Implementation of Telemental Health (TMH) psychological services for rural veterans at the VA New York Harbor Healthcare System
Meeting the mental health needs of our current veteran population is one of the primary challenges facing the Veteran's Health Administration (VHA). Particularly for veterans residing in rural areas, the lack of providers, high provider turnover, and the burden of traveling long distances to VHA facilities may contribute to difficulties accessing mental health care. Telemental Health (TMH) services help bridge the geographic gap between mental health providers and veterans who need mental health services. The VHA TMH Hub initiative has attempted to leverage changes in technology-facilitated care by developing a model in which a facility "hub" could expand mental health resources to remote "spoke" clinics and veterans' residences. This paper describes the implementation of the VA New York Harbor Health care System (VA NYH) TMH Hub, which was one of 6 programs funded by the VHA Office of Rural Health (ORH) in September 2016. We will describe the structure of the program, services provided, veterans served, and our efforts to integrate quality improvement, research, and clinical training into the operations of the program. (PsycINFO Database Record (c) 2019 APA, all rights reserved).
Barriers and facilitators to implementing a U.S. Department of Veterans Affairs Telemental Health (TMH) program for rural veterans
Telemental health refers to the use of information and technology to provide mental health services when providers and patients are separated geographically. The U.S. Department of Veterans Affairs' (VA) Telemental Health Hub (TMH) initiative started in 2002 to address the mental health needs of rural Veterans and has been increasingly used since that time. Services are typically provided from a VA medical center (VAMC) to a VA community-based outpatient clinic, as well as to Veterans' homes. The VA NY Harbor Health Care System TMH Hub (VA NYH TMH Hub) was established in 2016 through funding from VA's Office of Rural Health. Since March 2017, the VA NYH TMH Hub has provided individual, couples, and group therapy, as well as neuropsychological and psychodiagnostic testing to Veterans in rural New York and Iowa. As the TMH initiative continues to grow, it is increasingly important to understand program development, particularly barriers and facilitators to support ongoing growth. The present article examines factors that enhance and challenge the provision of psychotherapy via TMH, as experienced by TMH psychologists. Reflections are based on discussions among nine TMH psychologists regarding their experiences providing TMH treatment, generated and categorized during weekly staff and peer supervision meetings. Administrative, technical, and clinical barriers and facilitators are discussed. Unique considerations are also discussed, related to the structure of the VA NYH TMH Hub and the ways in which the therapeutic relationship may be impacted by TMH. Current considerations highlight strategies to improve telehealth processes and provide practical guidance to support TMH growth.
When distance brings us closer: leveraging tele-psychotherapy to build deeper connection
Predictors of Symptoms Remission Among Family Caregivers of Individuals With Dementia Receiving REACH VA
Resources for Enhancing All Caregivers Health (REACH VA) is a behavioral intervention for caregivers of individuals with dementia disseminated in the VA. Although shown to improve caregiver and care recipient outcomes, some caregivers continue to experience depression or caregiver burden following the intervention. Factors that predict symptom remission following REACH VA are unknown. The present study investigated attachment, social support, and psychopathology as predictors of symptom remission for family caregivers who completed REACH VA. Caregivers who do not remit perceive lower levels of social support from loved ones, endorse poorer attachment quality, and have more personality disorder characteristics, particularly affective instability. These factors that impair caregivers' abilities to be effectively attuned to the needs of their care recipients and to reap benefits from a brief and focused behavioral intervention such as REACH VA. Interventions that target caregiver interpersonal functioning and emotion regulation skills may be helpful to those who do not respond to REACH VA.
Psychosocial Correlates of Nocturnal Blood Pressure Dipping in African Americans: The Jackson Heart Study
BACKGROUND: African Americans exhibit a lower degree of nocturnal blood pressure (BP) dipping compared with Whites, but the reasons for reduced BP dipping in this group are not fully understood. The aim of this study was to identify psychosocial factors associated with BP dipping in a population-based cohort of African Americans. METHODS: This cross-sectional study included 668 Jackson Heart Study (JHS) participants with valid 24-hour ambulatory BP data and complete data on psychosocial factors of interest including stress, negative emotions, and psychosocial resources (e.g., perceived support). The association of each psychosocial factor with BP dipping percentage and nondipping status (defined as <10% BP dipping) was assessed using linear and Poisson regression models, respectively, with progressive adjustment for demographic, socioeconomic, biomedical, and behavioral factors. RESULTS: The prevalence of nondipping was 64%. Higher depressive symptoms, higher hostility, and lower perceived social support were associated with a lower BP dipping percentage in unadjusted models and after adjustment for age, sex, body mass index, and mean 24-hour systolic BP (P < 0.05). Only perceived support was associated with BP dipping percentage in fully adjusted models. Also, after full multivariable adjustment, the prevalence ratio for nondipping BP associated with 1 SD (7.1 unit) increase in perceived support was 0.93 (95% CI: 0.88-0.99). No other psychosocial factors were associated with nondipping status. CONCLUSIONS: Lower perceived support was associated with reduced BP dipping in this study. The role of social support as a potentially modifiable determinant of nocturnal BP dipping warrants further investigation.
