Posttraumatic stress disorder (PTSD), anxiety disorders, and alcohol use disorders commonly co-occur among veterans, resulting in greater impairment in the quality of life and other health outcomes than single disorders. Despite the availability of evidence-based psychotherapies, including integrated treatments addressing both anxiety/PTSD and alcohol use, treating comorbid disorders remains challenging. Leveraging providers' skills through modular, adjunctive materials focused on alcohol use might improve their ability to provide transdiagnostic care. Veterans (N = 6) with alcohol use disorder and anxiety and/or PTSD were recruited for an open pilot trial of Bridging the Gap, an adjunctive cognitive-behavioral manual used with the Unified Protocol. Pre- and posttreatment indicators of clinical impact, feasibility, and acceptability were examined; three cases illustrate the delivery of the clinical materials. Small-to-large effects for anxiety and PTSD outcomes and small effects for alcohol outcomes were observed. Bridging the Gap can support providers in delivering key elements of transdiagnostic care.

BACKGROUND:Alcohol use contributes to suboptimal HIV care outcomes, yet existing interventions for people with HIV (PWH) have demonstrated limited efficacy, particularly when outcomes are measured objectively with biomarkers. This proof-of-concept pilot investigated the feasibility and acceptability of integrating phosphatidylethanol (PEth) monitoring into behavioral treatment for alcohol use among Veterans with HIV and elevated depressive and/or anxiety symptoms. METHOD:Participants (N = 20) remotely self-collected dried blood spot (DBS) samples for PEth monitoring and completed a videoconference follow-up session reviewing personalized PEth results in comparison to self-reported alcohol use. Analyses used a mixed-methods approach to synthesize quantitative and qualitative data that assessed feasibility, acceptability, and preferences for a behavioral alcohol intervention. Feasibility and acceptability indicators included PEth sample return and analysis rates, and a PEth monitoring self-report questionnaire. RESULTS:Feasibility was high as 90% of participants submitted DBS samples with 100% of submitted samples successfully analyzed. Participants reported high satisfaction (M = 7.86, SD = 0.81) with remote DBS procedures and the PEth review session. Participants viewed PEth comparisons as useful (M = 8.33, SD = 1.14), easy to understand (M = 8.78, SD = 0.65), and motivating for reducing alcohol use (M = 6.72, SD = 3.14). Qualitative interviews revealed openness to integrating PEth monitoring into treatment, the importance of client-centered communication when delivering PEth feedback, and support for flexible, telehealth-delivered behavioral interventions. CONCLUSION:Findings demonstrated the feasibility and acceptability of remote PEth monitoring among PWH with elevated alcohol use and depressive/anxiety symptoms. PEth monitoring may enhance self-awareness and motivation, bolstering behavioral treatment effectiveness for alcohol use among PWH.

OBJECTIVE:This study explores factors associated with an increased likelihood of receiving mental health (MH) care exclusively via audio-only phone visits within the Department of Veterans Affairs (VA). METHODS:Included patients had ≥1 VA MH outpatient encounter between October 1, 2021-September 30, 2022 and October 1, 2022-September 30, 2023. Patients were divided into a "phone only" group and an "all other" group, which encompassed all patients who did not exclusively receive phone care, including video and/or in-person care. Logistic regression models evaluated demographic and clinical predictors of receiving MH care via phone only. RESULTS:The sample included 1,156,146 patients; 49,125 (4.25%) in the phone only group and 1,107,021 (95.75%) in the all other group. The following were associated with greater odds of receiving MH care via phone only in a multivariate model, all Ps<.0001: being highly rural (OR = 1.50), age 65+ (ORs ≥2.17), with fewer than 3 MH diagnoses (OR = 2.03), and >50% of MH visits conducted by a medical MH provider (OR = 1.87). CONCLUSIONS:Patients who were rural and older had greater odds of receiving MH care exclusively by phone. It will be important to assess whether this was by choice or whether they are experiencing barriers to accessing video or in-person care that could be addressed. Patients who were less clinically severe and were seen primarily by a medical MH provider were also more likely to receive phone-only care. Future research should examine the relative effectiveness of audio-only care as compared to video and in-person.

