A comparison of substance use stigma and health stigma in a population of veterans with co-occurring mental health and substance use disorders

OBJECTIVE: This pilot study examined whether substance use or mental illness was more stigmatizing among individuals with co-occurring mental health and substance abuse problems. METHODS: This study included 48 individuals with co-occurring substance use and mental health problems enrolled in a Substance Abuse and Mental Health Services funded treatment program. Subjects received a baseline assessment that included addiction, mental health, and stigma measures. RESULTS: The sample consisted primarily of White males with an average age of 38 years. Substance abuse was found to be more stigmatizing than mental illness, F(1, 47) = 14.213, p < .001, and stigma varied across four different levels of stigma (Aware, Agree, Apply, and Harm), F(2.099, 98.675) = 117.883, p < .001. The interaction between type and level of stigma was also significant, F(2.41, 113.284) = 20.250, p < .001, indicating that differences in reported stigma between types varied across levels of stigma. Post hoc tests found a significant difference between all levels of stigma except for the comparison between Apply and Harm. Reported stigma was significantly higher for substance abuse than mental illness at the Aware and Agree levels. In addition, pairwise comparisons found significant differences between all levels of stigma with the exception of the comparison between Apply and Harm, indicating a pattern whereby reported stigma generally decreased from the first level (Aware stage) to subsequent levels. CONCLUSIONS: These results have important implications for treatment, suggesting the need to incorporate anti-stigma interventions for individuals with co-occurring disorders with a greater focus on substance abuse

An evidence-based co-occurring disorder intervention in VA homeless programs: outcomes from a hybrid III trial

BACKGROUND: Evidence-based treatment for co-occurring disorders is needed within programs that serve homeless Veterans to assist with increasing engagement in care and to prevent future housing loss. A specialized co-occurring disorders treatment engagement intervention called Maintaining Independence and Sobriety Through Systems Integration, Outreach and Networking - Veterans Edition (MISSION-Vet) was implemented within the Housing and Urban Development - Veterans Affairs Supportive Housing (HUD-VASH) Programs with and without an implementation strategy called Getting To Outcomes (GTO). While implementation was modest for the GTO group, no one adopted MISSION in the non-GTO group. This paper reports Veteran level outcome data on treatment engagement and select behavioral health outcomes for Veterans exposed to the MISSION-Vet model compared to Veterans without access to MISSION-Vet. METHODS: This hybrid Type III trial compared 81 Veterans in the GTO group to a similar group of 87 Veterans with mental health and substance use disorders from the caseload of staff in the non-GTO group. Comparisons were made on treatment engagement, negative housing exits, drug and alcohol abuse, inpatient hospitalizations, emergency department visits and income level over time, using mixed-effect or Cox regression models. RESULTS: Treatment engagement, as measured by the overall number of case manager contacts with Veterans and others (e.g. family members, health providers), was significantly higher among Veterans in the GTO group (B = 2.30, p = .04). Supplemental exploratory analyses between Veterans who received higher and lower intensity MISSION-Vet services in the GTO group failed to show differences in alcohol and drug use, inpatient hospitalization and emergency department use. CONCLUSIONS: Despite modest MISSION-Vet fidelity among staff treating Veterans in the GTO group, differences were found in treatment engagement. However, this study failed to show differences in alcohol use, drug use, mental health hospitalizations and negative housing exits over time among those Veterans receiving higher intensity MISSION-Vet services versus low intensity services. This project suggests that MISSION-Vet could be used in HUD-VASH to increase engagement among Veterans struggling with homelessness, a group often disconnected from care. TRIAL REGISTRATION: Clinicaltrials.gov, registration number: NCT01430741 , registered July 26, 2011

Using Getting To Outcomes to facilitate the use of an evidence-based practice in VA homeless programs: a cluster-randomized trial of an implementation support strategy

BACKGROUND: Incorporating evidence-based integrated treatment for dual disorders into typical care settings has been challenging, especially among those serving Veterans who are homeless. This paper presents an evaluation of an effort to incorporate an evidence-based, dual disorder treatment called Maintaining Independence and Sobriety Through Systems Integration, Outreach, and Networking-Veterans Edition (MISSION-Vet) into case management teams serving Veterans who are homeless, using an implementation strategy called Getting To Outcomes (GTO). METHODS: This Hybrid Type III, cluster-randomized controlled trial assessed the impact of GTO over and above MISSION-Vet Implementation as Usual (IU). Both conditions received standard MISSION-Vet training and manuals. The GTO group received an implementation manual, training, technical assistance, and data feedback. The study occurred in teams at three large VA Medical Centers over 2 years. Within each team, existing sub-teams (case managers and Veterans they serve) were the clusters randomly assigned. The trial assessed MISSION-Vet services delivered and collected via administrative data and implementation barriers and facilitators, via semi-structured interview. RESULTS: No case managers in the IU group initiated MISSION-Vet while 68% in the GTO group did. Seven percent of Veterans with case managers in the GTO group received at least one MISSION-Vet session. Most case managers appreciated the MISSION-Vet materials and felt the GTO planning meetings supported using MISSION-Vet. Case manager interviews also showed that MISSION-Vet could be confusing; there was little involvement from leadership after their initial agreement to participate; the data feedback system had a number of difficulties; and case managers did not have the resources to implement all aspects of MISSION-Vet. CONCLUSIONS: This project shows that GTO-like support can help launch new practices but that multiple implementation facilitators are needed for successful execution of a complex evidence-based program like MISSION-Vet. TRIAL REGISTRATION: ClinicalTrials.gov NCT01430741

