervention protocol using subject matter expert (SME) feedback to guide the refinement of a preliminary treatment manual. The newly developed brief intervention (PC-TIME) was then tested in an open trial (n=9) to gather Veteran participant feedback to modify the treatment manual.Two rounds of SME feedback resulted in 80% agreement that manual content was "acceptable as-is" across all intervention domains. The resulting protocol is a five-session, integrated intervention with session 1 primarily focused on alcohol use reduction and sessions 2-5 consisting of narrative exposure and in-vivo exercises for PTSD symptoms with brief alcohol use check-ins. Open trial results indicated high Veteran acceptance of PC-TIME structure and content, and reductions in heavy drinking and PTSD symptoms. Preliminary data suggest PC-TIME to be a promising approach for treatment of heavy alcohol use and PTSD. A pilot randomized controlled trial is necessary to demonstrate the intervention's efficacy with Veterans in a PC setting.

Adapting Group CBT-I for Telehealth-to-Home With Military Veterans in Primary Care.

Utilization of telehealth modalities to provide cognitive and behavioral therapies is rapidly increasing. Limitations to access to care can prohibit individuals from getting the care they need, especially evidence-based treatments. In the U.S., Veterans are a population in great need of accessible and high-quality evidence-based psychotherapy for insomnia, as it often co-occurs with other common syndromes such as depression and PTSD. Cognitive Behavioral Therapy for Insomnia (CBT-I) offers effective treatment for insomnia and can be delivered via telehealth and in a group format to greatly increase availability and accessibility. To date, however, few programs exist offering telehealth-to-home CBT-I, fewer still are offered in a primary care setting, and none to our knowledge are offered in group format. We examine the feasibility and efficacy of a fully telehealth-to-home (TTH) group CBT-I pilot program in primary care and compare primary outcomes to those seen in a face-to-face (F2F) format as well as meta-analytic studies of group CBT-I. Primary endpoints, as typically defined such as sleep efficiency (SE) and scores on the insomnia severity index (ISI) appear comparable to those seen in F2F groups in our clinic, and to outcomes seen in the literature. We discuss challenges and strategies for successful implementation of such a program in integrated primary care to increase access and availability of this evidence-based treatment.

Integrating data analytics, peer support, and whole health coaching to improve the health outcomes of homeless veterans: Study protocol for an effectiveness-implementation trial

BackgroundHomelessness is a strong determinant of acute care service utilization (inpatient hospitalization, emergency department visits) among US adults. Data analytics, peer support, and patient-centered approaches can collectively offer high-quality care for homeless patients who frequently utilize acute care (“super utilizers”). However, few outpatient programs have integrated these components and tested their effectiveness for this patient population. ObjectiveTo test the effectiveness and implementation potential of a novel intervention that integrates data analytics with peers trained in whole health coaching (“Peer Whole Health”) to reduce use of acute care among homeless adults. MethodsUsing a randomized controlled trial design at two US Veterans Health Administration Medical Centers, we plan to enroll 220 veterans in primary care on VHA's Homeless Registry who are flagged on a super-utilizer clinical dashboard. Participants will complete a baseline interview, be randomized to Enhanced Usual Care (EUC; primary care and data analytics) or EUC plus 18 sessions of Peer Whole Health over 6 months, and be re-interviewed at 3, 6, and 9 months. Qualitative interviews with primary care staff and patients will identify facilitators and barriers to more widespread implementation of the intervention. DiscussionThe primary hypothesis is that those who receive the intervention will have fewer total days of all-cause hospitalization. If confirmed, the findings can provide healthcare systems that serve homeless super-utilizers with a high-value approach to care that can be integrated into primary care services and reduce overall costs for these patients.Clinical trial registration: The study is registered with ClinicalTrials.gov (NCT05176977).

