The mission of the VISN 3 MIRECC Education unit is to develop programs that help change provider behavior and that improve the use of evidence based effective practices in psychopharmacologic, psychotherapeutic, and psychosocial programs. In addition, the Education unit collaborates closely with other parts of our MIRECC, the Mental Health Executive Board (MHEB), the Veteran’s Advisory Council of VISN 3, and other MIRECCs to bring these programs to the network. Our newest effort involves assisting VISN 3 in implementing recovery throughout its mental health programs.
MIRECC Fellowship Advertisement - Start dates are flexible. Those wishing to start at the beginning of the academic year 2015-2016 should complete their applications by March 1, 2015.
The study’s purpose is to determine whether a small group of Veterans with Schizophrenia will complete a 4-session Problem Solving Training, and whether they will find it engaging and helpful. While lengthy interventions used in other studies of SMI patients have included training in problem solving, brief training has not previously been tried with this group. Participating Veterans will be asked to complete several brief self-report questionnaires on problem-solving skills and psychiatric symptoms, and the data will be analyzed to determine whether there have been changes on these measures during the study period.
TBI-related deficits in memory and executive functioning, if not understood and addressed, can lead to friction among family members. To begin to address this problem, a pilot study was recently conducted with funding from the Department of Defense (#W81XWH-08-0054) and the MIRECCs for VISNs 3 and 6. The study evaluated the feasibility, acceptability, and initial efficacy of implementing a novel adaptation of the multifamily group (MFG) treatment model developed for persons with Serious Mental Illness and members of their families to facilitate coping with the problems associated with mental illness. While the original MFG model teaches problem-solving skills, the adapted model also incorporates skills training from other evidence-based treatments (e.g., emotion regulation from Dialectical Behavior Therapy and communication training from Behavioral Family Therapy). Compensatory strategies for TBI-related deficits and education about TBI and comorbid disorders are included as well.
The study included 14 OEF/OIF Veterans and a spouse, partner or other family member for each. The intervention consisted of 2-3 initial “joining” sessions for individual families, a 2-session educational workshop, and 12 bimonthly MFG sessions. Participating Veterans reported significant positive outcomes, including improvements in anger control, use of social supports and occupational activity. Family members reported reduced burden and increased empowerment.
After the end of the treatment, MFG participants who took part in focus groups identified treatment benefits in four areas: 1) exploring common struggles and reducing isolation; 2) building skills to cope with TBI and related problems; 3) increasing understanding of the interconnection between TBI and PTSD; 4) rebuilding relationships through communication and understanding. Participating Veterans and family members also offered recommendations to improve and increase access to the program. Overall, they found MFG-TBI highly acceptable.
On the basis of these promising findings, Dr. Perlick received a Merit award from VA ORD to conduct a 3-site, 4-year randomized clinical trial of MFG for Veterans with mTBI and their spouses or partners (#1 IO1 RX0011 06). Participant enrollment is to start in June, 2014.
Coping with Bipolar Disorder can be challenging not only for persons with the illness but also for members of their families. The burden on family members puts them at risk for depression and other adverse health outcomes. To address this problem, this study (NIMH R34 MH071396) evaluated a family-focused cognitive behavioral intervention, delivered in 12-15 sessions, that was designed to promote the adoption of constructive coping strategies and increase self-care skills. The participants in this study were the primary caregivers of 46 individuals (a mix of Veterans and non-Veterans) diagnosed with Bipolar Disorder I or II. The caregivers were assigned at random either to receive the study intervention or to view health education videotapes. Reductions in caregiver depression, caregiver burden and health risk behavior were significantly greater for those who received the study intervention than for those who received health education only. These effects were found immediately after treatment and also at 6-month follow-up. Mood improvement was greatest for the caregivers who had reduced their use of emotion-focused coping styles and adopted more functional coping skills. Reductions in symptoms of Bipolar Disorder were greater for the individuals whose caregivers received the study intervention than for those whose caregivers who received health education only. Change in Bipolar Disorder symptoms was mediated by change in caregivers’ symptoms; in other words, the individuals with Bipolar Disorder whose symptoms decreased most were those whose caregivers felt less depressed. This finding suggests that, even when an individual with Bipolar Disorder is not available for treatment, working with a family member alone (i.e., to increase coping skills and reduce depression) can be beneficial, both for the family member and for the person with the illness.