OBJECTIVE:This study examined feasibility, acceptability, and preliminary clinical impact of Veterans Affairs Coordinated Anxiety Learning and Management- Substance (VA CALM-S), a computer-assisted, transdiagnostic cognitive behavioral intervention for co-occurring anxiety and substance use disorders (SUDs) among veterans. METHODS:Veterans with co-occurring anxiety and SUDs were randomized to receive VA CALM-S (n = 14) or usual care (n = 12). Acceptability and feasibility were assessed via treatment completion rates and qualitative feedback. Changes in self-reported anxiety symptoms, substance use, and substance-related consequences were assessed at posttreatment. RESULTS:Eighty-five percent of participants completed all VA CALM-S modules. Qualitative feedback indicated the intervention was well-received and helpful. Moderate-to-large effect sizes were observed for VA CALM-S in reducing anxiety symptoms (d = 0.64), substance use (d = 0.69), and substance-related consequences (d = 0.34). Relatively smaller effect sizes were observed for the usual care condition in anxiety symptoms (d = 0.24), substance use (d = 0.12), and substance-related consequences (d = -0.46). CONCLUSIONS:Findings support the feasibility and acceptability of VA CALM-S for veterans with co-occurring anxiety and SUDs.

OBJECTIVE:Veterans experience high rates of co-occurring anxiety disorders, posttraumatic stress disorder (PTSD), and unhealthy alcohol use. The goal of this study was to improve the understanding of veterans' beliefs about recovery from co-occurring anxiety/PTSD and alcohol use to direct treatment adaptation and implementation for providers. METHOD:Semistructured qualitative interviews were conducted with 20 veterans and analyzed with rapid qualitative analysis and inductive coding. RESULTS:Veterans' responses reflected themes related to improvement in functioning, including the use of coping skills and communication skills, engagement in therapy, and connection with other veterans. Veterans also described barriers and facilitators related to effective treatment for both disorders. CONCLUSIONS:Specific elements in treatment (e.g., coping and communication skills) and broader considerations (e.g., building community among others in recovery) contribute to relationship and occupational recovery from co-occurring disorders among veterans. Ensuring that these factors are considered in behavioral treatment and treatment programs more broadly for veterans with co-occurring disorders has the potential to enhance functional recovery by aligning with veterans' perspectives and priorities.

Improving health care is complex and challenging and requires robust interventions to create change. Quality improvement (QI) interventions represent the current state of the art for improving care practices. QI as a field of research and practice has five key areas: (a) generalizable scientific evidence, (b) contextual awareness, (c) performance measurement, (d) plans for change, and (e) execution of planned changes. Applied psychology is ideally situated to lead and inform health care change and engage in QI approaches. Applied psychologists share training in scientific and empirical methods and maintain expertise in diverse domains including clinical health and human behavior change, industrial and organizational systems, human performance, education and training, and other related domains of skill and knowledge with significant potential to strengthen QI programs in health care. Collectively, psychology has an opportunity to assemble expert teams that can drive empirically informed impactful programs to improve health and health care practices. Unfortunately, QI approaches are not comprehensively addressed in training and professional development programs for psychologists. This article reviews opportunities for the field of psychology to improve its engagement in QI in health care settings. (PsycInfo Database Record (c) 2026 APA, all rights reserved).

This study examined differences in mental health characteristics of Veterans who received VA Video Connect (VVC) or audio-only care during initial phases of the COVID-19 pandemic. A cohort of Veterans with primary diagnoses of depressive or anxiety disorders (diagnosed between March 2019 and February 2020) was identified, and data were obtained for Veterans who engaged in virtual care from April to December 2020. Two groups were created: Veterans receiving audio-only care (n = 161,071) and Veterans receiving two or more VVC visits (n = 84,505). Multiple logistic regression models examined symptom severity in the year before COVID as a predictor of treatment modality during COVID. Chi-square tests examined associations between modality and the number of assessments. Symptom severity as evaluated by the nine-item Patient Health Questionnaire and Generalized Anxiety Disorder-7 significantly predicted modality of encounters during the pandemic such that those who had moderate or severe symptoms prior to COVID-19 were more likely than those with low or no symptoms to have two or more VVC encounters during the pandemic. Of those who received VVC, 55.62% had no Patient Health Questionnaire-9 assessments compared to 68.96% of those who received audio-only. In the VVC group, 70.36% had no Generalized Anxiety Disorder-7 assessments compared to 81.02% in the audio-only group. Taken together, these findings suggest that VVC, when compared to audio-only, was used during the pandemic to reach Veterans with more severe mental health symptomatology and to engage in administration of measurement-based care. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