Case Management

This chapter describes the roles and responsibilities of the MISSION-VET Case Manager and how it relates to MISSION-VET service delivery. The chapter begins with an overview of the MISSION-VET Case Manager’s responsibilities. Settings in which MISSION-VET can be delivered and implications for case management are then reviewed. The importance of teamwork with the Peer Support Specialist is stressed, and the Case Manager’s role is distinguished from that of the Peer Support Specialist. The Chapter then reviews each of the Case Manager’s primary responsibilities. Because case management is seen as the foundation of the MISSION-VET model, this chapter refers to a number of appendices that will be useful tools for the Case Manager to use as MISSION-VET is implemented

A Qualitative Evaluation of Mental Health Clinic Staff Perceptions of Barriers and Facilitators to Treating Tobacco Use

Introduction: Veterans with mental health disorders smoke at high rates, but encounter low rates of tobacco treatment. We sought to understand barriers and facilitators to treating tobacco use in VA mental health clinics. Methods: This qualitative study was part of a trial evaluating a telephone care coordination program for smokers using mental health services at six VA facilities. We conducted semi-structured interviews with 14 staff: 12 mental health clinic staff working at the parent study\u27s intervention sites (n = 6 psychiatrists, three psychologists, two social workers, one NP), as well as one psychiatrist and one psychologist on the VA\u27s national tobacco advisory committee. Interviews were transcribed and inductively coded to identify themes. Results: Five barriers themes emerged: (1) competing priorities, (2) patient challenges/resistance, (3) complex staffing/challenging cross-discipline coordination, (4) mixed perceptions about whether tobacco is a mental health care responsibility, and (5) limited staff training/comfort in treating tobacco. Five facilitators themes emerged: (1) reminding mental health staff about tobacco, (2) staff belief in the importance of addressing tobacco, (3) designating a cessation medication prescriber, (4) linking tobacco to mental health outcomes and norms, and (5) limiting mental health staff burden. Conclusions: VA mental health staff struggle with knowing that tobacco use is important, but they face competing priorities, encounter patient resistance, are conflicted on their role in addressing tobacco, and lack tobacco training. They suggested strategies at multiple levels that would help overcome those barriers that can be used to design interventions that improve tobacco treatment delivery for mental health patients. Implications: This study builds upon the existing literature on the high rates of smoking, but low rates of treatment, in people with mental health diagnoses. This study is one of the few qualitative evaluations of mental health clinic staff perceptions of barriers and facilitators to treating tobacco. The study results provide a multi-level framework for developing strategies to improve the implementation of tobacco treatment programs in mental health clinics

A cluster randomized Hybrid Type III trial testing an implementation support strategy to facilitate the use of an evidence-based practice in VA homeless programs

BACKGROUND: The Housing and Urban Development-Veterans Affairs Supportive Housing (HUD-VASH) program is one of the largest initiatives to end Veteran homelessness. However, mental health and substance use disorders continue to reduce client stability and impede program success. HUD-VASH programs do not consistently employ evidence-based practices that address co-occurring mental health and substance use disorders. This paper presents a study protocol to evaluate the implementation of an evidence-based, co-occurring disorder treatment called Maintaining Independence and Sobriety Through Systems Integration, Outreach, and Networking-Veterans Edition (MISSION-Vet) in HUD-VASH using an implementation strategy called Getting To Outcomes (GTO). METHODS/DESIGN: In three large VA Medical Centers, this Hybrid Type III trial will randomize case managers and their clients by HUD-VASH sub-teams to receive either MISSION-Vet Implementation as Usual (IU-standard training and access to the MISSION-Vet treatment manuals) or MISSION-Vet implementation augmented by GTO. In addition to testing GTO, effectiveness of the treatment (MISSION-Vet) will be assessed using existing Veteran-level data from the HUD-VASH data monitoring system. This project will compare GTO and IU case managers and their clients on the following variables: (1) fidelity to the MISSION-Vet intervention; (2) proportion of time the Veteran is housed; (3) mental health, substance use, and functional outcomes among Veterans; and (4) factors key to the successful deployment of a new treatment as specified by the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) model. DISCUSSION: This project is an important step for developing an implementation strategy to increase adoption of evidence-based practice use in VA homeless programs, and to further examine efficacy of MISSION-Vet in HUD-VASH. This project has important implications for program managers, policy makers, and researchers within the homelessness field. VA Central IRB approval for this study was granted in October 2011. The three sites were trained on MISSION-Vet and GTO in the first half of 2013. The first GTO planning meetings began after training occurred, between January 2013 and November 2013, across the three sites. The data collection-via a fidelity measure embedded into the VA Computerized Patient Record System-began as each site initiated MISSION-Vet, between April 2013 and January 2014. TRIAL REGISTRATION: ClinicalTrials.gov: NCT01430741