Discriminatory practices and negative stereotypes are often directed at persons diagnosed with SMI. The resulting self-stigma – the internalization of the devaluing views of others - affects not only those who are mentally ill but members of their families as well. Studies have found associations between self-stigma and low self-esteem, social withdrawal (in response to anticipated rejection), psychological distress, and subjective burden. To reduce self-stigma, several studies have evaluated interventions targeting persons diagnosed with SMI; however, this pilot study was the first to evaluate a brief (1-session) intervention targeting family members. The study was done with the support of NIMH (R01 MH077168), in collaboration with the National Alliance on Mental Illness. The participants were assigned at random either to attend a formal presentation by a clinician on the subject of mental illness, or to receive the study intervention, which included a videotape showing family members describing their experiences of coping with stigma, and a discussion facilitated by two family peers who modeled and encouraged sharing within the group. Among participants with low-to-moderate anxiety prior to treatment, reductions in self-stigma were significantly greater for those receiving the study intervention than for those who attended the clinician’s presentation, suggesting that peer-led interventions deserve further study.
DBT is a manualized treatment that helps individuals to manage turbulent emotions. Veterans who received newly implemented DBT services at facilities in the metropolitan New York-New Jersey area (VISN 3) received questionnaires asking how they benefited. So far, 39 Veterans have returned completed questionnaires. Of these, 74% reported that DBT helped them to control their emotions and 72% reported that it helped them control their behavior. While most (54%) preferred family participation in some but not all skills training groups, 90% were open to the idea of involving family members in DBT. The Veterans anticipated that family member acquisition of DBT skills might increase the familial support available to them and improve family relations overall.
In January 2004, the Under Secretary for Health endorsed the Action Agenda "Achieving the Promise: Transforming Mental Health Care in VA". One of the action steps it contains is to "develop MyHealtheVet to better serve the needs of veterans with mental illnesses". MyHealtheVet provides web based information on VA benefits, special programs, health information and services to veterans who have access to the Internet. It is now being piloted at nine facilities which has generated much positive feedback as well as recommendations for improvement. The ultimate version of My HealtheVet will contain a fully functional secure personal health record system including e-prescription refills, messaging, copies of the veterans health record and self-care tracking and management tools.
My HealtheVet is intended to promote greater participation of veterans in their own health choices and care. In order to fully develop a Mental Health portal for My HealtheVet, it was critical to involve veterans and families in the needs assessment/requirements phase. An effective needs assessment tool included conducting Focus Groups with veterans and their families so they could identify what they need to better understand their own behavioral health concerns and/or diagnoses and treatment.
Eight MIRECCs (including VISN3 MIRECC) held a total of 14 focus group discussions and distributed needs assessment questionnaires to determine the types of health information that veterans are interested in, how they stay aware of their health information and needs, and what their thoughts are about using an internet-based personal health record and informational website. Two of the focus groups assessed veterans with psychotic diagnoses, two assessed only women, two involved those with PTSD, two groups evaluated veterans with anxiety and depression, two were held for veterans with substance use disorders, one group involved OEF/OIF returnees, one was held for veterans from primary care, one examined the views of veterans who do not receive VA care, and one group assessed family members of veterans. The outcome of the Focus Groups will be used to refine and improve the My HealtheVet Mental Health portal.
Bruce M. Levine, MD
The Suicide Risk Assessment and Prevention Initiative (SAP) was established in an effort to further enhance the lives of discharged SMI patients. The program achieves this goal by educating clinicians, increasing sensitivity to suicide risk, improving recognition of veterans with high risk of suicide, improving documentation of risk to enhance communication with non-mental health clinicians, and decreasing malpractice risk.
Since its first meeting in 2001, SAP’s suicide workgroup has produced the following:
Bruce M. Levine, MD
Despite remaining the gold standard for the treatment of treatment refractory schizophrenia, Clozapine has remained underutilized, and is the slowest step to be adopted in the various psychopharmacology algorithms. The VA has had an historically low use of Clozapine for seriously mentally ill veterans, and VISN 3 has had a low usage for the VA. In order to increase usage in VISN 3, the MIRECC developed a Clozapine education and consultation program. To date, the program has resulted in a 80 percent increase in Clozapine utilization, and in 37 additional Clozapine trials at the Montrose VA. Of particular import is that a 35 percent response rate, vigorous enough to lead to discharge, was achieved with severe nonresponders (VIDI patients).
