Erin Dawna Reilly

Since 1952, psychiatry has grappled with the concept of addiction in terms of diagnosis, treatment, and research; this work has been particularly complex given the common co-occurrence of other mental health concerns. Tracing the history of substance use disorder (SUD) comorbidity and exploring related concepts of dual diagnosis, co-occurring disorders, and multimorbidity highlights the necessity for a strong addiction comorbidity framework. In this commentary, we contend that to continue advancing our understanding of addiction comorbidities, a more nuanced and explicit framework is needed. Specifically, one that moves beyond the limitations of dual diagnosis and multimorbidity, and embraces a more integrative, biopsychosocial approach. The DSM offers a critical opportunity for dialogue and development of psychiatric comorbidity frameworks to guide future research, clinical practice, and educational initiatives in the field of addiction and mental health.

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Background: Over 600,000 student veterans use military benefits to pursue higher education annually, with 75% enrolled as full-time students. Advancing their education is an important step toward improving their employment, financial, and social opportunities. However, student veterans also experience high rates of co-occurring psychiatric concerns like substance use disorder (SUD), posttraumatic stress disorder (PTSD), or depression. For these students, additional psychoeducation, support, and guidance may be required. To support their goals, a mobile app with targeted content for student veterans managing common psychiatric concerns could be particularly helpful. Objective: The primary aim of this pilot study was to iteratively revise and assess usability, acceptability, and feasibility of the VetEd mobile app and study procedures. The secondary aim was to explore preliminary changes from preapplication to postapplication use in academic functioning and community reintegration. Methods: This study used a mixed methods approach; pilot usability testing and iterative revisions were completed across 3 waves of participants (wave 1=4; wave 2=4; wave 3=5; total n=13). Usability was measured using the System Usability Scale (SUS), and acceptability was measured using the Acceptability E-Scale (AES). App use feasibility was collected through app engagement data from the 4 weeks of mobile app use. Study feasibility was assessed by rates of recruitment, retention, and survey completion. Secondary, exploratory measures to assess potential VetEd use outcomes included academic self-efficacy, perceived ability to cope with educational barriers, and community reintegration. Participants were also given the opportunity to complete an exit interview to provide additional feedback. Results: Study feasibility was high, with greater than projected rates of recruitment (4-5 per month), retention (13/13, 100%), and survey completion at all 3 time points (100%, 85%, and 100%, respectively). Overall, 85% (11/13) of both usability and acceptability scores were above the predefined benchmarks. Completion of assigned VetEd activities was high, with participants completing, on average, 90.8% of requested app activities. Secondary exploratory outcomes in academic self-efficacy, coping with educational barriers, and community reintegration were nonsignificant but showed feasibility for use in future fully powered randomized VetEd trials. Exit interviews highlighted that VetEd was easy to use, included pertinent information for both academic and mental health functioning, and had vital information on connecting to additional resources. Conclusions: Pilot findings suggested that the VetEd mobile app is usable and acceptable as an asynchronous resource for student veterans managing psychiatric concerns. Exit interviews suggested that veterans found app content useful, with relevant information and resources to support their academic functioning. Additional research is needed to assess its effectiveness, implementation, and impact on student veterans nationwide. Trial Registration: ClinicalTrials.gov NCT05344092: https://clinicaltrials.gov/study/NCT05344092

