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VISN 1 New England MIRECC Current Human Services Research

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Enhancing Early-Phase Care for Primary Care Patients with Unhealthy Substance Use
Contact: Charles Drebing, Ph.D. (Charles.Drebing@va.gov

Most adults with substance use disorders (SUD) enter treatment after years of costly delays that are associated with accumulated losses in terms of work, family, and housing. Finding opportunities to engage individuals with SUD is a key strategy for increasing early treatment and reducing the negative impact on the person and society. Primary care is an opportune place to intervene with unhealthy substance use, but identification, treatment initiation, and engagement are currently suboptimal. This study aims to: (1) understand screening patterns; (2) identify early care trajectories among patients in primary care who are identified with SUD or screened positive but did not receive a diagnosis; and (3) enhance early treatment participation. We will analyze provider response and service utilization for Veterans in a VA primary care setting who have a positive substance use screen and/or SUD diagnosis. We will pilot test incentives to improve Veterans’ initiation, engagement, and early treatment retention. We will also interview Veterans and primary care providers regarding early-phase treatment and incentives. Findings will inform both efforts to improve care for primary care patients with unhealthy substance use issues as well as future research, including a full-scale randomized control trial of patient incentives.
Collaborators: Wenwu Gao, M.D., Ph.D. (Wenwu.Gao@va.gov) and Nitigna Desai, M.D. (Nitigna.Desai@va.gov). 

Evaluation and Treatment of Substance Use in Veterans with PTSD Disability Claims
Contact: Heather Fries, B.A. (Heather.Fries@va.gov) or Marc Rosen, M.D. (Marc.Rosen@va.gov

Post-deployment screening suggests that approximately 10% of OEF/OIF Veterans endorse screening questions suggesting they have post-traumatic stress disorder (PTSD). Because of these symptoms, they are at particularly high risk for alcohol and other substance use disorders. Fully half of all OEF/OIF Veterans, and a majority of those with PTSD, are expected to apply for disability benefits. Claimants undergo the required VA compensation examination to determine the nature and severity of their disability and ultimately, the amount they will be compensated. Veterans with PTSD symptoms who apply for compensation benefits are at a crucial stage in their disease course because they are making far-reaching global decisions about whether to consider themselves disabled, what their diagnoses are, and whether to engage in treatment. The disability evaluation presents a perfectly-timed opportunity to evaluate Veterans' concomitant substance abuse and offer treatment, but this opportunity is typically missed. There is also much speculation but little data concerning what factors determine which Veterans with PTSD attend treatment and the relationship of this attendance to their compensation claim. In the evaluative component of this study, a fixed-ratio sample of 640 OEF/OIF Veterans undergoing PTSD disability evaluations will complete an assessment battery consisting of potential predictors of outcome: substance use; PTSD severity; attitudes concerning compensation examinations; and others. Approximately 160 Veterans identified as having a substance use disorder or risky alcohol use will then enter the clinical trial component of the study. They will be randomly assigned to an intervention based on SAMHSA's Screening, Brief Intervention and Referral to Treatment (SBIRT) or No-Additional-Treatment. The primary clinical trial outcomes will be weeks attending any mental health and/or substance abuse treatment and days abstinent from illicit drugs and alcohol. All Veterans, including those from the evaluation component, will be re-assessed 4 weeks and 12 weeks after the compensation examination. VA service use data will be extracted through the period after a disability determination has been made. The effect of the predictors on Veterans' substance use, PTSD severity, and attendance at mental health and/or substance abuse treatment will be determined for the time periods before applying for service connection, after applying, and after disability determination. The proposed studies will determine: (1) the impact of substance abuse on outcomes and attendance at treatment; (2) the impact of attitudes about the compensation exam and other predictors on outcomes and attendance at treatment; and (3) the efficacy of screening and referral to treatment, a treatment approach that has the potential to transform a widely-used point of contact with the VA health care system. Recruitment is ongoing at the Nashville and West Haven sites.
Publication: Rosen, M.I., Afshartous, D., Nwosu, S., Scott, M.D., Jackson, J.C., Marx, B.P., Murdoch, M.M., Sinnot, P.L., & Speroff, T. (2013). Racial disparity in Veterans’ satisfaction with PTSD disability examination, Psychiatric Services, 64(4), 354-359. 

