John F. McCarthy

Introduction: To enhance mental health access and suicide prevention services for Veteran patients in Pain Management Teams and Oncology Clinics, the Veterans Health Administration (VHA) initiated the Mental and Behavioral Health Integration (MBHI) Demonstration Projects at 53 facilities in 2022. MBHI integrates colocated mental health providers into these settings to deliver brief mental/behavioral healthcare. Findings describe site visits assessing early implementation. Methods: Evaluators visited nine VHA facilities where MBHI providers were recruited and implementation was at early stages. Visits included program overviews, tours, and provider and site leadership interviews. Visits had consistent agendas and a framework of questions assessing fidelity to core components, site-specific modifications, and patients and conditions treated. Observations were content coded and organized thematically. Results and Discussion: MBHI services were available at each facility. Sites varied regarding clinic space for MBHI, brief treatment model use, and MBHI same-day access availability. All sites reported positive impacts for Veterans, clinical operations, and facilities. Implementation strengths and facilitators included local buy-in, MBHI provider integration into teams, utilizing partnerships and resources, MBHI provider experience and approach to care, and clinic workflow. Implementation challenges included space limitations, competing MBHI provider demands, productivity demands, uncertainty about intended patient populations, difficulty integrating MBHI staff, and hiring challenges and specialty clinic nascency. Visits identified positive impacts of MBHI, facilitators, and barriers to program implementation. Information gathered from site visits can inform VA policies and operations. Results continue to inform program modifications including enhancing role clarity, medical provider buy-in, and ongoing competency training.

Background: Hepatology visits present an opportunity to engage patients with alcohol-associated liver disease in care. This quality improvement pilot integrated a behavioral health provider (BHP) into the hepatology clinic at one Veterans Health Administration site and assessed its impact on alcohol use disorder (AUD) treatment. Methods and Results: Hepatologists across Veterans Health Administration facilities developed a workflow to refer patients with signs of unhealthy alcohol use to a BHP co-located in the hepatology clinic. Data during the first year of BHP integration (December 2022 to January 2024) were obtained through chart reviews and the Veterans Health Administration Corporate Data Warehouse. t tests and χ ² tests compared baseline characteristics and assessed the associations of referral status with receipt of evidence-based AUD treatments within 6 months of referral or index liver clinic appointment. Two hundred ninety-three patients with signs of unhealthy alcohol use were identified, representing 19.9% of all liver clinic patients engaged in care during the pilot. Of these, 86.4% had a prior mental health diagnosis, 79.2% had an AUD diagnosis, 57.7% had a positive AUDIT-C screen, 40.3% had an alcohol-associated liver disease diagnosis, and 71 patients (24% of patients with unhealthy alcohol use) were referred to the BHP. Referred patients were more likely to receive AUD psychotherapy and/or pharmacotherapy and had significantly more AUD pharmacotherapy fill days (35.2 vs. 10.3, p p =0.172). Conclusions: Referral to a co-located BHP was associated with a higher likelihood of receiving AUD treatment and a greater amount of AUD treatment, but gaps in referral remain and need to be addressed. Integrating BHPs into general hepatology clinics may improve AUD treatment uptake, addressing an important gap in care.

Veteran suicide rates exceed those of other US adults.^1,2 Suicide prevention is the top clinical priority of the Department of Veterans Affairs (VA).^3-5 Informed by prior work,^6,7 VA and National Institute of Mental Health scientists developed an expansive suicide mortality risk prediction algorithm using Veterans Health Administration (VHA) electronic health records.⁸ They identified individuals at risk rather than individual risk factors. Patients in the top 0.1% tier of risk died from suicide at a rate 30-fold higher than the overall VHA patient population.⁸ Machine learning analyses⁹ generated prediction similar to that of the proof-of-concept model⁸ using fewer variables, facilitating further targeted efforts¹⁰ to complement clinical assessments.

Objectives. To evaluate the sensitivity of health care facility documentation of suicide deaths among US veterans with recent Veterans Health Administration (VHA) care and assess variation in identification by veteran, clinical, and suicide death characteristics.Methods. Cross-sectional analyses included 11 148 veterans who died by suicide in 2013 to 2017, per National Death Index death certificate information, with VHA encounters in the year of death or the previous year. Facility suicide ascertainment was assessed per site reports in the VHA Suicide Prevention Applications Network. Bivariate and multivariable analyses assessed ascertainment by decedent demographic, clinical, utilization, and method of suicide characteristics.Results. Site reports identified 3667 suicide decedents (32.9%). Veteran suicide decedents identified by facilities were more likely to be younger and with clinical risk factors and more recent VHA encounters. Suicide deaths involving poisoning were less likely to be identified than deaths involving other methods.Conclusions. VHA facility ascertainment of suicide deaths among recent patients was neither comprehensive nor representative. Findings will inform efforts to enhance facility suicide surveillance and veteran suicide prevention.

In large health care systems, decision regarding broad implementation of psychotherapies for inpatients with psychosis require substantial evidence regarding effectiveness and feasibility for implementation. It is important to recognize challenges in conducting research to inform such decisions, including difficulties in obtaining consent from and engaging inpatients with psychosis in research. We set out to conduct a feasibility and effectiveness Hybrid Type I pilot randomized controlled trial of acceptance and commitment therapy (ACT) and a semi-formative evaluation of barriers and facilitators to implementation. We developed a training protocol and refined an ACT treatment manual for inpatient treatment of psychosis for use at the Veterans Health Administration. While our findings on feasibility were mixed, we obtained supportive evidence of the acceptability and safety of ACT. Identified strengths of ACT included a focus on achievement of valued goals rather than symptoms. Weaknesses included that symptoms may limit patient’s understanding of ACT. Facilitators included building trust and multi-stage informed consent processes. Barriers included restrictive eligibility criteria, rigid use of a manualized protocol, and individual therapy format. Conclusions are limited by our randomization of only 18 patient participants (with nine completing all aspects of the study) out of 80 planned. Future studies should include (1) multi-stage informed consent processes to build trust and alleviate patient fears, (2) relaxation of restrictions associated with obtaining efficacy/effectiveness data, and (3) use of Hybrid Type II and III designs.