ObjectiveBrief cognitive behavior therapy (bCBT) is effective in reducing symptoms of depression and anxiety disorders and improving health-related quality of life (HRQoL). However, the mechanisms through which cognitive behavior therapy impact HRQoL are not well understood. This study evaluated whether anxiety and depression symptom reduction is a mechanism of treatment for HRQoL outcomes.Method:Using secondary data from a multisite, pragmatic, randomized trial, this study evaluated bCBT vs enhanced usual care in 16 VA community-based outpatient clinics. Ordinary least-squares path analysis testing multiple mediators was used to evaluate the role of change in depression and anxiety symptoms in the relationship between treatment condition and HRQoL.Results:Receiving bCBT (vs. enhanced usual care) was significantly negatively associated with change (reduction) in depression and anxiety scores. The indirect effect of treatment on mental HRQoL was significant with change in depression scores as mediator. A similar pattern was observed for physical HRQoL and change in anxiety scores as mediator.Conclusion:Findings suggest reduction of depression and anxiety symptoms as a mechanism through which bCBT for depression promoted improvements in HRQoL, with important implications for understanding how CBT impacts functioning, as well as the utility of bCBT in nontraditional mental health settings.Trial registration:ClinicalTrials.gov identifier: NCT02466126.

Black veterans experience disparities in mental health (MH) care access and are disproportionately affected by COVID-19. Video telehealth to home (VTH) may reduce disparities by addressing barriers, particularly with pandemic-related shifts to remotely delivered care. Considering potential needs for tailored implementation across racial/ethnic groups, we examined differences in VTH use by non-Hispanic Black veterans versus all other races/ethnicities and among Black (Hispanic and non-Hispanic) veterans by age, rurality, and gender during the pandemic. We extracted a cohort of Veterans Health Administration-enrolled veterans receiving at least one MH encounter between October 2019 and September 2020 (n = 1,627,791) from electronic health records. Multilevel linear growth curve models examined the percentage of VTH use for non-Hispanic Black versus other races/ethnicities before and after pandemic onset. Black veteran-only subgroup analyses examined differences by ethnicity in percentage of VTH MH encounters since pandemic onset by age, rurality, and gender, using regression and analysis of covariance models. Despite significant increases in VTH during the pandemic, on average, VTH use was consistently lower for non-Hispanic Black veterans across both periods. During the pandemic, differences in VTH use between non-Hispanic Black and non-Black veterans accelerated over time. VTH use was greater during the pandemic for Black veterans who were Hispanic, younger, urban, and female. Adoption of VTH for MH was low for non-Hispanic Black veterans before COVID-19 and during COVID-19 compared to non-Black groups. Future VTH research and implementation efforts should question why adoption remains low, work to meet cultural needs, and promote equitable adoption for Black veterans.

BACKGROUND:Obsessive compulsive disorder (OCD) is effectively treated with exposure and response prevention (ERP), yet very few veterans receive ERP for OCD within the Veterans Health Administration (VHA). Veterans are a clinically complex population, and no prior research has evaluated the effectiveness of ERP in veterans with OCD or comorbid OCD and posttraumatic stress disorder (PTSD). Given the limited accessibility of ERP-trained providers within VHA, assessment of video telehealth (VTH) delivery of ERP is warranted.METHODS:A sample of 160 veterans with OCD (80 diagnosed with comorbid PTSD) will be randomly assigned to receive up to 16 sessions of ERP or a stress management training control delivered via VTH. Assessments will occur at baseline, posttreatment, and 6-month follow-up. The primary outcome will evaluate the impact of ERP on participants' functioning, and secondary outcomes will include quality of life and OCD symptoms. At posttreatment, qualitative interviews with veterans, clinicians, and administrators will explore barriers and facilitators to treatment delivery, and the implementation potential of ERP.CONCLUSIONS:Results will provide direction for the treatment of OCD and comorbid PTSD in veterans, as well as guidance for future implementation efforts for ERP within VHA.CLINICALTRIALS:gov Identifier:NCT05240924.

Objective: Depressed youth exhibit higher rates of suicidal behavior compared to healthy controls, with problematic substance use potentially intensifying this risk. Accordingly, this study aimed to examine the impact of comorbid depression and problematic substance use and its association with suicidality in youth populations. Methods: We examined differences in clinical features and demographic characteristics between 797 depressed youth ages 8-20 years with and without problematic substance use from the Texas Youth Depression and Suicide Research Network (TX-YDSRN). Additionally, to assess whether the effect of depression severity on suicidal ideation and suicide attempt history were influenced by problematic substance use, multivariable linear and logistic regression analyses were conducted. Results: Depressed youth with problematic substance use (versus those without) were significantly older, more likely to exhibit suicidal ideation and a history of suicide attempts and had significantly worse school functioning after controlling for age, sex, race, and ethnicity. Problematic substance use did not moderate the effect of depression severity on suicidal ideation or suicide attempt history. Conclusions: Findings shed light on the impact of problematic substance use in depressed youth which may allow for earlier and more specified intervention efforts aimed at identifying and targeting youth suicidality.