Evaluation of VA's Supported Housing Program for Homeless Veterans
Contact: Jack Tsai, Ph.D. (Jack.Tsai2@va.gov)

This project will examine: (1) use of a new group-oriented peer support (GIPS) model for the Housing and Urban Development-Veteran Affairs Supportive Housing (HUD-VASH) program among VAs in the New England area and compare outcomes to other HUD-VASH sites nationally; (2) conduct a survey of HUD-VASH clinicians to understand their attitudes about groups; (3) and assess rapidity of housing placement and length of program participation in the HUD-VASH program nationally. National administrative data on HUD-VASH from 2009-2012 will be obtained and an online anonymous survey of HUD-VASH clinicians will be conducted with the online survey system, SurveyMonkey. Use of groups and their association with outcomes will be analyzed using various mixed model regression analyses. Survey data will be downloaded from SurveyMonkey and analyzed with descriptive and correlational statistics.  National administrative data on HUD-VASH will be examined to evaluate the impact of GIPS implementation among HUD-VASH programs in the New England area and to assess rapidity of housing placement and program participation. There will be no specific inclusion or exclusion criteria except all participants will be Veterans served by the HUD-VASH program. A sample size of over 40,000 is expected. The main outcomes examined will be the number of group contacts, housing and mental health outcomes, and time to housing and time in program. Also, an anonymous online national survey using SurveyMonkey will be conducted of HUD-VASH clinicians to understand current practices and attitudes about using groups. A sample size of 150 is expected.
Findings: The GIPS model of case management for the HUD-VASH program is not associated with any adverse clinical or housing outcomes, and it is associated with greater social integration than conventional case management. The GIPS model has begun to be disseminated throughout the New England area. Surveys of clinicians indicate that many are receptive to using groups as part of their case management services. This project is ongoing with further data analysis.
Publications: (1) Tsai, J. & Rosenheck, R.A. (2012). Outcomes of a group intensive peer-support model of case management for supported housing. Psychiatric Services, 63(12), 1186-1194; (2) Tsai, J. & Rosenheck, R.A. (2013). Use of group treatment among case managers in the Veterans Affairs supported housing program. Journal of Rehabilitation Research & Development, 50(4), 471-476; (3) Tsai, J., Reddy, N., & Rosenheck, R. (2014). Client satisfaction with a group-based model of case management for supported housing services. Evaluation and Program Planning, 43, 118-123; and (4) Tsai, J., Stefanovics, E., & Rosenheck, R.A. (2014). Predictors of group attendance in a group-based model of case management for supported housing. Psychiatric Rehabilitation Journal, 37(4), 324-328. 

Implementing and Evaluating Computer-Based Interventions for Mental Health: Evaluating VA-Wide Diffusion/Dissemination
Contact: Eric Hermes, M.D. (Eric.Hermes@va.gov

The purpose of this project is to explore the use of information retrieval from primary care and specialty mental health documentation to analyze the diffusion of Computer-Based Psychotherapy Interventions (CBPIs) use throughout VA by: (1) identifying documented CBPI use in the VA medical record using information retrieval; (2) describing the CBPIs used and the context of that use; and (3) prepare for machine learning algorithm development to facilitate the identification of CBPI use in future projects. Data will be obtained on a national cohort of VA patients who have at least one outpatient primary care clinic visit in fiscal year (FY) 2014. For this cohort, information retrieval will be preformed on text information utility data associated with all outpatient primary care, primary care mental health integration (PCMHI), and specialty mental health clinical notes. A specialized search engine and terms previously identified, as associated with CBPI use, will be used for information retrieval. Notes identified as potentially associated with CBPI use will be manually analyzed to confirm: (1) CBPI use; (2) the program type used; and (3) the level on integration of the CBPI into clinical care. The content of notes related to the use of CBPIs will be annotated to develop machine-learning algorithms to be used in future projects. Associations between VA patient, provider, and health system level factors developed from structured data will be used to describe CBPI use. 