Clients of VA-Housed Legal Clinics: Legal and Psychosocial Needs When Seeking Services and Two Months Later.

Veterans often need civil legal services, yet little is known about veterans use and consequences of these services. This study examined veterans seeking legal services at VA-housed legal clinics. Baseline data from 61 clients of two VA-housed legal clinics were used to identify clients legal needs and psychosocial characteristics. Data collected from 49 (80%) of the same clients two months later were used to address clients improvement and satisfaction after receiving legal services. At baseline, clients reported a mean of 6.0 (SD = 4.2) legal needs, with the most common being help obtaining VA benefits (87%). Clients represented a vulnerable population in that most had an extensive criminal history (e.g., had been arrested, charged, and incarcerated) and multiple health care needs (had a chronic medical condition, had recently received treatment in an emergency department, and had received psychological treatment due to significant psychological symptoms). At follow-up, clients reported a mean of 4.4 (SD = 3.8) legal needs. Tests to identify changes between baseline and follow-up on legal needs, housing arrangement, psychological symptoms, and substance use yielded few significant results. Most participants did not receive additional help with their legal matters after the baseline appointment. At follow-up, clients reported that few of their legal needs were met but also that they were mostly satisfied with the legal services they received. Findings suggest that because clients may need more intensive legal intervention of longer duration to resolve their legal needs and achieve better housing and health status, VA-housed legal clinics require greater resources and expansion

National Survey of Legal Clinics Housed by the Department of Veterans Affairs to Inform Partnerships with Health and Community Services.

Legal clinics housed by the Department of Veterans Affairs (VA) help veterans eliminate service access barriers. In this survey of 95 VA-housed legal clinics (70% of clinics), clients legal problems were mainly estate planning, family, obtaining VA benefits, and housing (14-17% of clients). Most clinics rarely interacted with VA health care providers, did not have access to clients VA health care records, and did not track clients VA health care access (58-81% of clinics); 32% did not have dedicated and adequate space. Most clinic staff members were unpaid. Survey findings-that most VA-housed legal clinics do not interact with VA health care or directly address clients mental health and substance use needs, and lack funds to serve fully all veterans seeking services-suggest that VA and community agencies should enact policies that expand and fund veterans legal services and health system interactions to address health inequities and improve health outcomes

Preliminary Efforts Directed Toward the Detection of Craving of Illicit Substances: The iHeal Project

Many behavioral interventions, whether for the management of chronic pain, overeating, medication adherence, or substance abuse, are ineffective outside of the clinic or office environments in which they are taught. This lack of utility has spawned interest in enabling technologies that are capable of detecting changes in affective state that potentially herald a transition to risky behaviors. We have therefore undertaken the preliminary development of “iHeal”, an innovative constellation of technologies that incorporates artificial intelligence, continuous biophysical monitoring, wireless connectivity, and smartphone computation. In its fully realized form, iHeal can detect developing drug cravings; as a multimedia device, it can also intervene as the cravings develop to prevent drug use. This manuscript describes preliminary data related to the iHeal Project and our experience with its use.United States. American Recovery and Reinvestment Act of 2009National Institutes of Health (U.S.

The MISSION-VET Consumer Workbook

Summary: Supplemental workbook for the Maintaining Independence and Sobriety through Systems Integration, Outreach, and Networking (MISSION) treatment approach, which was adapted specifically for Veterans (MISSION-VET). MISSION-VET, a flexible, integrated, time-limited, yet assertive service delivery platform was designed specifically to provide direct treatment, ongoing support, and care coordination to homeless Veterans suffering from co-occurring disorders and transitioning and/or adjusting to independent living in the community. The Consumer Workbook is a supplemental workbook to engage homeless Veterans by providing exercises and resources to aid in their recovery from a co-occurring disorder and homelessness. Peer Support Specialists and Case Managers should work with the Veteran to complete the items in the workbook that correspond with specific Dual-Recovery Therapy sessions and use the workbook as a talking point in helping clients with co-occurring mental illness and substance abuse, homelessness and related issues that arise in the various stages of their recovery