Predictors of Primary Care Management of Depression in the Veterans Affairs Healthcare System

BACKGROUND

Primary care providers (PCPs) vary in skills to effectively treat depression. Key features of evidence-based collaborative care models (CCMs) include the availability of depression care managers (DCMs) and mental health specialists (MHSs) in primary care. Little is known, however, about the relationships between PCP characteristics, CCM features, and PCP depression care.

OBJECTIVE

To assess relationships between various CCM features, PCP characteristics, and PCP depression management.

DESIGN

Cross-sectional analysis of a provider survey.

PARTICIPANTS

180 PCPs in eight VA sites nationwide.

MAIN MEASURES

Independent variables included scales measuring comfort and difficulty with depression care; collaboration with a MHS; self-reported depression caseload; availability of a collocated MHS, and co-management with a DCM or MHS. Covariates included provider type and gender. For outcomes, we assessed PCP self-reported performance of key depression management behaviors in primary care in the past 6 months.

KEY RESULTS

Response rate was 52 % overall, with 47 % attending physicians, 34 % residents, and 19 % nurse practitioners and physician assistants. Half (52 %) reported greater than eight veterans with depression in their panels and a MHS collocated in primary care (50 %). Seven of the eight clinics had a DCM. In multivariable analysis, significant predictors for PCP depression management included comfort, difficulty, co-management with MHSs and numbers of veterans with depression in their panels.

CONCLUSIONS

PCPs who felt greater ease and comfort in managing depression, co-managed with MHSs, and reported higher depression caseloads, were more likely to report performing depression management behaviors. Neither a collocated MHS, collaborating with a MHS, nor co-managing with a DCM independently predicted PCP depression management. Because the success of collaborative care for depression depends on the ability and willingness of PCPs to engage in managing depression themselves, along with other providers, more research is necessary to understand how to engage PCPs in depression management.     

Barriers to Veterans Health Administration Care in a Nationally Representative Sample of Women Veterans

BACKGROUND: Women veterans are generally less healthy than their nonveteran female counterparts or male veterans. Accumulating evidence suggests there may be barriers to women veterans' access to and use of Veterans Health Administration (VHA) care.
OBJECTIVE: To document perceived and/or actual barriers to care in a nationally representative sample of women veterans and examine associations with VHA use.
DESIGN: Cross-sectional telephone survey.
PARTICIPANTS: Women who are current and former users of VHA from VA's National Registry of Women Veterans.
MEASUREMENTS: Assessments of perceptions of VHA care, background characteristics, and health service use.
RESULTS: Perceptions of VHA care were most positive regarding facility/physical environment characteristics and physician skill and sensitivity and least positive regarding the availability of needed services and logistics of receiving VHA care ( M =0.05 and M =−0.10; M =−0.23 and M =−0.25, respectively). The most salient barrier to the use of VHA care was problems related to ease of use. Moreover, each of the barriers constructs contributed unique variance in VHA health care use above and beyond background characteristics known to differentiate current users from former VHA users (Odds ratio [OR]=4.03 for availability of services; OR=2.63 for physician sensitivity and skill: OR=2.70 for logistics of care; OR=2.30 for facility/physical environment). Few differences in barriers to care and their association with VHA health care use emerged for women with and without service-connected disabilities.
CONCLUSIONS: Findings highlight several domains in which VHA decisionmakers can intervene to enhance the care available to women veterans and point to a number of areas for further investigation.     

Spouse Concordance for Alcohol Dependence and Heavy Drinking: Evidence from a Community Sample

Using data from a community sample of 586 married couples, levels of spouse concordance for lifetime and current alcohol dependence and heavy drinking were estimated. In addition, marital quality ratings in concordant and discordant couples were compared. Spouse concordance was significant for lifetime alcohol dependence and for both lifetime and current heavy drinking. Marital quality varied as a function of current heavy drinking and alcohol dependence such that members of couples in which neither spouse drank heavily reported better marital quality than other couples. Furthermore, although marital quality did not differ significantly between concordant and discordant couples, couples concordant for current heavy drinking consistently reported poorer marital quality than other couples.     