Key Elements: Motivational Interviewing for Supported Employment Entry & Outcomes
Contact: Nancy Wewiorski, Ph.D. (Nancy.Wewiorski@va.gov

Supported employment is an evidence-based practice that is offered by VA but underutilized by its target population, adults with serious mental illnesses. The purpose of this project is to identify the key ingredients of motivational interviewing (MI) practice that are associated with the action of taking a step toward using supported employment services when motivational interviewing is used with Veterans who have serious mental illnesses. This is an archival study that will transcribe existing audiotapes and further analyze data from research sessions conducted in the Mueller study (VHA RR&D Grant # D7306-R). This two-year study will analyze archival data from 79 participants in the Mueller study, all of who were unemployed Veterans with serious mental illnesses who agreed to audiotaping and received either general supportive counseling (control group) or Motivational Interviewing (experimental group) in up to six sessions conducted over a period of six months. Based on review of session transcripts and retrospective medical record review, each MI research session will be rated as having either a successful or unsuccessful outcome on the variable of “taking a step toward supported employment utilization,” which serves as the study dependent variable. The independent variables are: (a) therapist behaviors (spirit of MI and MI technical proficiency); and (b) client behaviors (intensity and frequency of change talk and counter change talk). Covariates to be examined include age, race, mental health diagnosis, health status, work motivation, work importance, duration of unemployment, and type of disability benefits received. The 206 audiotaped MI sessions conducted with participants in the experimental condition will be transcribed and coded using MISC 2.1 coding, then analyzed using Generalized Estimating Equation modeling to identify significant predictors of taking a step toward using supported employment. The study also will qualitatively analyze transcribed sessions from 16 experimental participants and 16 control participants using thematic coding to identify emergent patterns and themes in the research sessions. Qualitative findings will be combined with the quantitative findings to develop conceptual frameworks that explain differences between Veterans with a successful outcome and those with an unsuccessful outcome. 

Medical-Legal Partnership (MLP) Model in VA Settings, An Evaluation of Process and Outcomes of Medical Legal Partnership for Homeless and Mentally Ill VA Patients in New York and Connecticut
Contact: Jack Tsai, Ph.D. (Jack.Tsai2@va.gov

We are partnering with the New York Legal Assistance Group and Connecticut Veterans Legal Clinic on a first-of-its-kind study of how civil legal services impact mental health and quality of life outcomes for Veterans treated in VA mental health and homeless programs. Medical-legal partnerships are designed to help patients address legal problems that may negatively impact their health. Homeless Veterans may particularly be in need of legal assistance according to annual needs surveys of homeless VA service providers. VA researchers participating in the partnership will evaluate the integration of free legal assistance and VA healthcare as it relates to Veterans’ mental health and quality of life; it will be conducted in two VA settings in New York and two in Connecticut. This project is funded by the Bristol Meyers Squibb Foundation, and we are currently in the recruiting stage.
Collaborators: Connecticut Veterans Legal Center, New York Legal Assistance Group, Bronx VA Medical Center, Manhattan VA Medical Center 

A Retrospective Study of Veterans with PTSD in Compensated Work Therapy: The Impact of Supported Employment vs. Standard Vocational Rehabilitation
Contact: Lisa Mueller, Ph.D. (Lisa.Mueller@va.gov