Veterans with obsessive–compulsive disorder (OCD) often face barriers to receiving evidence-based treatments such as exposure and response prevention (ERP). Through retrospective review of electronic medical records, this study examined the rates of ERP delivery in a national sample of 554 veterans newly diagnosed with OCD in the Veterans Health Administration between 2016 and 2017. Results indicated that only 4

Co-occurring substance use disorder (SUD) and posttraumatic stress disorder (PTSD) or anxiety disorders are related to compounded impairment relative to anxiety or PTSD and SUD occurring alone. Despite these problems, treatment for this comorbidity can vary widely; and care is often fragmented across separate clinics and providers. The objective of the study was to understand the perspectives of veterans who navigate the treatment system and providers who care for these veterans. This study used qualitative interviews conducted with 9 veterans with SUD and co-occurring PTSD and/or anxiety disorders and 7 Veterans Health Administration mental health providers. Participants completed a semistructured interview that was recorded and transcribed. Interview data were examined through matrix analysis, a rapid qualitative data-compilation technique to organize domains of responses. Results showed that veterans believe that SUD and PTSD and/or anxiety symptoms are linked, and that treatment for both SUD and the disorders simultaneously could be beneficial. Interviews with providers found that factors of the healthcare system such as siloed clinics serve as barriers to optimal treatment and that co-occurring disorder treatment requires unique skill, training, and dedicated time to treat. Results of these interviews inform gaps in the delivery of care for co-occurring SUD, PTSD, and anxiety disorders and potential avenues to improve care delivery, including transdiagnostic interventions and system-focused innovations.

Background: Video-to-home telehealth (VTH) is promising for increasing access to mental health (MH) services. VA Video Connect (VVC) facilitates video-based teleconferencing between patients and providers and can reduce barriers while maintaining clinical effectiveness. Little is known about the preferences of Hispanic veterans for VTH. Methods: A retrospective cohort investigation of VTH for MH care utilization among veterans having at least one MH visit from October 2019 to September 2020. The veterans consisted of 155,492 Hispanic/Latino and 1,544,958 non-Hispanic/Latino. VVC involved face-to-face synchronous video-based teleconferencing between patients and providers, enabling care at home or another private location. The main measures included the percentage of MH encounters delivered through VVC. Results: Compared with non-Hispanic veterans, Hispanic veterans had 3.28% greater percentage of VVC MH encounters. Furthermore, there was a 2.65% increase per month in percentage of VVC MH encounters. Conclusions: Contrary to preconceived notions, Hispanic veterans access VTH at higher rates than their non-Hispanic counterparts.

PURPOSE:Alcohol use disorder (AUD) is highly prevalent among Veterans with HIV. Rural Veterans with HIV are at especially high risk for not receiving appropriate treatment. This retrospective cohort cross-sectional study aimed to investigate patterns of mental health treatment utilization across delivery modality among Veterans diagnosed with HIV and AUD. It was hypothesized that rural Veterans with HIV and AUD would receive a lower rate of mental health treatment delivered via video telehealth than urban Veterans with HIV and AUD.METHODS:A national Veterans Health Association administrative database was used to identify a cohort of Veterans diagnosed with HIV and AUD (N = 2,075). Geocoding was used to categorize rural Veterans (n = 246) and urban Veterans (n = 1,829). Negative binomial regression models tested associations between rurality and mental health treatment delivered via face-to-face, audio-only, and video telehealth modalities.FINDINGS:Results demonstrated that rural Veterans with HIV and AUD received fewer mental health treatment sessions delivered via telehealth than urban Veterans with HIV and AUD (incidence rate ratio = 0.62; 95% confidence intervals [0.44, 0.87]; P < .01). No differences were found in terms of treatment delivered face-to-face or by audio-only.CONCLUSIONS:Rural Veterans with HIV and AUD represent a vulnerable subpopulation of Veterans who may most benefit from video telehealth. Efforts to increase access and improve the uptake of evidence-based mental health treatment delivered via video telehealth are needed.

