Mental disorders and mental health treatment among U.S. Department of Veterans Affairs outpatients: the Veterans Health Study

OBJECTIVE: The authors examined the self-reported presence and treatment of current depressive disorder, posttraumatic stress disorder (PTSD), and alcohol-related disorder in a group of outpatient veterans. METHOD: Data were obtained from the Veterans Health Study, a longitudinal investigation of male veterans' health. A representative sample of 2,160 outpatients (mean age = 62 years) was drawn from Boston-area U.S. Department of Veterans Affairs (VA) outpatient facilities. The participants completed screening measures for depression, PTSD, and alcohol-related disorder. Mental health treatment was assessed by interviews. RESULTS: The screening criteria for at least one current mental disorder were satisfied by 40% (N = 856) of the patients. Screening rates were 31% (N = 676) for depression, 20% (N = 426) for PTSD, and 12% (N = 264) for alcohol-related disorder. Patients who screened positively for current mental disorders were younger, less likely to be married or employed, and more likely to report traumatic exposure than were those without mental disorders. Of those who met the screening criteria for any of the targeted mental disorders, 68% (N = 579) reported receiving mental health treatment. Younger, Caucasian men and those who reported more traumatic exposure were more likely to report receiving mental health treatment than were others who screened positively for mental disorders. CONCLUSIONS: Screening rates of depression and PTSD and rates of mental health treatment were considerably higher among these VA outpatients than among similar patients in primary care in the private sector. Although the VA is currently meeting the mental health care needs of its patients, future fiscal constraints could affect most adversely the treatment of non-Caucasian and older patients and those with a history of traumatic exposure.     

Screening for mental illness in a Veterans Affairs women's health clinic.

This study examined the prevalence of self-reported mental illness and related impairment in social and occupational functioning among 209 female veterans enrolled in a primary care clinic. Ninety-four (45 percent) of the women screened positive for at least one psychiatric disorder, 46 (22 percent) for two or more coexisting psychiatric disorders, and 40 (19 percent) for only subthreshold disorders. The degree of self-reported impairment in social and occupational functioning was strongly related to the number of psychiatric diagnoses. Women who were under the age of 50 and those who had a service-connected disability were more likely to screen positive for a mental disorder.     

Bed closures and incarceration rates among users of Veterans Affairs mental health services

OBJECTIVE: This study examined incarceration rates of users of Department of Veterans Affairs (VA) mental health services in 16 northeastern New York State counties between 1994 and 1997-a time of extensive bed closures in the VA system-to determine whether incarceration rates changed during this period. METHODS: Data were obtained for male patients who used inpatient and outpatient VA mental health services between 1994 and 1997 and for men incarcerated in local jails during this period. For comparison, services use and incarceration data were obtained for all men who received inpatient behavioral health care at community general hospitals and state mental hospitals between 1994 and 1996 in the same counties. Probabilistic population estimation, a novel statistical technique, was employed to evaluate the degree of overlap between clinical and incarceration populations without relying on person-specific identifiers. RESULTS: Of all male users of VA mental health services between 1994 and 1997, a total of 15.7 percent-39.6 percent of those age 18 to 39 years and 9.1 percent of those age 40 years and older-were incarcerated at some time during that period. Dual diagnosis patients had the highest rate of incarceration (25 percent), followed by patients with substance abuse problems only (21 percent) and those with mental health problems only (11 percent). The rate of incarceration among male patients hospitalized in VA facilities was lower than among men in general hospitals or state hospitals (11.6 percent, 23 percent, and 21.7 percent, respectively), but was not significantly different. No significant increase occurred in the annual rate of incarceration among VA patients from 1994 to 1997 (3.7 percent to 4 percent), despite extensive VA bed closures during these years. CONCLUSIONS: Substantial proportions of mental health system users were incarcerated during the study period, especially younger men and those with both substance use and mental health disorders. Rates of incarceration were similar across health care systems. The closure of a substantial number of VA mental health inpatient beds did not seem to affect the rate of incarceration among VA service users.     

Contributions of the Department of Veterans Affairs to clinical aphasiology

Background: For more than 60 years, clinicians and researchers in the Department of Veterans Affairs Health Care System (VA) have contributed to our understanding of aphasia and its related neurogenic communication disorders. VA clinician‐researchers have made a major and lasting impact on clinical practice, training, and aphasia outcomes research.

Aims: To overview the development of aphasia rehabilitation in the VA. To provide an introduction and background for a series of papers highlighting contributions from VA clinician‐researchers to the assessment and treatment of persons with aphasia and related disorders.