This retrospective archival study will compare the effect of two vocational services (transitional work experience (TWE) and supported employment program (SEP)) on employment, health, and treatment outcomes for Veterans with PTSD. This study will consist of a retrospective review of the medical records of Veterans who entered the Compensated Work Therapy (CWT) Program at the Bedford VAMC between December 2008 and October 2010. Each of these records will initially be reviewed for inclusion and exclusion criteria. A review of the medical records of Veterans meeting the inclusion criteria will be conducted to gather the following data: demographic information; psychiatric diagnoses and symptom severity; medical problems; employment information; vocational, medical, mental health, and substance use treatment utilization; disability status; and level of functional impairment. A comparison of the demographic and clinical correlates of Veterans who participated in SEP or TWE will be performed. The two groups will also be compared in the following areas: obtaining and maintaining employment; PTSD symptom severity; degree of functional impairment; and treatment utilization. The knowledge learned in this study will contribute to the results of recent studies examining the impact of vocational services for individuals with PTSD. Since this study will be looking at Veterans who chose which type of treatment to enter, it will provide important data on how TWE and SEP compare in the “real world” in terms of employment, health, and treatment adherence in Veterans with PTSD and may improve our understanding of the impact of treatment preferences on randomized trials. This research will inform the ongoing efforts of VA to reduce unemployment among Veterans by improving vocational services. Findings: To date, the study team reviewed the medical records for those who entered into the Compensated Work Therapy (CWT) program between December 2008 and October 2010. Of the Veterans screened and who met the inclusion criteria for the study, 54 Veterans chose to participate in the Supported Employment Program (SEP), 182 Veterans chose to participate in the Transitional Work Experience (TWE) Program, and the remaining 8 Veterans demonstrated no interest in either SEP or TWE. Data collection and analysis are continuing regarding information on treatment utilization, disability status, functional impairment, and use of vocational rehabilitation services. As a next step, we will be looking at another part of the data for analysis. Using pre-existing clinical trials data and newly acquired archival health service data, analysis will be conducted to: (1) compare the acute care utilization over an 12-month period in Veterans with PTSD randomized to IPS versus TWP (n=188); (2) compare the acute care utilization in Veterans with PTSD who become or do not become steady workers following randomization to either IPS or TWP over 12- months; and (3) compare the social return on investment between Veterans with PTSD randomized to SEP versus TWE, defined as Veteran earnings divided by the cost of the intervention and cost of inpatient services. The study will also characterize and compare the utilization of residential, domiciliary, pharmacy, and outpatient health service utilization in Veterans with PTSD randomized to SEP versus those randomized to TWE over a 12-month period. 

SBIRT (Pain Management) for Veterans Filing Compensation Claims
Contacts: Christina Lazar, MPH (Christina.Lazar@va.gov) and Marc Rosen, M.D. (Marc.Rosen@va.gov

This project involves modifying and pilot-testing an established SBIRT intervention for Veterans being evaluated for painful musculoskeletal disorders (MSD) who are at risk for substance use disorders. The modified intervention, SBIRT-PM (Pain Management) is for Veterans who have filed a claim for a (military) service-connected injury for which they have requested financial compensation. Projections are that at least half of Operations Enduring Freedom, Iraqi Freedom, New Dawn (OEF/OIF/OND) Veterans will have some compensable service-connected condition with 140,452 already compensated for back/neck conditions and comparable numbers for other joint conditions. For a significant proportion, the disability evaluation is their first encounter with VA health care. The disability evaluation is a perfectly-timed opportunity to enlist Veterans in a preventive intervention, but this opportunity is typically missed. In our group's completed clinical trial, Veterans applying for Compensation for PTSD were able to be engaged in health-promoting activities significantly more often if they received active counseling around the time of their Compensation claim than controls, but counseling after Compensation exams has not been piloted in Veterans applying for MSD. SBIRT-PM will be delivered around the time of the Compensation examination by a counselor, with confidentiality assured. The counselor will explain that treating both physical and psychological aspects of pain leads to the best outcomes and will outline what VA services are available to Veterans. After discussing management of pain and things that can impact pain, the counselor will then explain that while substances are sometimes used for pain relief, they can negatively impact pain control. The counselor will then segue into SBIRT. This project will involve two stages: (1) a Counseling Refinement phase during which SBIRT-PM will be pre-piloted in 20 Veterans, qualitative data will be collected immediately after counseling sessions, and the intervention's appeal to Veterans will be optimized; and (2) a randomized clinical trial in which 100 Veterans with MSD and recent risky substance use will be assigned to a No Additional Referral condition, a Pain Module Only condition, or SBIRT- PM in a 1:1:2 ratio and followed for 12 weeks. The primary outcome to be estimated is the slope of weeks with risky substance use. Secondary analyses will estimate the slope of pain intensity and the relationship of substance use and pain slopes, controlling for stage-of-change. Screening and referral to treatment at Compensation examinations can transform a widely-used point of entry to VA into a health-promoting encounter. The study is active and in the recruitment and data collections phase. 