On Being the Same in Different Places: Evaluating Frame-of-Reference Effects Across Two Social Contexts
Frame-of-reference (FOR) effects in personality assessment are demonstrated when self-rated items oriented to specific contexts (e.g., workplace) show better predictive validity than noncontextualized items. Empirical support of FOR effects typically relies on job performance ratings or academic grades for criteria. The current study evaluates FOR effects using ratings of personality provided by informants from the home or school context. Items from the NEO Five-Factor Inventory (NEO-FFI; Costa & McCrae, 1992) were contextualized to the home and school contexts to create NEO-Home and NEO-School versions. One hundred fifty-eight college students completed the NEO-Home and NEO-School questionnaires, and 161 college students completed the standard, noncontextualized NEO-FFI. All participants recruited one peer from college and at least one parent to complete standard rater versions of the NEO-FFI. Contextualized self-ratings did not show FOR effects. NEO-Home self-ratings did not correlate higher with parent ratings than with peer ratings, and NEO-School self-ratings did not correlate higher with peer ratings than with parent ratings. Standard NEO-FFI self-ratings generally showed higher self-informant agreement with both types of informants than contextualized self-ratings. The pattern of correlations suggests that validity is enhanced more by specific trait-informant combinations than by the contextualization of items to social contexts.
Relapse prevention in major depressive disorder: Mindfulness-based cognitive therapy versus an active control condition
OBJECTIVE: We evaluated the comparative effectiveness of mindfulness-based cognitive therapy (MBCT) versus an active control condition (ACC) for depression relapse prevention, depressive symptom reduction, and improvement in life satisfaction. METHOD: Ninety-two participants in remission from major depressive disorder with residual depressive symptoms were randomized to either an 8-week MBCT or a validated ACC that is structurally equivalent to MBCT and controls for nonspecific effects (e.g., interaction with a facilitator, perceived social support, treatment outcome expectations). Both interventions were delivered according to their published manuals. RESULTS: Intention-to-treat analyses indicated no differences between MBCT and ACC in depression relapse rates or time to relapse over a 60-week follow-up. Both groups experienced significant and equal reductions in depressive symptoms and improvements in life satisfaction. A significant quadratic interaction (Group x Time) indicated that the pattern of depressive symptom reduction differed between groups. The ACC experienced immediate symptom reduction postintervention and then a gradual increase over the 60-week follow-up. The MBCT group experienced a gradual linear symptom reduction. The pattern for life satisfaction was identical but only marginally significant. CONCLUSIONS: MBCT did not differ from an ACC on rates of depression relapse, symptom reduction, or life satisfaction, suggesting that MBCT is no more effective for preventing depression relapse and reducing depressive symptoms than the active components of the ACC. Differences in trajectory of depressive symptom improvement suggest that the intervention-specific skills acquired may be associated with differential rates of therapeutic benefit. This study demonstrates the importance of comparing psychotherapeutic interventions to active control conditions. (PsycINFO Database Record
The FAITH Trial: Baseline Characteristics of a Church-based Trial to Improve Blood Pressure Control in Blacks
OBJECTIVE: To describe the baseline characteristics of participants in the Faith-based Approaches in the Treatment of Hypertension (FAITH) Trial. DESIGN: FAITH evaluates the effectiveness of a faith-based lifestyle intervention vs health education control on blood pressure (BP) reduction among hypertensive Black adults. SETTING PARTICIPANTS AND MAIN MEASURES: Participants included 373 members of 32 Black churches in New York City. Baseline data collected included participant demographic characteristics, clinical measures (eg, blood pressure), behaviors (eg, diet, physical activity), and psychosocial factors (eg, self-efficacy, depressive symptoms). RESULTS: Participants had a mean age of 63.4 +/- 11.9 years and 76% were female. About half completed at least some college (53%), 66% had an income >/=$20,000, and 42.2% were retired or on disability. Participants had a mean systolic and diastolic BP of 152.1 +/- 16.8 mm Hg and 86.2 +/- 12.2 mm Hg, respectively, and a mean BMI of 32 kg/m2. Hypertension (HTN) medications were taken by 95% of participants, but most (79.1%) reported non-adherence to their regimen. Participants reported consuming 3.4 +/- 2.6 servings of fruits and vegetables and received 30.9% of their energy from fat. About one-third (35.9%) reported a low activity level. CONCLUSIONS: Participants in the FAITH trial exhibited several adverse clinical and behavioral characteristics at baseline. Future analyses will evaluate the effectiveness of the faith-based lifestyle intervention on changes in BP and lifestyle behaviors among hypertensive Black adults.