Linkage Analysis of Alcohol Dependence Symptoms in the Community

Background:  We have previously identified suggestive linkage for alcohol consumption in a community-based sample of Australian adults. In this companion paper, we explore the strength of genetic linkage signals for alcohol dependence symptoms.
Methods:  An alcohol dependence symptom score, based on DSM-IIIR and DSM-IV criteria, was examined. Twins and their nontwin siblings (1,654 males, 2,518 females), aged 21 to 81 years, were interviewed, with 803 individuals interviewed on 2 occasions, approximately 10 years apart. Linkage analyses were conducted on datasets compiled to maximize data collected at either the younger or the older age. In addition, linkage was compared between full samples and truncated samples that excluded the lightest drinkers (approximately 10% of the sample).
Results:  Suggestive peaks on chromosome 5p (LODs >2.2) were found in a region previously identified in alcohol linkage studies using clinical populations. Linkage signal strength was found to vary between full and truncated samples and when samples differed only on the collection age for a sample subset.
Conclusions:  The results support the finding that large community samples can be informative in the study of alcohol-related traits .     

Patterns of Lifetime Alcohol Use in a Clinical Sample of Older Male Veterans

Abstract

In our clinical work with veterans enrolled in psycho geriatric clinical study, we became intrigued by their range of alcohol histories and undertook a study to understand more about older veterans' experiences with alcohol over a lifetime. A questionnaire designed for the purposes of this study included the CAGE, a lifetime drinking graph, and questions about how and why veterans quit drinking. Eighty-three male veterans participated in this clinical study. Participants described a range of drinking histories, although most were currently abstinent, having quit drinking without participation in a treatment program. Five case studies are presented to illustrate these lifetime patterns, as well as clinical challenges for working with older veterans with drinking problems.     

Primary Care Tasks Associated with Provider Burnout: Findings from a Veterans Health Administration Survey

Background

The patient-centered medical home (PCMH) is a primary care delivery model predicated on shared responsibility for patient care among members of an interprofessional team. Effective task sharing may reduce burnout among primary care providers (PCPs). However, little is known about the extent to which PCPs share these responsibilities, and which, if any, of the primary care tasks performed independently by the PCPs (vs. shared with the team) are particularly associated with PCP burnout. A better understanding of the relationship between these tasks and their effects on PCP burnout may help guide focused efforts aimed at reducing burnout.

Objective

To investigate (1) the extent to which PCPs share responsibility for 14 discrete primary care tasks with other team members, and (2) which, if any, of the primary care tasks performed by the PCPs (without reliance on team members) are associated with PCP burnout.

Design

Secondary data analysis of Veterans Health Administration (VHA) survey data from two time periods.

Participants

327 providers from 23 VA primary care practices within one VHA regional network.

Main Measures

The dependent variable was PCP report of burnout. Independent variables included PCP report of the extent to which they performed 14 discrete primary care tasks without reliance on team members; team functioning; and PCP-, clinic-, and system-level variables.

Key Results

In adjusted models, PCP reports of intervening on patient lifestyle factors and educating patients about disease-specific self-care activities, without reliance on their teams, were significantly associated with burnout (intervening on lifestyle: b = 4.11, 95% CI = 0.39, 7.83, p = 0.03; educating patients: b = 3.83, 95% CI = 0.33, 7.32, p = 0.03).

Conclusions

Performing behavioral counseling and self-management education tasks without relying on other team members for assistance was associated with PCP burnout. Expanding the roles of nurses and other healthcare professionals to assume responsibility for these tasks may ease PCP burden and reduce burnout.