Methods & Procedures: The papers in this special section recognise some of the contributions of VA clinician‐researchers to clinical aphasiology. The papers were solicited by the journal's North American Editor. For the most part, they focus on assessment and treatment of persons with aphasia and apraxia of speech. All papers were authored by persons currently and/or previously working in the VA in some capacity and were reviewed by the North American Editor.     

The Camberwell assessment of need as an outcome measure in routine mental health care

BACKGROUND: Subsidiary findings in several studies indicate that the standard summary scores (total number of needs, met needs and unmet needs) of the Camberwell Assessment of Need (CAN) may conceal important differences among patient populations at the item level of the measure. The aim of this study was to investigate whether changes in need and need status at the item level are adequately reflected by changes in the summary scores. METHODS: In a longitudinal design assessments of need in 1997 and 2003 of 192 outpatients (mean age 45.4 years, 78.1% psychotic disorders) in routine mental health care were compared. RESULTS: None of the summary scores changed between 1997 and 2003. This result, however, was contradicted by significant changes in needs at the item level. CONCLUSIONS: The summary scores conceal changes in need on the underlying items and thus is recommended not to be used as dependent measures when comparisons among populations or between points in time are of interest.     

Effectiveness of the Tobacco Tactics Program in the Department of Veterans Affairs

Purpose

The purpose was to determine the effectiveness of the Tobacco Tactics program in three Veterans Affairs hospitals.

Methods

In this effectiveness trial, inpatient nurses were educated to provide the Tobacco Tactics intervention in Ann Arbor and Detroit, while Indianapolis was the control site (N?=?1,070). Smokers were surveyed and given cotinine tests. The components of the intervention included nurse counseling, brochure, DVD, manual, pharmaceuticals, 1-800-QUIT-NOW card, and post-discharge telephone calls.

Results

There were significant improvements in 6-month quit rates in the pre- to post-intervention time periods in Ann Arbor (p?=?0.004) and Detroit (p?Conclusion The Tobacco Tactics program, which meets the Joint Commission standards that apply to all inpatient smokers, has the potential to significantly decrease smoking among Veterans.     

Quality of life as an outcome measure in evaluating mental health services: a review of the empirical evidence

This paper addresses the question of how well quality of life measures function as valid and sensitive outcome indicators of mental health services. Findings from the major empirical studies of quality of life in the mental health area over the last 15 years are reviewed. The extent to which existing studies provide evidence of the ability of quality of life measures to discriminate the impact of service interventions on the well-being of psychiatric clients is examined. Findings from crosssectional, comparative, repeated-measures and randomised studies are presented. The available empirical evidence is critically examined and the methodological and theoretical implications of current findings for future work are considered.     

Legal abortion as a positive mental health measure in family planning

Abortion is the most ancient, most inefficient, and most unsatisfactory way of limiting family size ever devised by man. Yet millions of abortions, most of them illegal, are performed each year throughout the world, leaving in their wake thousands of cases of maternal sepsis, sterility, and death at the worst; emotional and psychic trauma in most cases at the best.Abortions, legal and illegal, are still practiced in all countries regardless of politics or race and often in defiance of legal or religious restrictions. It is only within the past decade that physicians, demographers, sociologists, family planners, and other scientists, have been able to study with objectivity this almost universal practice. In spite of the wide availability of contraceptives, none is yet foolproof and unwanted pregnancies will continue to occur. Until we develop some safe nonsurgical method of terminating unwanted pregnancies, women will persist in resorting to abortion.Psychiatry by its very nature should become more deeply concerned about the positive aspects of family planning and the quality of life that results from such planning. The population explosion with its dire effects on the total environment has already made dangerous inroads on the quality of life on this planet. It is altogether fitting that psychiatry become involved in these areas since the sexual act begins first in the psyches of men and women. Abortion will continue to be practiced all over the world whether it is legal or illegal. Therefore, it is imperative that we give intelligent and objective thought to this problem as physicians and psychiatrists without religious or moral bias. We must assume the lead in making it possible for women, regardless of socio-economic status, to terminate unwanted pregnancies with medical safety, dignity, and privacy and without public stigma. We must make it possible for women to limit family size to their own needs and desires and make every child a wanted child. We must remove the moral and social stigmata from the practice of legal abortion and make it as acceptable as any other surgical procedure. This would be the practice of humanitarian medicine at the very best.     