Survey of the Experiences of Returning Veterans (SERV) Study
Contact: Rani Hoff, Ph.D., MPH (Rani.Hoff@va.gov

The current conflicts in Iraq and Afghanistan have been marked by an unprecedented number of women entering military service and serving in combat. Although returning Veterans can experience significant physical and psychological burdens following deployments, there is little research on gender differences in post-deployment health and functioning. There is good reason for concern that Veterans may have different risks by gender for negative health outcomes, such as much higher rates of military sexual trauma (MST) in women, and have different predictors and patterns of post-deployment outcomes in terms of use and effects of addictive behaviors. Yet, no studies have examined gender differences in risk for, or patterns in, post-deployment addictive behaviors and their relationship to co-occurring psychiatric disorders such as post-traumatic stress disorder (PTSD). This study proposes to follow a cohort of 1200 male and female OEF/OIF Veterans for up to 5 years to examine gender differences in risk and protective factors for addictive behaviors, and the relationships of these behaviors to co-occurring psychiatric disorders. The project involves telephone questionnaires at baseline, 3 months, 6 months, 9 months, 12 months and every 6 months thereafter. Domains of interest include deployment experiences, addictive behaviors, methods of coping, current stressors, childhood adversity and trauma, social support, physical and mental health concerns, employment, family functioning and health care utilization. This project will assist us to better understand coping strategies in male and female Veterans and to assist VA in developing appropriate treatment strategies. Recruitment and data collection are ongoing.
Collaborators: Shane Kraus, Ph.D., (Shane.Kraus@va.gov) and Elizabeth Porter, Ph.D., (Elizabeth.Porter5@va.gov)
Publication: Smith, P.H., Potenza, M.N., Mazure, C.M., McKee, S.A., Park, C.L., & Hoff, R.A. (2014). Compulsive sexual behavior among male military Veterans: Prevalence and associated clinical factors. Journal of Behavioral Addictions, 3(4), 214-222. 

Survey of Veterans’ Sexual Health and Well-being
Contacts: Rani Hoff, Ph.D., MPH (Rani.Hoff@va.gov) and Shane Kraus, Ph.D. (Shane.Kraus@va.gov

The purpose of this project is to investigate the sexual health and well-being of returning Veterans. Specifically, the researchers developed the current study after initial data analyses from the Survey of Experiences of Returning Veterans (SERV) study (e.g., Smith et al., 2014) found that a large proportion of male returning Veterans (i.e., 16.7%) were endorsing symptoms associated with sexual compulsivity. The prevalence and severity of compulsive sexual behaviors (CSBs) among returning Veterans has not been widely examined in the literature. Using Qualtrics, an online survey platform, we propose to use a web-based questionnaire to assess Veterans’ difficulty managing emotions, recent sexual history, symptoms associated with hypersexuality, dimensions of impulsivity, recent use of and problems associated with sexually explicit material, risky online sexual behaviors, and interest in seeking treatment for sexual compulsivity. The findings from the proposed analyses will provide insight into the sexual practices of returning Veterans. This study, the first of its kind, will provide detail on the kind of problems returning Veterans are having as they related to sexual compulsivity. In addition, results from this study might shed light on areas where there are unmet treatment needs for returning Veterans.

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Contact

Mehmet Sofuoglu, M.D., Ph.D.
Director
203-937-4809
Mehmet.Sofuoglu@va.gov

Patricia Sweeney, Psy.D., CPRP
Director for Education
781-687-3015
Patricia.Sweeney@va.gov

Richard Carson, LCSW
Administrative Officer
203-932-5711 Ext. 4338
Richard.Carson@va.gov

Ilan Harpaz-Rotem, Ph.D.
Co-Director for MIRECC Fellowship Program
203-932-5711 Ext. 2599
Ilan.Harpaz-Rotem@va.gov

Suzanne Decker, Ph.D.
Co-Director for MIRECC Fellowship Program
203-932-5711 Ext. 7425
Suzanne.Decker@va.gov