Lithium has been reported in some, but not all, studies to be associated with reduced risks of suicide death or suicidal behavior. The objective of this nonrandomized cohort study was to examine whether lithium was associated with reduced risk of suicide death in comparison to the commonly-used alternative treatment, valproate. A propensity score-matched cohort study was conducted of Veterans Health Administration patients (n=21,194/treatment) initiating lithium or valproate from 1999-2008. Matching produced lithium and valproate treatment groups that were highly similar in all 934 propensity score covariates, including indicators of recent suicidal behavior, but recent suicidal ideation was not able to be included. In the few individuals with recently diagnosed suicidal ideation, a significant imbalance existed with suicidal ideation more prevalent at baseline among individuals initiating lithium than valproate (odds ratio (OR) 1.30, 95% CI 1.09, 1.54; p=0.003). No significant differences in suicide death were observed over 0-365 days in A) the primary intent-to-treat analysis (lithium/valproate conditional odds ratio (cOR) 1.22, 95% CI 0.82, 1.81; p=0.32); B) during receipt of initial lithium or valproate treatment (cOR 0.86, 95% CI 0.46, 1.61; p=0.63); or C) after such treatment had been discontinued/modified (OR 1.51, 95% CI 0.91, 2.50; p=0.11). Significantly increased risks of suicide death were observed after the discontinuation/modification of lithium, compared to valproate, treatment over the first 180 days (OR 2.72, 95% CI 1.21, 6.11; p=0.015). In this somewhat distinct sample (a predominantly male Veteran sample with a broad range of psychiatric diagnoses), no significant differences in associations with suicide death were observed between lithium and valproate treatment over 365 days. The only significant difference was observed over 0-180 days: an increased risk of suicide death, among individuals discontinuing or modifying lithium, compared to valproate, treatment. This difference could reflect risks either related to lithium discontinuation or higher baseline risks among lithium recipients (i.e., confounding) that became more evident when treatment stopped. Our findings therefore support educating patients and providers about possible suicide-related risks of discontinuing lithium even shortly after treatment initiation, and the close monitoring of patients after lithium discontinuation, if feasible. If our findings include residual confounding biasing against lithium, however, as suggested by the differences observed in diagnosed suicidal ideation, then the degree of beneficial reduction in suicide death risk associated with active lithium treatment would be underestimated. Further research is urgently needed, given the lack of interventions against suicide and the uncertainties concerning the degree to which lithium may reduce suicide risk during active treatment, increase risk upon discontinuation, or both.

Objectives. We assessed suicide rates up to 6 months following discharge from US Department of Veterans Affairs (VA) nursing homes. Methods. In VA Minimum Data Set (MDS) records, we identified 281 066 live discharges from the 137 VA nursing homes during fiscal years 2002 to 2008. We used MDS and administrative data to assess resident age, gender, behaviors, pain, and indications of psychoses, bipolar disorder, dementia, and depression. We identified vital status and suicide mortality within 6 months of discharge through National Death Index searches. Results. Suicide rates within 6 months of discharge were 88.0 per 100 000 person-years for men and 89.4 overall. Standardized mortality ratios relative to age- and gender-matched individuals in the VA patient population were 2.3 for men (95% confidence interval [CI] = 1.9, 2.8) and 2.4 overall (95% CI = 2.0, 2.9). In multivariable proportional hazards regression analyses, resident characteristics, diagnoses, behaviors, and pain were not significantly associated with suicide risk. Conclusions. Suicide risk was elevated following nursing home discharge. This underscores the importance of ongoing VA efforts to enhance discharge planning and timely postdischarge follow-up.

Objectives: Associations between BMI and suicide risks and methods for individuals receiving care in the Veterans Health Administration (VHA) health system were evaluated.Design and Methods: For 4,005,640 patients in fiscal years 2001‐2002, multivariable survival analyses assessed associations between BMI and suicide, through FY2009. Covariates included demographics, psychiatric, and nonpsychiatric diagnoses, receipt of VHA mental health encounters, and regional network. Among suicide decedents, multivariable Generalized Estimating Equations (GEE) regression examined associations between BMI and suicide method.Results: 1.3% of patients were underweight, 24.3% normal weight, 40.6% overweight, and 33.8% obese. Underweight was associated with increased suicide risk (adjusted hazard ratio [AHR] = 1.17, 95% CI: 1.01, 1.36) compared to normal. Overweight and obese status were associated with lower risk (AHR = 0.78, 95% CI: 0.74, 0.82; AHR = 0.63, 95% CI: 0.60, 0.66, respectively). Among suicide decedents, high lethality methods were most common among underweight and least common among obese individuals. Adjusting for covariates, BMI was not associated with method lethality, yet some associations were observed between BMI and specific methods.Conclusion: Among VHA patients, BMI was negatively associated with suicide risks. These differences may partly relate to choice of suicide method. Low BMI offers an additional resource for clinical suicide risk assessments.