     

Alcohol Dependence and Abuse Diagnoses: Validity in Community Sample Heavy Drinkers

Despite the widespread influence of the alcohol dependence syndrome concept on the major nosological classification systems, little work has been done to test the validity of the alcohol dependence syndrome in community samples. In addition, numerous questions have been asked about the validity of current definitions of alcohol abuse. We examined the cross-sectional validity of DSM-IV alcohol dependence and abuse in 936 household residents randomly selected and screened for elevated drinking. We investigated validity by testing the association of a set of seven "criterion" variables, external to the alcohol diagnostic criteria, with dependence and abuse diagnoses. Results indicated that dependence diagnoses were significantly associated with all criterion variables when compared to those with no diagnosis, even though all subjects had elevated drinking and the cases of alcohol dependence were mild. In contrast, abuse diagnoses did not show a pattern of association with the criterion variables when compared to no diagnosis. When associations were tested comparing dependence cases to those with abuse only, results were mixed. This study is one in a series of investigations in this sample of household residents screened for elevated drinking levels.     

A Randomized Clinical Trial of Alcohol Care Management Delivered in Department of Veterans Affairs Primary Care Clinics Versus Specialty Addiction Treatment

BACKGROUNDAlcohol use disorder is one of the leading causes of disability worldwide. Despite the availability of efficacious treatments, few individuals with an alcohol use disorder are actively engaged in treatment. Available evidence suggests that primary care may play a crucial role in the identification of patients with an alcohol use disorder, delivery of interventions, and the success of treatment.OBJECTIVEThe principal aims of this study were to test the effectiveness of a primary care-based Alcohol Care Management (ACM) program for alcohol use disorder and treatment engagement in veterans.DESIGNThe design of the study was a 26-week single-blind randomized clinical trial. The study was conducted in the primary care practices at three VA medical centers. Participants were randomly assigned to treatment in ACM or standard treatment in a specialty outpatient addiction treatment program.PARTICIPANTSOne hundred and sixty-three alcohol-dependent veterans were randomized.INTERVENTIONACM focused on the use of pharmacotherapy and psychosocial support. ACM was delivered in-person or by telephone within the primary care clinic.CONCLUSIONSResults demonstrate that treatment for an alcohol use disorder can be delivered effectively within primary care, leading to greater rates of engagement in treatment and greater reductions in heavy drinking.KEY WORDS: addiction, primary care, treatment, randomized clinical trial     

Prevalence and Correlates of Withdrawal‐Related Insomnia among Adults with Alcohol Dependence: Results from a National Survey

Insomnia during acute alcohol withdrawal (AWD) as well as persisting insomnia during postacute withdrawal is associated with relapse. Rates of insomnia in clinical samples of alcohol‐dependent patients range from 36% to 91%, but the prevalence of AWD‐related insomnia in the general population is unknown. The purpose of this study was to describe the prevalence of insomnia as a symptom of acute AWD and its correlates in a general population of alcohol‐dependent individuals. Data were analyzed from the 2001 to 2002 National Epidemiologic Survey on Alcohol and Related Conditions, which sampled 43,093 adults. The prevalence of AWD‐related insomnia among individuals with a lifetime diagnosis of alcohol dependence was 31.7%, which ranked fourth among the eight listed DSM‐IV withdrawal symptoms. Among individuals who met lifetime criteria for both alcohol dependence and AWD, the prevalence of insomnia was approximately 50%. Lifetime diagnoses of major depression and drug use disorders were significant correlates of AWD‐related insomnia in multivariate analyses. A less than 1‐year duration of the heaviest drinking period as well as the onset of alcohol dependence between ages 18 and 27 were negatively associated with AWD‐related insomnia. AWD‐related insomnia is a common symptom among alcohol‐dependent adults in the general population and is related to lifetime co‐occurring diagnoses, age at onset of alcohol dependence, and duration of heaviest drinking period. Its prevalence in the general population provides a representative base rate against which to compare the widely varying rates reported in clinical populations. Because of its relatively frequent prevalence and association with relapse, assessment and treatment of AWD‐related insomnia should be routinely considered in clinical settings. (Am J Addict 2010;19:238–244)     

A Preliminary Investigation of the Management of Alcohol Dependence With Naltrexone by Primary Care Providers