Background: US veterans with mental health disorders have high rates of smoking and low rates of smoking cessation. Objective: This study aims to focus on an adaptation of a web-based acceptance and commitment therapy (ACT) tobacco cessation intervention (Vet WebQuit) for veterans with mental health disorders who use tobacco and used a qualitative approach to test its usability (n=16). Methods: Participants were asked to walk through the site during laboratory-based usability testing and “think aloud” about the features of the intervention. A trained facilitator used semistructured interview questions to assess participants’ experiences with Vet WebQuit and obtain feedback on their impressions of the site. Qualitative analyses identified themes regarding participants’ experiences with the intervention, usability concerns, and recommendations for improving Vet WebQuit. Results: Overall, veterans found that the Vet WebQuit layout was simple and easy to navigate and use. Veterans reported that several features of the program were useful, including the quit plan, identification of triggers, content that targets mental health concerns (eg, dealing with anger), information on the health effects of smoking, tools for managing triggers (eg, urge surfing), and involving others in their quit plan. Veterans reported that particular features of the ACT approach for tobacco cessation were appealing to them, including the distinction between internal and external smoking triggers, the inclusion of the serenity prayer, and mindfulness exercises, which they could use as a tool reduce the intensity of cravings. Veterans reported wanting more information on the health aspects of smoking (ie, effects on breathing and lung capacity) as a way to motivate them to quit smoking. In addition, they suggested targeting specific mental health concerns that serve as triggers for smoking, including nightmares, boredom, and social isolation. Conclusions: Overall, results from this project identified important elements of ACT digital tobacco cessation interventions for veterans with mental health disorders.

BACKGROUND Over 600,000 student veterans use military benefits to pursue higher education annually, with 75% enrolled as full-time students. Advancing their education is an important step toward improving their employment, financial, and social opportunities. However, student veterans also experience high rates of co-occurring psychiatric concerns like substance use disorder (SUD), posttraumatic stress disorder (PTSD), or depression. For these students, additional psychoeducation, support, and guidance may be required. To support their goals, a mobile app with targeted content for student veterans managing common psychiatric concerns could be particularly helpful. OBJECTIVE The primary aim of this pilot study was to iteratively revise and assess usability, acceptability, and feasibility of the VetEd mobile app and study procedures. The secondary aim was to explore preliminary changes from preapplication to postapplication use in academic functioning and community reintegration. METHODS This study used a mixed methods approach; pilot usability testing and iterative revisions were completed across 3 waves of participants (wave 1=4; wave 2=4; wave 3=5; total n=13). Usability was measured using the System Usability Scale (SUS), and acceptability was measured using the Acceptability E-Scale (AES). App use feasibility was collected through app engagement data from the 4 weeks of mobile app use. Study feasibility was assessed by rates of recruitment, retention, and survey completion. Secondary, exploratory measures to assess potential VetEd use outcomes included academic self-efficacy, perceived ability to cope with educational barriers, and community reintegration. Participants were also given the opportunity to complete an exit interview to provide additional feedback. RESULTS Study feasibility was high, with greater than projected rates of recruitment (4-5 per month), retention (13/13, 100%), and survey completion at all 3 time points (100%, 85%, and 100%, respectively). Overall, 85% (11/13) of both usability and acceptability scores were above the predefined benchmarks. Completion of assigned VetEd activities was high, with participants completing, on average, 90.8% of requested app activities. Secondary exploratory outcomes in academic self-efficacy, coping with educational barriers, and community reintegration were nonsignificant but showed feasibility for use in future fully powered randomized VetEd trials. Exit interviews highlighted that VetEd was easy to use, included pertinent information for both academic and mental health functioning, and had vital information on connecting to additional resources. CONCLUSIONS Pilot findings suggested that the VetEd mobile app is usable and acceptable as an asynchronous resource for student veterans managing psychiatric concerns. Exit interviews suggested that veterans found app content useful, with relevant information and resources to support their academic functioning. Additional research is needed to assess its effectiveness, implementation, and impact on student veterans nationwide. CLINICALTRIAL ClinicalTrials.gov NCT05344092: https://clinicaltrials.gov/study/NCT05344092