Multifacility utilization by the chronically mentally ill in the Department of Veterans Affairs

The objectives of this research are (1) to quantify the multifacility utilization patterns ("shared care") for a selected subset of patients with a chronic mental disorder, (2) to examine the patient characteristics correlated with several observed utilization patterns, and (3) to determine facility groups through cluster analysis, based on multifacility readmissions. Patients were identified from the VA's hospital discharge abstract system based on a diagnosis of schizophrenia in any discharge during the two-year study period. All discharges for this cohort during the period were analyzed. Essentially, three different groups of patients from this cohort were found. The vast majority have one or two hospitalizations and in the process are seen at one or maybe two facilities. However, two small minorities are hospitalized many times. One small group confines these hospitalizations to relatively few facilities while the other travels from facility to facility around the country. These two groups present very different clinical management problems from each other as well as from the majority. Since the distribution of travel distance between facilities remained similar for all types of patients (median distance was about 120 miles), facilities were clustered based on the number of linkages they shared. By use of six different measures of the disjointedness of shared care, clustering produced a reasonable number of meaningful groups which account for a majority of possibly uncoordinated shared care. We feel that these results and this approach can be useful for administrators, policymakers, and researchers. By looking simultaneously at the utilization patterns of its clients and their characteristics (e.g., age) as well as the utilization patterns within groups of facilities, any multifacility health system can characterize its shared care and identify those clients and facilities most in need of intervention, resources, and future study.     

Consumer Satisfaction with Inpatient Mental Health Treatment in the Department of Veterans Affairs

This study used hierarchical linear models to analyze post-discharge data among 17,130 veterans who received inpatient VA mental health services between 1995 and 2001, in order to determine whether changes in mental health service affected inpatient satisfaction. In models without covariants, half the satisfaction measures increased while the other half indicated no significant change. After adjusting for changes in patient characteristics, however, nine measures indicated no change and seven showed significant declines. Demonstrating the importance of risk-adjustment, satisfaction appeared to increase over time prior to risk adjustment, but declined after adjusting for changes in patient characteristics that were associated with patient satisfaction.     

Interrater reliability of neuropsychological diagnoses: a Department of Veterans Affairs cooperative study.

This study examined the interrater reliability of neuropsychological diagnoses produced by clinical neuropsychologists across 4 medical centers. These diagnoses were based on evaluations using a comprehensive battery of commonly used neuropsychological test instruments, interview, history and medical chart review. The diagnoses of individual neuropsychologists were compared to those made by members of an external review panel for each patient evaluated. Patients were first diagnosed as showing cognitive impairment versus no cognitive impairment. If a patient was diagnosed as impaired, a specific neuropsychological diagnosis was assigned. The diagnostic classification for cognitive impairment was moderately reliable [kappa = .48 +/- s.e.(kappa) = .062]. The interrater reliability for specific diagnoses was in the fair to good range [kappa = .44 +/- s.e.(kappa) = .029]. These levels of reliability are comparable to those found for other psychiatric and neurologic specialties and for medical diagnoses made by other health care disciplines.     

Inpatient suicide on mental health units in Veterans Affairs (VA) hospitals: avoiding environmental hazards

Introduction

One thousand five hundred suicides take place on inpatient psychiatry units in the United States each year, over 70% by hanging. Understanding the methods and the environmental components of inpatient suicide may help to reduce its incidence.

Methods

All Root Cause Analysis reports of suicide or suicide attempts in inpatient mental health units in Veterans Affairs (VA) hospitals between December 1999 and December 2011 were reviewed. We coded the method of suicide, anchor point and lanyard for cases of hanging, and implement for cutting, and brought together all other reports of inpatient hazards from VA staff for review.

Results

There were 243 reports of suicide attempts and completions: 43.6% (106) were hanging, 22.6% (55) were cutting, 15.6% (38) were strangulation, and 7.8% (19) were overdoses. Doors accounted for 52.2% of the anchor points used for the 22 deaths by hanging; sheets or bedding accounted for 58.5% of the lanyards. In addition, 23.1% of patients used razor blades for cutting.

Conclusions

The most common method of suicide attempts and completions on inpatient mental health units is hanging. It is recommended that common lanyards and anchor points be removed from the environment of care. We provide more information about such hazards and introduce a decision tree to help healthcare providers to determine which hazards to remove.     

Some contributions of the Department of Veterans Affairs to the epidemiology of multiple sclerosis

The first class 1 treatment trial ever conducted in multiple sclerosis (MS) was a Veterans Administration Cooperative Study. This led us to explore MS in the military-veteran populations of the United States in three main series: Army men hospitalized with final diagnoses of MS in World War II, all veterans of World War II and the Korean Conflict, and veterans of later service up to 1994. In each series, all cases had been matched with pre-illness military peers. These series provide major information on its clinical features, course and prognosis, including survival, by sex and race (white men and women; black men), as well as risk factors for occurrence, course, and survival. They comprise the only available nationwide morbidity distributions of MS in the United States. Veterans who are service-connected for MS by the Department of Veterans Affairs and matched with their military peers remain a unique and currently available resource for further clinical and epidemiological study of this disease.