PURPOSE: To describe a preliminary investigation of a model of naltrexone therapy and counselling for use by primary care providers and evaluate its impact on drinking behaviors in a cohort of alcohol-dependent subjects.PATIENTS AND METHODS: The subjects enrolled in this study were 29 alcohol-dependent individuals. They were managed within a primary care treatment model located at a university-affiliated substance research program in New Haven, Connecticut. Subjects were assigned to a primary care provider for treatment of their alcohol dependence and were placed on naltrexone at a dose of 50 mg per day. They were seen for an initial “new patient” visit and 7 “brief” follow-up visits during the 10-week study. The primary outcomes for this study were completion of treatment, change in drinking behaviors from baseline, change in liver enzymes from baseline, provider ratings of improvement, and patient ratings of improvement and satisfaction with treatment.RESULTS: Of the 29 subjects: 21 (72%) completed treatment, and 10 (35%) relapsed to heavy drinking. All drinking behaviors improved significantly from baseline: percent of days abstinent increased from 36.6% to 88.8% (P < 0.0001), percent days abstinent from heavy drinking increased from 48.7% to 97.3% (P < 0.0001), and mean number of drinks per occasion decreased from 9.5 to 2.5 (P < 0.0001). The mean serum gamma glutamyl transferase (GGT) for the group decreased from 67.1 U/L to 45.3 U/L (P < 0.0001).CONCLUSIONS: In this preliminary investigation, treatment of alcohol dependence with our model of naltrexone and counselling by primary care providers appeared to be both feasible and effective.     

Predictors of Treatment Outcome in Outpatient Cocaine and Alcohol Dependence Treatment

We examined the ability of several baseline variables to predict treatment outcome in a pharmacotherapy trial that included 164 participants who were both cocaine‐ and alcohol‐dependent and were selected for a randomized, double‐blind, placebo‐controlled study. Predictor variables included results from the baseline Addiction Severity Index (ASI), initial Urine Drug Screen results, cocaine and alcohol craving and cocaine and alcohol withdrawal symptoms at the start of treatment. Successful treatment was defined as four continuous weeks of self‐reported cocaine abstinence verified by urine drug screens. In respect to demographic characteristics, there were no significant differences between patients who achieved four weeks of abstinence from cocaine and those who did not. Baseline variables that most consistently predicted cocaine abstinence included initial urine drug screen (UDS) results, the initial Cocaine Selective Severity Assessment (CSSA) scores, and initial self‐reported cocaine use in past 30 days, whereas cocaine craving, cocaine composite scores, alcohol craving, alcohol withdrawal symptoms, and alcohol composite scores did not. The results of this study suggest that cocaine dependence severity in general, and initial UDS results, the CSSA scores and frequency of recent cocaine use in particular, have a significant impact on treatment outcome in the treatment of cocaine‐dependent patients with comorbid alcoholism. Initial UDS results and CSSA scores are very useful predictors of treatment outcome and could be used as stratifying variables in outpatient cocaine and alcohol medication trials.     

Primary Care Validation of a Single-Question Alcohol Screening Test

BACKGROUND

Unhealthy alcohol use is prevalent but under-diagnosed in primary care settings.

OBJECTIVE

To validate, in primary care, a single-item screening test for unhealthy alcohol use recommended by the National Institute on Alcohol Abuse and Alcoholism (NIAAA).

DESIGN

Cross-sectional study.

PARTICIPANTS

Adult English-speaking patients recruited from primary care waiting rooms.

MEASUREMENTS

Participants were asked the single screening question, “How many times in the past year have you had X or more drinks in a day?”, where X is 5 for men and 4 for women, and a response of >1 is considered positive. Unhealthy alcohol use was defined as the presence of an alcohol use disorder, as determined by a standardized diagnostic interview, or risky consumption, as determined using a validated 30-day calendar method.

MAIN RESULTS

Of 394 eligible primary care patients, 286 (73%) completed the interview. The single-question screen was 81.8% sensitive (95% confidence interval (CI) 72.5% to 88.5%) and 79.3% specific (95% CI 73.1% to 84.4%) for the detection of unhealthy alcohol use. It was slightly more sensitive (87.9%, 95% CI 72.7% to 95.2%) but was less specific (66.8%, 95% CI 60.8% to 72.3%) for the detection of a current alcohol use disorder. Test characteristics were similar to that of a commonly used three-item screen, and were affected very little by subject demographic characteristics.