Background: Chronic pain is a debilitating condition that disproportionately impacts US veterans who manage numerous negative pain-related outcomes. There is an urgent need for accessible, engaging, and innovative treatments that can help veterans with chronic pain better self-manage their pain at home and improve their daily functioning. Technology-delivered acceptance- and mindfulness-based interventions for pain have shown strong efficacy, particularly when they are engaging and tailored to specific client needs. However, more research is needed to assess the impact of such interventions, particularly in terms of pain-related functioning and quality of life. Objective: The primary aim of this study is to test the efficacy of Veteran Acceptance and Commitment Therapy for Chronic Pain (VACT-CP), an online self-management pain program, compared to an active online control (Online Pain School) for improving pain-related functioning in a 3-site randomized controlled trial. The secondary aim is to explore psychological flexibility as a potential mediator between pain severity and pain-related functioning. Methods: This study will use a mixed methods approach to examine the efficacy of VACT-CP in a 2-arm, multisite, randomized controlled superiority trial including 200 participants with chronic musculoskeletal pain compared to Online Pain School. Participants will be assigned to 1 of these 2 online interventions. Both interventions will include 7 modules delivered over 7 weeks, with each module lasting approximately 15 minutes. Mixed effects models will be used to analyze the primary hypothesis that participants in the VACT-CP group will have greater improvement in pain-related functioning (Brief Pain Inventory–Interference subscale) than those in the active control group (Online Pain School). The main acceptance and commitment therapy process mediator (ie, Multidimensional Psychological Flexibility Inventory), pain-related functioning outcomes (Brief Pain Inventory–Interference subscale), and quality of life (Veterans RAND 36-Item Health Survey) will be measured at baseline, end of treatment, and 3 and 6 months after treatment. In addition, qualitative exit interviews will be conducted with a random set of 30 VACT-CP users (n=10, 33% per site) to obtain intervention usability, feasibility, and acceptability information. Results: The recruitment for this study began in January 2025. It is expected to continue through January 2027. Data collection is expected to be completed by June 2027, and primary data analyses are expected to be completed by early 2028. Conclusions: Online interventions such as VACT-CP and Online Pain School have the potential to expand access to behavioral interventions that improve quality of life and provide nonpharmacological pain treatment options for veterans experiencing chronic pain. However, research on their impact and underlying mechanisms of change is required to support this area of potential at-home programming. Trial Registration: ClinicalTrials.gov NCT06058624; https://clinicaltrials.gov/study/NCT06058624 International Registered Report Identifier (IRRID): PRR1-10.2196/70601

BACKGROUND US veterans with mental health disorders have high rates of smoking and low rates of smoking cessation. OBJECTIVE This study aims to focus on an adaptation of a web-based acceptance and commitment therapy (ACT) tobacco cessation intervention (Vet WebQuit) for veterans with mental health disorders who use tobacco and used a qualitative approach to test its usability (n=16). METHODS Participants were asked to walk through the site during laboratory-based usability testing and “think aloud” about the features of the intervention. A trained facilitator used semistructured interview questions to assess participants’ experiences with Vet WebQuit and obtain feedback on their impressions of the site. Qualitative analyses identified themes regarding participants’ experiences with the intervention, usability concerns, and recommendations for improving Vet WebQuit. RESULTS Overall, veterans found that the Vet WebQuit layout was simple and easy to navigate and use. Veterans reported that several features of the program were useful, including the quit plan, identification of triggers, content that targets mental health concerns (eg, dealing with anger), information on the health effects of smoking, tools for managing triggers (eg, urge surfing), and involving others in their quit plan. Veterans reported that particular features of the ACT approach for tobacco cessation were appealing to them, including the distinction between internal and external smoking triggers, the inclusion of the serenity prayer, and mindfulness exercises, which they could use as a tool reduce the intensity of cravings. Veterans reported wanting more information on the health aspects of smoking (ie, effects on breathing and lung capacity) as a way to motivate them to quit smoking. In addition, they suggested targeting specific mental health concerns that serve as triggers for smoking, including nightmares, boredom, and social isolation. CONCLUSIONS Overall, results from this project identified important elements of ACT digital tobacco cessation interventions for veterans with mental health disorders.

