Thad E. Abrams

Background: Women experiencing mental health disorders (MHD) have shown lower preventive mammography screening rates. Studies in veterans have shown inconsistent results and been limited to single facilities, failed to separate substance use and MHD into individual categories, and have had limited analyses on systems level covariates. Objective: The study examined the individual associations between MHD in univariate and multivariate analyses and included adjustments for factors previously shown to impact on the rate of receipt of recommended preventive breast cancer screening. Participants: Women veterans ages 50 through 54 receiving primary care in the Veterans Health Administration (VHA) in 2021 and 2022. Study Design: The design was an observational cohort study using health data including patient level factors and system factors. Women veterans were studied over a 2-year period and generalized liner mixed regression models examined for the association between MHD (e.g., depression, PTSD, anxiety, opioid, cannabis) on mammography. Results: A total of 36,720 eligible women veterans were identified in the 2-year evaluation period, of which 79.2% received preventive breast cancer screening. Depression was the most common MHD (17,798; 48.5%). In univariate analyses, depression, PTSD, and anxiety disorders were not associated with mammography receipt. For individual substance use disorders, univariate analyses revealed opioid, cocaine, cannabis, and alcohol were all significantly associated with lower mammogram rates. In multivariate models including any significant univariate person or system factors, decreased rates of mammography were associated with bipolar (OR 0.76, p < .001), schizophrenia (OR 0.62, p < .001), opioid use (OR 0.50, p < .001), and cannabis use (OR 0.77, p < .001). Conclusions: Multivariate regression revealed that bipolar disorder, schizophrenia, opioid and cannabis use disorders are significantly associated with lower mammography rates while depression, anxiety, PTSD and alcohol use disorder are not.

Background: Over 25% of veterans seeking care at U.S. Veterans Health Administration facilities have chronic low back pain (LBP), with high rates of mental health comorbidities. The primary objective of this study was to assess the feasibility of participant recruitment, retention, and electronic data collection to prepare for the subsequent randomized trial of multimodal chiropractic care for pain management of veterans with chronic low back pain. The secondary objectives were to estimate effect sizes and variability of the primary outcome and choose secondary outcomes for the full-scale trial. Methods: This single-arm pilot trial enrolled 40 veterans with chronic LBP at one Veterans Health Administration facility for a 10-week course of pragmatic multimodal chiropractic care. Recruitment was by (1) provider referral, (2) invitational letter from the electronic health record pre-screening, and (3) standard direct recruitment. We administered patient-reported outcome assessments through an email link to REDCap, an electronic data capture platform, at baseline and 5 additional timepoints. Retention was tracked through adherence to the treatment plan and completion rates of outcome assessments. Descriptive statistics were calculated for baseline characteristics and outcome variables. Results: We screened 91 veterans over 6 months to enroll our goal of 40 participants. Seventy percent were recruited through provider referrals. Mean age (range) was 53 (22–79) years and 23% were female; 95% had mental health comorbidities. The mean number of chiropractic visits was 4.5 (1–7). Participants adhered to their treatment plan, with exception of 3 who attended only their first visit. All participants completed assessments at the in-person baseline visit and 80% at the week 10 final endpoint. We had no issues administering assessments via REDCap. We observed clinically important improvements on the Roland-Morris Disability Questionnaire [mean change (SD): 3.6 (6.1)] and on PROMIS® pain interference [mean change (SD): 3.6 (5.6)], which will be our primary and key secondary outcome, respectively, for the full-scale trial. Conclusions: We demonstrated the feasibility of participant recruitment, retention, and electronic data collection for conducting a pragmatic clinical trial of chiropractic care in a Veterans Health Administration facility. Using the pilot data and lessons learned, we modified and refined a protocol for a full-scale, multisite, pragmatic, National Institutes of Health-funded randomized trial of multimodal chiropractic care for veterans with chronic LBP that began recruitment in February 2021. Trial registration: ClinicalTrials.gov NCT03254719

Objective: To determine the associations between PTSD, psychotropic medication use, and the risk for dementia. Design: Retrospective cohort. Participants: Nationwide sample of US veterans (N = 417,172) aged ≥56 years during fiscal year (FY) 2003 without a diagnosis of dementia or mild cognitive impairment at baseline (FY02‐03) and ≥1 clinical encounter every 2 years during follow‐up (FY04‐12). Measures: Demographic characteristics; diagnosis of PTSD, dementia, and medical and psychiatric comorbidity (defined by ICD‐9 codes); and psychotropic medication use including selective serotonin reuptake inhibitors (SSRI), serotonin‐norepinephrine reuptake inhibitors (SNRI), novel antidepressants (NA), benzodiazepines (BZA), and atypical antipsychotics (AA). Cox proportional hazard models examined for associations between PTSD diagnosis, psychotropic medication use, and risk for a dementia diagnosis. Results: PTSD diagnosis significantly increased the risk for dementia diagnosis (HR = 1.35; [95% CI = 1.27–1.43]). However, there were significant interactions between PTSD diagnosis and use of SSRIs ( P < .001), NAs ( P = .014), and AAs ( P < .001) on the risk for dementia diagnosis. HR for dementia diagnosis among veterans diagnosed with PTSD and not using psychotropic medications was 1.55 [1.45–1.67]. Among veterans diagnosed with PTSD prescribed SSRI, SNRI, or AA, HR for dementia diagnosis varied by drug class use ranging from 1.99 for SSRI to 4.21 for AA, relative to veterans without a PTSD diagnosis and no psychotropic medication receipt. BZAs or SNRIs use at baseline was associated with a significantly increased risk for dementia diagnosis independent of a PTSD diagnosis. Conclusion: PTSD diagnosis is associated with an increased risk for dementia diagnosis that varied with receipt of psychotropic medications. Further research would help to delineate if these findings are due to differences in PTSD severity, psychiatric comorbidity, or independent effects of psychotropic medications on cognitive decline.