CONCLUSIONS

The single screening question recommended by the NIAAA accurately identified unhealthy alcohol use in this sample of primary care patients. These findings support the use of this brief screen in primary care.

     

Does Mental Health Care Integration Affect Primary Care Clinician Burnout? Results from a Longitudinal Veterans Affairs Survey

BackgroundBurnout among primary care clinicians (PCPs) is associated with negative health and productivity consequences. The Veterans Health Administration (VA) embedded mental health specialists and care managers in primary care to manage common psychiatric diseases. While challenging to implement, mental health integration is a team-based care model thought to improve clinician well-being.ObjectiveTo examine the relationships between PCP-reported burnout (and secondarily, job satisfaction) and mental health integration at provider and clinic levelsDesignAnalysis of 286 cross-sectional surveys in 2012 (n = 171) and 2013 (n = 115)Participants210 PCPs in one VA regionMain MeasuresOutcomes were PCP-reported burnout (Maslach Burnout Inventory emotional exhaustion subscale), and secondarily, job satisfaction. Two independent variables represented mental health integration: (1) PCP-specialty communication rating and (2) proportion of clinic patients who saw integrated specialists. Using multilevel regression models, we examined PCP-reported burnout (and job satisfaction) and mental health integration, adjusting for PCP characteristics (e.g., gender), PCP ratings of team functioning (communication, knowledge/skills, satisfaction), and organizational factors.Key ResultsOn average, PCPs reported high burnout (29, range = 9–54) across all VA healthcare systems. In total, 46% of PCPs reported “very easy” communication with mental health; 9% of primary clinic patients had seen integrated specialists. Burnout was not significantly associated with mental health communication ratings (β coefficient = − 0.96, standard error [SE] = 1.29, p = 0.46), nor with proportion of clinic patients who saw integrated specialists (β = 0.02, SE = 0.11, p = 0.88). No associations were observed with job satisfaction either. Among study participants, PCPs with poor team functioning, as exhibited by low team communication ratings, reported high burnout (β = − 1.28, SE = 0.22, p < 0.001) and low job satisfaction (β = 0.12, SE = 0.02, p < 0.001).ConclusionsAs currently implemented, primary care and mental health integration did not appear to impact PCP-reported burnout, nor job satisfaction. More research is needed to explore care model variation among clinics in order to optimize implementation to enhance PCP well-being.KEY WORDS: burnout, primary care, mental health, communication, veterans     

Women and Alcohol Abuse in Primary Care

Female problem drinkers are less likely than men to be identified in the primary care setting. The authors studied 24 adult women attending a general, internal medicine clinic to assess the efficiency of self reports of alcohol consumption when compared with physician identification and other measures and the impact of a brief intervention on alcohol consumption. Despite the high rate of lifetime (79%) and current (67%) alcohol diagnoses, no patient was in alcohol treatment. Physician identification of alcohol problems was least sensitive but most specific, when compared with other measures. Brief intervention, as offered in this study, did not appear to modify alcohol consumption.     

Alcohol Dependence and Responsivity to an Ethanol Stimulus as Predictors of Alcohol Consumption*

Withdrawal symptoms during the previous 30 days were examined in relation to psychophysiological arousal, desire to drink, and operant behavior associated with alcohol consumption. The subjects were 16 male alcoholic patients and 16 control subjects that had been randomly assigned to either an alcohol or placebo condition. Alcoholics showed a greater desire to drink than their respective controls. There was also a significant correlation between autonomic arousal and desire to drink among alcoholics but not controls. There was some evidence that arousal was related to alcohol dependence among alcoholics. Placebo responding among alcoholics was also related to alcohol dependence. Of particular significance was that desire to drink, withdrawal symptomatology, and heart rate accounted for over 57% of the variance in predicting which alcoholics would choose the drink reward following the operant task. These results support the notion that disposition to drink in alcoholics should be examined in a multivariate context.