BACKGROUND Chronic pain is a debilitating condition that disproportionately impacts US veterans who manage numerous negative pain-related outcomes. There is an urgent need for accessible, engaging, and innovative treatments that can help veterans with chronic pain better self-manage their pain at home and improve their daily functioning. Technology-delivered acceptance- and mindfulness-based interventions for pain have shown strong efficacy, particularly when they are engaging and tailored to specific client needs. However, more research is needed to assess the impact of such interventions, particularly in terms of pain-related functioning and quality of life. OBJECTIVE The primary aim of this study is to test the efficacy of Veteran Acceptance and Commitment Therapy for Chronic Pain (VACT-CP), an online self-management pain program, compared to an active online control (Online Pain School) for improving pain-related functioning in a 3-site randomized controlled trial. The secondary aim is to explore psychological flexibility as a potential mediator between pain severity and pain-related functioning. METHODS This study will use a mixed methods approach to examine the efficacy of VACT-CP in a 2-arm, multisite, randomized controlled superiority trial including 200 participants with chronic musculoskeletal pain compared to Online Pain School. Participants will be assigned to 1 of these 2 online interventions. Both interventions will include 7 modules delivered over 7 weeks, with each module lasting approximately 15 minutes. Mixed effects models will be used to analyze the primary hypothesis that participants in the VACT-CP group will have greater improvement in pain-related functioning (Brief Pain Inventory–Interference subscale) than those in the active control group (Online Pain School). The main acceptance and commitment therapy process mediator (ie, Multidimensional Psychological Flexibility Inventory), pain-related functioning outcomes (Brief Pain Inventory–Interference subscale), and quality of life (Veterans RAND 36-Item Health Survey) will be measured at baseline, end of treatment, and 3 and 6 months after treatment. In addition, qualitative exit interviews will be conducted with a random set of 30 VACT-CP users (n=10, 33% per site) to obtain intervention usability, feasibility, and acceptability information. RESULTS The recruitment for this study began in January 2025. It is expected to continue through January 2027. Data collection is expected to be completed by June 2027, and primary data analyses are expected to be completed by early 2028. CONCLUSIONS Online interventions such as VACT-CP and Online Pain School have the potential to expand access to behavioral interventions that improve quality of life and provide nonpharmacological pain treatment options for veterans experiencing chronic pain. However, research on their impact and underlying mechanisms of change is required to support this area of potential at-home programming. CLINICALTRIAL ClinicalTrials.gov NCT06058624; https://clinicaltrials.gov/study/NCT06058624 INTERNATIONAL REGISTERED REPORT PRR1-10.2196/70601

Background: Veterans are disproportionately affected by chronic pain, with high rates of pain diagnoses (47%-56%) and a 40% higher rate of prevalence of severe pain than nonveterans. This is often accompanied by negative functional outcomes and higher mortality. Combined with research suggesting medical treatments for chronic pain are often insufficient, there is an urgent need for nonmedical pain self-management programs. An interactive online platform to deliver an efficacious treatment for chronic pain such as acceptance and commitment therapy (ACT) could be a valuable option to assist veterans with pain care at home. Objective: This study aims to evaluate the virtual coach–guided Veteran ACT for Chronic Pain (VACT-CP) online program compared to a waitlist and treatment as usual (WL+TAU) control group through a small pilot feasibility randomized controlled trial. The primary aim was to evaluate the feasibility and acceptability of VACT-CP and study procedures, such as ease of recruitment, treatment receptivity, attrition and retention, sustained participation, system usability, and assessment of trial procedures. Secondary aims explored differences in the VACT-CP and WL+TAU groups on pre- and posttest (week 7) outcome measures for pain, mental health, functioning, and ACT processes. Methods: Veterans with chronic pain were recruited and randomized to either the VACT-CP (n=20) or the WL+TAU (n=22) group in a parallel group trial design. Self-report surveys were administered to participants at baseline (week 0), at the intervention midpoint (week 3), immediately after the intervention (week 7), and at the 1-month follow-up (week 11). We used Wilcoxon signed rank tests with the intention-to-treat sample to describe changes in secondary outcomes from pre- to postintervention within each group. Results: Study procedures showed good feasibility related to recruitment, enrollment, randomization, and study completion rates. Participants reported that VACT-CP was easy to use (System Usability Scale: mean 79.6, SD 12.8; median 82.5, IQR 70-87.5); they completed an average of 5 of the 7 total VACT-CP modules with high postintervention satisfaction rates. Qualitative feedback suggested a positive response to program usability, content tailoring, veteran centeredness, and perceived impact on pain management. Although the pilot feasibility trial was not powered to detect differences in clinical outcomes and significant findings should be interpreted with caution, the VACT-CP group experienced significant increases in chronic pain acceptance (P<.001) and decreases in depressive symptoms (P=.03). Conclusions: VACT-CP showed encouraging evidence of feasibility, usability, and acceptance, while also providing promising initial results in improving a key process in ACT for chronic pain—chronic pain acceptance—after online program use. A full-scale efficacy trial is needed to assess changes in clinical outcomes. Trial Registration: ClinicalTrials.gov NCT03655132; http://clinicaltrials.gov/ct2/show/NCT03655132 International Registered Report Identifier (IRRID): RR2-10.2196/45887