Bruce M. Levine, MD
After a VISN wide conference: “Recovery in Action” which introduced VISN 3’s recovery implementation initiative, the MIRECC organized veteran and staff focus groups about the barriers to recovery and needs of staff and veterans for implementation. The experience was so powerful that the recommendation was to do this at each facility for all staff and as many veterans as possible. We have trained 65 leaders across all facilities in the network, half staff and half veterans. The “Recovery Discussions” have begun at 1 facilitiy, is awaiting IRB approval at the other facilities within the VISN and the rollout will be administered by the VISN 3 LRCs. We plan to evaluate the efficacy of this modality for implementation of recovery transformation in the VA.
A Dialectical Behavior Therapy (DBT) Clinic is being piloted at the Bronx VA to treat Self-Destructive Personality Disordered veterans. This project, led by Dr. Marianne Goodman, uses a manualized cognitive behavioral treatment approach that was developed to treat chronically suicidal individuals, many of whom met criteria for Borderline Personality Disorder (BPD). The approach combines behavioral interventions including skills training, exposure, problem solving with cognitive techniques of mindfulness, and stresses the importance of client-therapist connection. The DBT approach has also been successfully adapted to inpatient settings, criminal justice settings, outpatient populations of BPD substance abusers, depressed and suicidal adolescents with BPD or BPD traits, and binge-eating disordered individuals.
Despite the pronounced difficulties in interpersonal relationships inherent in BPD, minimal attention has been paid to couples and family treatment in the literature. We are currently treating subjects with Borderline Personality Disorder and their family memberswith a seven-session course of familyDialectical Behavioral Therapy to examine the impact of family DBTon measures of mood and emotion, aggression, family function, intrafamily conflict tactics and violence, relationship quality and adjustment, and communication patterns. Preliminary data will be available after January 2005.
Family Interventions for Serious Psychiatric Disorders in VA: Implementing a Continuum of Services
This September, 2009, conference will provide VISN 3 Mental Health staff with increased knowledge and skills to deal with family psychoeducation, which includes Behavioral Family Therapy and Family Focused Therapy and family consultation. It is the VISN 3 expectation that all attendees will identify three (3) families, apply one of the interventions learned in the conference and participate in the post-conference bi-monthly 60 minute family intervention consultation sessions for approximately 6-9 months following the training. These will occur either in person or via telephone and might run for up to 75 minutes, depending on the number of participants.
VISN 3 Peer Technician Retreat
MIRECC, MHCL, and LRCs collaborated on this one day conference for Peer Technicians hired in recent enhancements. This conference focused on professional identity and development. Dan O’Brien-Mazza was the keynote speaker. The curriculum included roles within the VISN with an outline of the mental health care system structure in VISN 3 and the VA, as a whole, followed by talks on ethics, professional development, and breakout sessions, which featured role plays and discussions of a variety of clinical/professional situations that Peer Technicians would encounter.
As a result of growing interest among the MIRECC & COE Education Group in implementation science, we have collaborated with EES, the GRECCs, and Ken Shay, Director of VA Geriatric Programs, to develop a workshop focused on implementation science theory and its application. The multi-day meeting during the fall of 2008 was a small skill-based workshop to meet the needs of our two groups. QUERI, HSR&D staff, and other implementation experts with successful projects served as faculty.
Planning Committees for Continuing the Transformation of VA Mental Health Services: Bridging the Gaps
This, 740 person, conference combined the national MIRECC conference and the Best Practices conference into one comprehensive meeting. Additional partners included NEPEC, SMITRC, PERC, Mental Health (MH) and Substance Abuse Disorder (SUD), QUERIs, NCPTSD, CESATE, VISN 2 Center for Integrated Healthcare, and Vet Centers. The conference focused on progress toward implementing the VA MH Strategic plan and its goals. MIRECC directors agreed to support needed training initiatives for local recovery coordinators.
VHA Local Recovery Coordinator Training
The MIRECCs spearheaded efforts to develop the first national training for the Local Recovery Coordinators (LRCs). The LRCs are given the task of facilitating the implementation of recovery-oriented mental health programs at their respective sites. This training served to communicate a common philosophy and policy to LRCs and assisted them in assessing their needs for program development. By the close of training, the LRCs had set two short-term and one long-term goal for program change and drafted an Action Plan for meeting their goals.
National Suicide Prevention Coordinators Training
The VA hired Suicide Prevention Coordinators at each Medical Center facility during the spring and summer of 2007. An initial face-to-face training for coordinators was held in Atlanta, in August, 2007. This meeting, attended by 175 Suicide Prevention Coordinators and other key mental health officials, was designed to alert everyone to best practices in suicide prevention strategies, as well as help newly hired coordinators understand their role and the expectations of their position. Monthly and as-needed audio-conferences are held to continue providing on-going education and direction. Continual support is provided by the CoE, the VISN 3 & 19 MIRECCs, the Office of Mental Health, and the National Center for Patient Safety. Attendance at the conference exceeded expectations and attendee evaluations of the conference were excellent. Suicide Prevention Coordinators have already begun to implement selected strategies in the area of suicide prevention.