Importance:American Indian/Alaska Native veterans experience a high risk for health inequities, including mental health (MH) care access. Rapid virtualization of MH care in response to the COVID-19 pandemic facilitated care continuity across the Veterans Health Administration (VHA), but the association between virtualization of care and health inequities among American Indian/Alaska Native veterans is unknown. Objective:To examine differences in video telehealth (VTH) use for MH care between American Indian/Alaska Native and non-American Indian/Alaska Native veterans by rurality and urbanicity. Design, Setting, and Participants:In this cohort study, VHA administrative data on VTH use among a veteran cohort that received MH care from October 1, 2019, to February 29, 2020 (prepandemic), and April 1 to December 31, 2020 (early pandemic), were examined. Exposures:At least 1 outpatient MH encounter during the study period. Main Outcomes and Measures:The main outcome was use of VTH among all study groups (ie, American Indian/Alaska Native, non-American Indian/Alaska Native, rural, or urban) before and during the early pandemic. American Indian/Alaska Native veteran status and rurality were examined as factors associated with VTH utilization through mixed models. Results:Of 1 754 311 veterans (mean [SD] age, 54.89 [16.23] years; 85.21% male), 0.48% were rural American Indian/Alaska Native; 29.04%, rural non-American Indian/Alaska Native; 0.77%, urban American Indian/Alaska Native; and 69.71%, urban non-American Indian/Alaska Native. Before the pandemic, a lower percentage of urban (b = -0.91; SE, 0.02; 95% CI, -0.95 to -0.87; P < .001) and non-American Indian/Alaska Native (b = -0.29; SE, 0.09; 95% CI, -0.47 to -0.11; P < .001) veterans used VTH. During the early pandemic period, a greater percentage of urban (b = 1.37; SE, 0.05; 95% CI, 1.27-1.47; P < .001) and non-American Indian/Alaska Native (b = 0.55; SE, 0.19; 95% CI, 0.18-0.92; P = .003) veterans used VTH. There was a significant interaction between rurality and American Indian/Alaska Native status during the early pandemic (b = -1.49; SE, 0.39; 95% CI, -2.25 to -0.73; P < .001). Urban veterans used VTH more than rural veterans, especially American Indian/Alaska Native veterans (non-American Indian/Alaska Native: rurality b = 1.35 [SE, 0.05; 95% CI, 1.25-1.45; P < .001]; American Indian/Alaska Native: rurality b = 2.91 [SE, 0.38; 95% CI, 2.17-3.65; P < .001]). The mean (SE) increase in VTH was 20.34 (0.38) and 15.35 (0.49) percentage points for American Indian/Alaska Native urban and rural veterans, respectively (difference in differences [DID], 4.99 percentage points; SE, 0.62; 95% CI, 3.77-6.21; t = -7.999; df, 11 000; P < .001), and 12.97 (0.24) and 11.31 (0.44) percentage points for non-American Indian/Alaska Native urban and rural veterans, respectively (DID, 1.66; SE, 0.50; 95% CI, 0.68-2.64; t = -3.32; df, 15 000; P < .001). Conclusions and Relevance:In this cohort study, although rapid virtualization of MH care was associated with greater VTH use in all veteran groups studied, a significant difference in VTH use was seen between rural and urban populations, especially among American Indian/Alaska Native veterans. The findings suggest that American Indian/Alaska Native veterans in rural areas may be at risk for VTH access disparities.

In this chapter we discuss the prevalence, etiology, and maintenance of cannabis use disorders (CUD) in active duty service members (ADSMs) and veterans. We provide a historical context for cannabis use and CUD within the military, ranging from prescriptive to recreational use. We describe the current landscape of CUD within civilians and military sample, with CUD being the most common illicit substance use disorder in the US. CUD is related to long-term negative health outcomes, can negatively impact education and occupation, and is also associated with several co-occurring mental health disorders, including anxiety and trauma-related disorders. U.S. military veterans may be especially at risk for impairment related to CUD, given that increases in CUD diagnoses have been observed in recent years and that there are high rates of cannabis use among veterans. Differences in the prevalence of CUD are observed in the general population, as well as within veterans (e.g., younger veterans; those with PTSD). Further, legal issues related to cannabis use that are unique to military populations will be reviewed. This work aims to understand differences in cannabis use, subsequent risk factors, and treatment approaches for ADSMs and veterans with special attention on individual characteristics, such as ethnocultural differences and service histories.