BACKGROUND Veterans are disproportionately affected by chronic pain, with high rates of pain diagnoses (47%-56%) and a 40% higher rate of prevalence of severe pain than nonveterans. This is often accompanied by negative functional outcomes and higher mortality. Combined with research suggesting medical treatments for chronic pain are often insufficient, there is an urgent need for nonmedical pain self-management programs. An interactive online platform to deliver an efficacious treatment for chronic pain such as acceptance and commitment therapy (ACT) could be a valuable option to assist veterans with pain care at home. OBJECTIVE This study aims to evaluate the virtual coach–guided Veteran ACT for Chronic Pain (VACT-CP) online program compared to a waitlist and treatment as usual (WL+TAU) control group through a small pilot feasibility randomized controlled trial. The primary aim was to evaluate the feasibility and acceptability of VACT-CP and study procedures, such as ease of recruitment, treatment receptivity, attrition and retention, sustained participation, system usability, and assessment of trial procedures. Secondary aims explored differences in the VACT-CP and WL+TAU groups on pre- and posttest (week 7) outcome measures for pain, mental health, functioning, and ACT processes. METHODS Veterans with chronic pain were recruited and randomized to either the VACT-CP (n=20) or the WL+TAU (n=22) group in a parallel group trial design. Self-report surveys were administered to participants at baseline (week 0), at the intervention midpoint (week 3), immediately after the intervention (week 7), and at the 1-month follow-up (week 11). We used Wilcoxon signed rank tests with the intention-to-treat sample to describe changes in secondary outcomes from pre- to postintervention within each group. RESULTS Study procedures showed good feasibility related to recruitment, enrollment, randomization, and study completion rates. Participants reported that VACT-CP was easy to use (System Usability Scale: mean 79.6, SD 12.8; median 82.5, IQR 70-87.5); they completed an average of 5 of the 7 total VACT-CP modules with high postintervention satisfaction rates. Qualitative feedback suggested a positive response to program usability, content tailoring, veteran centeredness, and perceived impact on pain management. Although the pilot feasibility trial was not powered to detect differences in clinical outcomes and significant findings should be interpreted with caution, the VACT-CP group experienced significant increases in chronic pain acceptance (P<.001) and decreases in depressive symptoms (P=.03). CONCLUSIONS VACT-CP showed encouraging evidence of feasibility, usability, and acceptance, while also providing promising initial results in improving a key process in ACT for chronic pain—chronic pain acceptance—after online program use. A full-scale efficacy trial is needed to assess changes in clinical outcomes. CLINICALTRIAL ClinicalTrials.gov NCT03655132; http://clinicaltrials.gov/ct2/show/NCT03655132 INTERNATIONAL REGISTERED REPORT RR2-10.2196/45887