Two-year change in latent classes of comorbidity among high-risk Veterans in primary care: a brief report

BackgroundSegmentation models such as latent class analysis are an increasingly popular approach to inform group-tailored interventions for high-risk complex patients. Multiple studies have identified clinically meaningful high-risk segments, but few have evaluated change in groupings over time.ObjectivesTo describe population-level and individual change over time in latent comorbidity groups among Veterans at high-risk of hospitalization in the Veterans Health Administration (VA).Research designUsing a repeated cross-sectional design, we conducted a latent class analysis of chronic condition diagnoses. We compared latent class composition, patient high-risk status, and patient class assignment in 2018 to 2020.SubjectsTwo cohorts of eligible patients were selected: those active in VA primary care and in the top decile of predicted one-year hospitalization risk in 2018 (n = 951,771) or 2020 (n = 978,771).MeasuresMedical record data were observed from January 2016–December 2020. Latent classes were modeled using indicators for 26 chronic health conditions measured with a 2-year lookback period from study entry.ResultsFive groups were identified in both years, labeled based on high prevalence conditions: Cardiometabolic (23% in 2018), Mental Health (18%), Substance Use Disorders (16%), Low Diagnosis (25%), and High Complexity (10%). The remaining 8% of 2018 patients were not assigned to a group due to low predicted probability. Condition prevalence overall and within groups was stable between years. However, among the 563,725 patients identified as high risk in both years, 40.8% (n = 230,185) had a different group assignment in 2018 versus 2020.ConclusionsIn a repeated latent class analysis of nearly 1 million Veterans at high-risk for hospitalization, population-level groups were stable over two years, but individuals often moved between groups. Interventions tailored to latent groups need to account for change in patient status and group assignment over time.

Primary Care Veteran Preferences for Receiving Information about Mental Health Services: Cross-Sectional Survey

The purpose of this study was to understand contextual characteristics of how veterans in primary care prefer to receive mental healthcare information (i.e., information about mental health symptoms/services) in terms of provider, location, and format. One hundred sixteen primary care veterans with behavioral health concerns (58% depression, 37% PTSD, 50% hazardous alcohol use) participated in a cross-sectional phone and mail survey. Forty-seven percent had recently received mental health services; Fifty-three percent had not. Overall, veterans preferred receiving mental health information from behavioral health providers (<em>n</em> = 55, 47%) and via individual face-to-face communication (<em>n</em> = 65, 56%). However, veterans without recent mental health treatment were more likely to endorse home as their most preferred location (<em>n</em> = 18, 29%) and mailed self-help materials as their most preferred format (<em>n</em> = 11, 18%) compared to veterans with recent mental health treatment. Veterans with recent mental health treatment were more likely to endorse Veterans Affairs behavioral health clinics as their most preferred location (<em>n</em> = 23, 43%) and face-to-face communication as their most preferred format (<em>n</em> = 37, 69%) compared to veterans without recent mental health treatment. When tailoring mental health communication to veterans with behavioral health concerns, findings suggest that recent mental health treatment history is an important distinction. These results can inform development of public health messaging, decision aids, and psychoeducational material for veterans. Future research should evaluate the impact of age, gender, and service era on preferences to better understand how to tailor messaging and materials to more specific groups of veterans.

Effect of Pharmacist Interventions on Hospital Readmissions for Home-Based Primary Care Veterans

Several studies indicate that when patients transition from one level of care to another, errors may occur. Pharmacists can play an integral role in the transitions of care process. At Michael E. DeBakey Veteran Affairs Medical Center, the Home-Based Primary Care (HBPC) service has implemented a streamlined hospital discharge plan to improve 30-day readmission rates after 1 year of HBPC enrollment. Our aim was to identify specific pharmacist interventions to improve the HBPC discharge process and ultimately, improve hospital readmission rates. A Plan-Do-Study-Act quality improvement project was initiated. We conducted a review of veterans enrolled in HBPC from October 2019 to March 2020. Of 175 patients assessed postdischarge, a medication reconciliation was completed by an HBPC pharmacist in 118 (67.4%) patients. Of the 118 medication reconciliations completed, 92 (78%) interventions were made by HBPC pharmacists. During the 6-month study period, 30-day hospital readmission rates decreased from 19% to 13%. This study demonstrates several opportunities for interventions to lower readmission rates. Using the results from this study, education has been provided for the HBPC service and its readmission committee.

Engagement, experience, and satisfaction with peer-delivered whole health coaching for veterans with PTSD: A mixed methods process evaluation.