Evidence-Based Interventions for Suicidal Persons
This was a regional conference in collaboration with VISN 4 MIRECC and VISN 19 MIRECC, which was held in Atlantic City, NJ from June 13th to June 14th of 2006, and repeated, with some modifications, in February, 2007, in Denver, CO. The conference focused on educating providers on the state-of-the-art evidence-based interventions for persons at risk for suicide. These included psychopharmacological as well as psychosocial interventions such as CBT, DBT, IPT, family and web-based treatments. There were also programs focused on research and evaluation issues, and the implementation of these interventions within the VA.
This project involved review of every longstay patient remaining in VISN 3. A team of clinicians co-chaired by the MIRECC Education Director and MHEB Business Manager reviewed and discussed each patient in terms of diagnostic assessment, psychopharmacologic treatment, psychosocial and rehabilitation interventions, as well as behavioral, family, community and financial discharge impediments. Some of these patients have made progress through recommended interventions, and a white paper is being prepared which characterizes the population and makes recommendations for enhancing recovery.
Juan Mezzich, MD, PhD
The goal of cultural competency training at the Bronx VA was to enhance clinical and cultural competence through the DSM-IV cultural formulation. This involved a specially prepared guidebook to the culturally competent assessment and a reader of important papers on cross-cultural psychiatry. The course was delivered to one team at the Bronx VA through 10 weekly sessions. Data was collected on the impact of the course upon the trained mental health professionals, and subsequent steps include evaluation of impact on patient care and outcomes, as well as offering the course to other facilities in the network.
This implementation pilot study examined the effect of clinical monitoring and feedback on physicians’ level of clinical practice guideline adherence. In addition, researchers investigated the effect of guideline adherence on clinical outcomes, such as community tenure and hospitalization frequency. Results revealed that monitoring had weak effects on guideline adherence, and no effect was found on mental health service utilization. Thus, researchers concluded that labor-intensive use of clinical monitors might not be justified.
The project involved formation of Internal and External Advisory Boards that assisted with rolling out of staff training on the algorithm and instruments, development of a side effect and co-existing symptom algorithm, development of a fidelity measure, and development of a consumer satisfaction measure. Two groups of physicians were analyzed from VA facilities in East Orange and Lyons, NJ, and 51 patients were followed for one year after being placed into the treatment algorithms. Below is a brief explanation of the algorithm’s development, instruments used, assessment measures, and possible future directions.
A review of existing algorithms, including VA National Guidelines, APA, the Texas Medication Algorithm Project (TMAP), and PORT was conducted. After careful consideration, a modified version of TMAP was selected, and named the New Jersey Algorithm.
The sequence includes two trials of atypical antipsychotics followed by a Clozaril trial. If no favorable response is observed, a third atypical neuroleptic is tried, followed by a typical neuroleptic, followed by a combination of antipsychotic medications. The consensus of the internal advisory committee was to provide a flexible algorithm that will allow for minor modifications as new research is disseminated. Though a positive outcome has not been observed with the NJ Algorithm to date, researchers suspect that a larger sample size might generate significant findings in the future.
A modified set of TMAP assessment measures was used to evaluate patient progress and algorithm effectiveness, a fidelity measure was developed to ensure physician compliance with prescription guidelines, and a survey was administered to assess patient concerns.
A pre-study survey was distributed to evaluate physician background knowledge and needs. Results indicated that physicians were familiar with clinical practice guidelines, believed guidelines would be beneficial based on expert consensus, and expressed eagerness to learn more about the use of algorithms.
Training experiences from the project led investigators to begin developing a clinical practice guidelines exportable educational curriculum. This curriculum could be used for implementing clinical practice guidelines at both VA and non-VA sites. The internal advisory committee agreed on the ten topics listed below, and plans to partner with the NY State Office of Mental Health in developing this curriculum. This curriculum program will be recorded on audiotapes, and will have accompanying continuing education credit to facilitate participation.
Members also recognized the need to develop a dual-diagnosis clinical practice guideline, and put together a workgroup comprised of local and national experts in this area. Depending on the study results, we also want to explore the use of computerized clinical reminders as a more cost effective method for doing monitoring and guideline adherence.