Tobacco use remains prevalent among Veterans of military service and those residing in rural areas. Smokers frequently experience tobacco-related issues including risky alcohol use, post-cessation weight gain, and depressive symptoms that may adversely impact their likelihood of quitting and maintaining abstinence. Telephone-based interventions that simultaneously address these issues may help to increase treatment access and improve outcomes. This study was a two-group randomized controlled pilot trial. Participants were randomly assigned to an individually-tailored telephone tobacco intervention combining counseling for tobacco use and related issues including depressive symptoms, risky alcohol use, and weight concerns or to treatment provided through their state tobacco quitline. Selection of pharmacotherapy was based on medical history and a shared decision interview in both groups. Participants included 63 rural Veteran smokers (mean age = 56.8 years; 87 % male; mean number of cigarettes/day = 24.7). The primary outcome was self-reported 7-day point prevalence abstinence at 12 weeks and 6 months. Twelve-week quit rates based on an intention-to-treat analysis did not differ significantly by group (Tailored = 39 %; Quitline Referral = 25 %; odds ratio [OR]; 95 % confidence interval [CI] = 1.90; 0.56, 5.57). Six-month quit rates for the Tailored and Quitline Referral conditions were 29 and 28 %, respectively (OR; 95 % CI = 1.05; 0.35, 3.12). Satisfaction with the Tailored tobacco intervention was high. Telephone-based treatment that concomitantly addresses other health-related factors that may adversely affect quitting appears to be a promising strategy. Larger studies are needed to determine whether this approach improves cessation outcomes. ClinicalTrials.gov identifier number NCT01592695 registered 11 April 2012.

Introduction: Emerging evidence indicates associations between extra‐central nervous system (CNS) bacterial infections and an increased risk for dementia; however, epidemiological evidence is still very limited.Methods: This study involved a retrospective cohort of a national sample of US veterans (N = 417,172) aged ≥56 years. Extended Cox proportional hazard models adjusted for demographic characteristics and medical and psychiatric comorbidities determined the associations between systemic and localized extra‐CNS bacterial infections occurring >2 years before the initial dementia diagnosis and the risk for dementia.Results: Exposure to any extra‐CNS bacterial infection was associated with a significantly increased risk for dementia (hazard ratio [HR] = 1.20 [95% confidence interval = 1.16–1.24]). Independently, septicemia (HR = 1.39 [1.16–1.66]), bacteremia (HR = 1.22 [1.00–1.49]), osteomyelitis (HR = 1.20 [1.06–1.37]), pneumonia (HR = 1.10 [1.02–1.19]), urinary tract infections (HR = 1.13 [1.08–1.18]), and cellulitis (HR = 1.14 [1.09–1.20]) were associated with a significantly increased risk for dementia.Discussion: Both systemic and localized extra‐CNS bacterial infections are associated with an increased risk for developing dementia.

Background: Several studies have reported on the co-occurrence of chronic obstructive pulmonary disease (COPD) and psychiatric conditions, with the most robust evidence base demonstrating an impact of comorbid anxiety and depression on COPD-related outcomes. In recent years, research has sought to determine if there is a co-occurrence between COPD and posttraumatic stress disorder (PTSD) as well as for associations between PTSD and COPD-related outcomes. To date, there have been no published reviews summarizing this emerging literature. Objectives: The primary objective of this review was to determine if there is adequate evidence to support a co-occurrence between PTSD and COPD. Secondary objectives were to: 1) determine if there are important clinical considerations regarding the impact of PTSD on COPD management, and 2) identify targeted areas for further research. Methods: A structured review was performed using a systematic search strategy limited to studies in English, addressing adults, and to articles that examined: 1) the co-occurrence of COPD and PTSD and 2) the impact of PTSD on COPD-related outcomes. To be included, articles must have addressed some type of nonreversible obstructive lung pathology. Results: A total of 598 articles were identified for initial review. Upon applying the inclusion and exclusion criteria, n=19 articles or abstracts addressed our stated objectives. Overall, there is inconclusive evidence to support the co-occurrence between PTSD and COPD. Studies finding a significant co-occurrence generally had inferior methods of identifying COPD; in contrast, studies that utilized more robust COPD measures (such as a physician exam) generally failed to find a relationship. Among studies that examined the impact of PTSD on COPD-related outcomes, there was more consistent evidence that PTSD affects the perception of respiratory symptom burden and management. In addition, methods for measuring an important confounder (smoking) were generally lacking. Conclusion: There is inconclusive evidence to support the co-occurrence of COPD and PTSD. There was stronger evidence implicating PTSD as an important comorbidity impacting COPD management. Further research is needed to: 1) determine whether or not COPD and PTSD are likely to be comorbid, and 2) further elucidate the mechanisms connecting PTSD and COPD-related outcomes.