To describe the process of peer-delivered Whole Health Coaching, a primary care-based intervention in which peers provide patients with individualized support to set and work toward wellness goals. Fifteen primary care Veterans with PTSD participated in peer-delivered Whole Health Coaching during a multiple baseline design study. This is a planned mixed methods concurrent equal status analysis of the process of peer-delivered Whole Health Coaching including patient engagement, patient experience, fidelity to the coaching and peer roles, and patient satisfaction. Data sources were feedback interviews, electronic medical record reviews, self-report assessments, and observer fidelity ratings of session recordings. Qualitative data were used to expand the interpretation of quantitative descriptive data. A rapid assessment approach was used for qualitative analysis. Retention in peer-delivered Whole Health Coaching was 11 of 15 participants, and factors facilitating engagement were peers as providers and flexibility in scheduling/modality of sessions. Peers demonstrated high fidelity to coaching skills, Whole Health Coaching phases and stages, and the peer role. Participants expressed high satisfaction and perceived peer-delivered Whole Health Coaching as helpful with making progress on individualized wellness goals. Results build on the literature describing the expansion of peer services into primary care and implementation of interventions such as wellness coaching. This initial small study suggests that peers can deliver high-quality wellness coaching, and this description of the process can guide the integration of peers doing wellness coaching in similar clinical settings and for future research trials. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

The Flares of Low back pain with Activity Research Study (FLAReS): study protocol for a case-crossover study nested within a cohort study

BackgroundAlthough it is generally accepted that physical activity and flares of low back pain (LBP) are related, evidence for the directionality of this association is mixed. The Flares of Low back pain with Activity Research Study (FLAReS) takes a novel approach to distinguish the short-term effects of specific physical activities on LBP flares from the cumulative effects of such activities, by conducting a longitudinal case-crossover study nested within a cohort study. The first aim is to estimate the short-term effects (≤ 24 h) of specific physical activities on LBP flares among Veterans in primary care in the Veterans Affairs healthcare system. The second aim is to estimate the cumulative effects of specific activities on LBP-related functional limitations at 1-year follow-up.MethodsUp to 550 adults of working age (18—65 years) seen for LBP in primary care complete up to 36 “Scheduled” surveys over 1-year follow-up, and also complete unscheduled “Flare Window” surveys after the onset of new flares. Each survey asks about current flares and other factors associated with LBP. Surveys also inquire about activity exposures over the 24 h, and 2 h, prior to the time of survey completion (during non-flare periods) or prior to the time of flare onset (during flares). Other questions evaluate the number, intensity, duration, and/or other characteristics of activity exposures. Other exposures include factors related to mood, lifestyle, exercise, concurrent treatments, and injuries. Some participants wear actigraphy devices for weeks 1–4 of the study. The first aim will examine associations between 10 specific activity categories and participant-reported flares over 1-year follow-up. The second aim will examine associations between the frequency of exposure to 10 activity categories over weeks 1–4 of follow-up and long-term functional limitations at 12 months. All analyses will use a biopsychosocial framework accounting for potential confounders and effect modifiers.DiscussionFLAReS will provide empirically derived estimates of both the short-term and cumulative effects of specific physical activities for Veterans with LBP, helping to better understand the role of physical activities in those with LBP.Trial RegistrationClinicalTrials.gov NCT04828330, registered April 2, 2021.

Racial Disparities in Prescription of Antidepressants Among U.S. Veterans Referred to Behavioral Health Care.

Antidepressants are often prescribed in primary care to treat veterans who have depression. An evaluation of current racial disparities in integrated primary care is warranted. This study examined the association between race and prescription of antidepressants among veterans in primary care. Veterans in primary care (Black, N=4,120; White, N=4,372) who were referred from primary care to a collaborative care program completed an assessment of demographic characteristics and clinical symptoms, including of current antidepressant prescription before the referral, verified by chart review. Patient data were collected from January 1, 2015, to December 22, 2020. Logistic regression analyses were conducted to examine the relationships between patient race and both depression symptoms and antidepressant prescription. Analyses were also stratified by severity of depression symptoms to understand the results in the context of clinical guidelines. White patients were almost two times (odds ratio=1.96, 95% confidence interval [CI]=1.75–2.19, p<0.001) more likely than Black patients to receive an antidepressant prescription, after the analysis was controlled for depression symptoms, demographic characteristics, and other clinical symptoms. Among patients with severe depression, for whom prescription of antidepressants is clinically indicated, White patients were 1.87 times more likely than Black patients to receive an antidepressant prescription (95% CI=1.40–2.50, p<0.001). The findings reveal racial disparities in antidepressant prescription for veterans in primary care. Regular clinical review of antidepressant prescription is recommended to identify disparities in individual clinics. Future research should aim to identify drivers of racial disparities and provide recommendations for health care systems, providers, and patients.