Comparison of blood pool and extracellular gadolinium chelate for functional MR evaluation of vascular thoracic outlet syndrome
OBJECTIVE: To compare performance of single-injection blood pool agent (gadofosveset trisodium, BPA) against dual-injection extracellular contrast (gadopentetate dimeglumine, ECA) for MRA/MRV in assessment of suspected vascular TOS. MATERIALS AND METHODS: Thirty-one patients referred for vascular TOS evaluation were assessed with BPA (n=18) or ECA (n=13) MRA/MRV in arm abduction and adduction. Images were retrospectively assessed for: image quality (1=non-diagnostic, 5=excellent), vessel contrast (1=same signal as muscle, 4=much brighter than muscle) and vascular pathology by two independent readers, with a separate experienced reader providing reference assessment of vascular pathology. RESULTS: Median image quality was diagnostic or better (score >/=3) for ECA and BPA at all time points, with BPA image quality superior at abduction late (BPA 4.5, ECA 4, p=0.042) and ECA image quality superior at adduction-early (BPA 4.5; ECA 4.0, p=0.018). High qualitative vessel contrast (mean score >/=3) was observed at all time points with both BPA and ECA, with superior BPA vessel contrast at abduction-late (BPA 3.97+/-0.12; ECA 3.73+/-0.26, p=0.007) and ECA at adduction-early (BPA 3.42+/-0.52; ECA 3.96+/-0.14, p<0.001). Readers readily identified arterial and venous pathology with BPA, similar to ECA examinations. CONCLUSION: Single-injection BPA MRA/MRV for TOS evaluation demonstrated diagnostic image quality and high vessel contrast, similar to dual-injection ECA imaging, enabling identification of fixed and functional arterial and venous pathology.
Exploring mediators of the relationship between sleep duration and body mass index [Meeting Abstract]
Introduction: Although the relationship between sleep duration and body mass index (BMI) has been well-characterized, the underlying mechanisms have not. Understanding which factors explain this relationship would provide important insights in developing effective public health interventions to reduce associated cardiometabolic risks. The present study investigated 5 potential mediators of the relationship between sleep duration and BMI. Methods: Data from the 2009 Behavioral Risk Factor Surveillance System (BRFSS) was used in our analysis. BRFSS is a CDC-sponsored project representing the world's largest ongoing, state-speciic, randomized telephone survey that measures behavioral risk factors among U.S. adults [mean age = 56 + 16 years, female = 63%]. Analysis focused on interviews conducted in six representative states, soliciting sociodemographic, medical, sleep, and health-risk data, yielding observations for n = 35,895 respondents. A bootstrapping method was employed to generate conidence intervals (BCCI) ascertaining total and unique mediation across all 5 hypothesized mediators simultaneously (using 1,000 bootstrap samples) of the sleep duration and BMI relationship. The hypothesized mediators included: alcohol use, diet, physical activity, general health status, and life satisfaction. Age and sex were adjusted in all tested models. Results: Analysis showed that for each additional hour of sleep BMI decreases by 0.15 unit. Evidence of unique mediation was noted for: physical activity (BCCI = 0.0017 to 0.0102; SE = 0.0022), diet (BCCI =-0.0138 to-0.0052; SE = 0.0022), and general health status (BCCI =-0.0379 to-0.0079; SE = 0.0423). However, there was no evidence of unique mediation for: alcohol use (BCCI =-0.0013 to 0.0019; SE = 0.0008) or life satisfaction (BCCI =-0.0057 to 0.0057; SE = 0.0028). Conclusion: These indings suggest that the sleep and BMI relationship may be partially mediated by physical activity, diet, and general health. This is consistent with previous hypotheses regard!