Prevalence of medical and nonmedical cannabis use among veterans in primary care.

This study examined past-year cannabis use prevalence and sociodemographic and clinical correlates of cannabis use among Veterans Health Administration (VHA) primary care patients in a state with legalized medical cannabis. Participants were 1,072 predominantly white, male, VHA primary care patients enrolled in a drug screening validation study (2012-2014). Sociodemographic and clinical correlates were examined by past-year cannabis use status. Multivariate regression models, adjusted for demographics, estimated cannabis use prevalence and clinical correlates among recreational, medical, and both medical and recreational users. Nearly one in five (18.7%) veterans endorsed past-year cannabis use, with 14.1% of the total sample reporting any recreational use and 7.0% reporting any medical use. Correlates of any past-year use included younger age, period of service, being unmarried, lower education, lower income, other substance use, meeting criteria for an alcohol or drug use disorder or posttraumatic stress disorder, higher pain rating, and lower self-reported well-being. Compared to veterans endorsing only recreational use, veterans endorsing only medical use reported more cannabis use days but had lower odds of other drug use, alcohol or drug-related problems, or alcohol or drug use disorders. Differences between recreational only users and those using medical and recreational cannabis were minimal. Veterans enrolled in VHA in states with legalized cannabis may be particularly likely to use cannabis. Veterans identifying as recreational users may be at increased risk for adverse clinical outcomes compared to medical-only users. Prevalence monitoring, assessment, and intervention services should be considered, particularly in states with legalized cannabis. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Impact of Social Isolation Due to COVID-19 on VA Home-Based Primary Care Veterans and Caregivers

In December 2020 we began conducting phone interviews with Veterans, and their caregivers, receiving care through the United Sates (US) Department of Veterans Affairs (VA) Home Based Primary Care (HBPC) program. Our goal was to describe experiences of Veterans and caregivers managing changes in care delivery related to the COVID-19 pandemic and navigating increased social isolation due to social distancing. We interviewed 38 Veterans (average age 78) and caregivers (average age 62) across seven VA HBPC programs. Findings showed those living in their own homes found increased isolation more manageable than those living in assisted living facilities, which restricted visitors. Caregivers had a harder time managing isolation than Veterans, as Veterans were used to being primarily homebound. Veterans and caregivers relied on increased phone communication with their HBPC teams, with some began participating in virtual visits. Implications include insights into better supporting older, homebound adults and their caregivers during disasters.

Anxiety treatment preferences among veteran primary care patients: Demographic, mental health, and treatment-related correlates.

Anxiety symptoms are common, yet undertreated, among primary care patients. Accommodating patient treatment preferences improves engagement and retention. In contrast to depression, little is known about primary care patients' preferences for anxiety treatment. Participants were 144 veterans experiencing anxiety symptoms but not receiving psychotherapy who were recruited from primary care. Preferences for 11 anxiety treatment attributes (method; location; type; format; provider; frequency, length, and number of appointments; psychotherapy orientation; symptom focus; and topic/skill) and demographic, mental health (e.g., anxiety symptom severity), and treatment-related (e.g., psychotherapy history) variables were assessed via mailed survey. We used chi-square goodness of fit tests to identify patient preferences for each attribute and multivariate multinomial logistic regression models to explore demographic, mental health, and treatment-related correlates of treatment preferences. Patient preferences were largely consistent with integrated primary care models, particularly Primary Care Behavioral Health, with a few exceptions. Patients preferred longer appointments (e.g., 45-60 minutes) and a longer duration of treatment (e.g., ≥13 appointments) than is typically offered in primary care. Several variables, particularly education level, perceived need for help, anxiety symptom severity, and attitudes toward psychotherapy, were repeatedly associated with preferences for various anxiety treatment attributes. Results from this study suggest that patients tend to have distinct preferences for anxiety treatment in primary care that are largely consistent with common integrated primary care models. Results also identify several variables that may be associated with specific preferences, which may help match patients to their preferred type of care. (PsycInfo Database Record (c) 2021 APA, all rights reserved).