Tracey L. Smith, PhD, first went to work for the Veterans Health Administration 12 years ago to start an evidence-based psychotherapy clinic for post-traumatic stress disorder (PTSD). At the time, the mainstream thinking was that veterans with the condition would continue to spiral downhill, regardless of what psychologists like Smith tried to do, she says.
But by using a rigorously tested intervention for PTSD patients, Smith and her VA colleagues helped to change that negative outlook. The team used cognitive-processing therapy, developed by VA clinical psychologist Patti Resick, PhD, which involves challenging and changing unhelpful thoughts about trauma. Many of the patients had served in Vietnam and had struggled for decades with unemployment and family schisms as a result of their trauma.
With the treatment, they started to get some relief, Smith says. "I had one veteran who went back to Vietnam," she says. "He went and saw people in the village where he served. His whole life just changed. There's nothing better than that, to be part of that journey with somebody."
Cognitive-processing therapy is now considered one of the gold-standard evidence-based treatments for PTSD.
Talk to psychologist researchers at the VA, and that's the sort of story you'll hear: They can watch their work move into clinical practice, or shepherd it there themselves thanks to the VA's expansive, integrated structure. And with more than 9 million patients being treated at 1,240 facilities by more than 20,000 mental health professionals—including more than 5,000 psychologists—there's a dizzying range of work being done, much of which goes on to influence the private sector.
"We are the largest system of psychologists and we train more psychologists than any other group in the United States," says Smith, who this year serves as president of the Association of VA Psychologist Leaders (AVAPL).
Much of the VA's mental health research takes place at its 17 Centers of Excellence (COE), which include 10 Mental Illness Research, Education and Clinical Centers (MIRECCs). MIRECCs are overseen by the VA's Office of Mental Health and Suicide Prevention. Each COE and MIRECC has its own focus, though they collaborate with one another and coordinate projects in line with the VA's Office of Research and Development. Research is conducted both by dedicated staff at the MIRECC or COE as well as by academic psychologists who collaborate with VA scientists.
Here, the Monitor explores the work taking place at the research hubs directed by psychologists.
A focus on suicide prevention
Rocky Mountain MIRECC
The research at each center runs the gamut from basic to translational. The Rocky Mountain MIRECC, with its spotlight on veteran suicide prevention, is a good example. Based in Denver and Salt Lake City, this MIRECC supports researchers who are looking at basic physiological correlates of suicide and suicidality, a major priority for the VA. Others work on translating basic science to treatment, and still others on dissemination and implementation.
An average of 20 veterans die by suicide each day, and veterans account for 14.3 percent of all suicides among U.S. adults, according to a VA reportopens in new window. Of those 20 veterans, however, 14 are not in VA care—hence the agency's increased urgency in reaching out to vets in need of mental health services, Smith says.
One project, led by MIRECC director and psychologist Lisa Brenner, PhD, is recruiting veterans to provide blood samples so that researchers can try to untangle the relationships among markers of inflammation, PTSD and post-concussive symptoms. An emerging line of research at the site by Teodor Postolache, MD, a psychiatrist at the University of Maryland School of Medicine and a VA Capitol Health Care Network and Rocky Mountain MIRECC research psychologist, suggests that inflammation may be linked to suicide (Acta Psychiatrica Scandinavica, Vol. 132, No. 3, 2015opens in new window). Another line of research, led by University of Utah psychiatrist Perry Renshaw, MD, PhD, MBA, asks how the high altitude of the Rocky Mountain West might affect brain chemistry and thus suicide risk (Journal of Affective Disorders, Vol. 129, No. 1–3, 2011opens in new window).
The center also hosts research on suicide prevention. One project that particularly excites Brenner is a small-group counseling method called Window to Hope, which focuses on veterans with moderate to severe traumatic brain injury (Brain Injury, Vol. 28. No. 10, 2014opens in new window). Window to Hope puts veterans into groups of two or three, each with a facilitator who leads training on problem-solving, coping and other cognitive-behavioral interventions. There is also a heavy focus on re-establishing a sense of identity after a life-altering brain injury.
"We showed that we could reduce hopelessness in those with moderate to severe TBI [traumatic brain injury]," Brenner says, "and hopelessness is a well-known precursor to suicide risk."
In the future, Brenner hopes to do more research on early suicide prevention. While it's crucial to intervene when someone is contemplating suicide, she wants to reach veterans before crises occur, catching risk factors like sleeplessness or unemployment before they spiral into suicide risk. However, this does create some methodological challenges.
"How do you, as a researcher, measure something that doesn't happen?" Brenner says. "That's a really hard question." Even just improving veteran quality of life by targeting risk factors would be a step forward, she says. "It just requires us to rethink and broaden what we conceptualize as suicide prevention."
Helping recent veterans
The Mid-Atlantic MIRECC
The veterans who rely on the VA for their care span many demographic categories: young, old, male, female. At the Mid-Atlantic MIRECC, the focus is on post-deployment mental health, primarily among a younger subset of veterans—those who have served since the Sept. 11, 2001, terrorist attacks.
"We're thinking in terms of relatively recently returning veterans who have been deployed to combat situations," says psychologist John Fairbank, PhD, who directs the Mid-Atlantic MIRECC, which is made up of sites in Durham, North Carolina; Richmond, Virginia; Hampton, Virginia; and Salisbury, North Carolina.
"The issues facing these veterans include well-known injuries of war, both physical and psychological, such as PTSD, TBI and substance use," says Deputy Director Mira Brancu, PhD. Working with these vets, though, clinicians and researchers have also uncovered lesser-studied problems, including chronic pain, impacts on families and the challenges of access to mental health care for rural vets. Taking a translational approach, this MIRECC starts with studies of animal models of PTSD and TBI and advances through clinical studies, health-service studies and all the way to implementation studies to get evidence-based practices into the real world.
Among this MIRECC's hallmark efforts is the Post-Deployment Mental Health studyopens in new window, with data from more than 3,800 veterans serving during the Afghanistan and Iraq conflicts. Participants filled out detailed questionnaires about post-deployment mental health, participated in a structured clinical interview of psychiatric disorders, donated blood for genetic and biomarker studies and in some cases underwent neuroimaging. One of the revelations from this multisite study was the finding published by Nathan Kimbrel, PhD, and colleagues that combat exposure increases suicidal behavior by increasing PTSD and depressive symptoms (Journal of Affective Disorders, Vol. 235, 2018opens in new window). Another key study from the center looked at the association between suicide-risk factors and receiving an "other-than-honorable" military discharge—the type of discharge issued when a veteran is convicted of a crime or otherwise breaks the military code of conduct. Many veterans with such discharge status are ineligible for VA care and benefits, Brancu says, but there's a chicken-and-egg problem for this population. Veterans "often get an ‘other-than-honorable' discharge because they were struggling with mental health issues while on deployment," she says.
In 2017, the VA secretary expanded emergency mental health care to this group, and Mid-Atlantic MIRECC researchers jumped at the opportunity to examine the factors linked to this kind of discharge. In research led by psychologist Eric Elbogen, PhD, and co-authored by Brancu and Fairbank, the team found that veterans discharged under other-than-honorable conditions were younger than average and reported more intensive family histories of drug abuse and depression. The researchers found no overall difference in suicidal ideation or behavior between veterans discharged other-than-honorably and those receiving honorable discharges. However, they did find differences in suicide-risk factors, including more self-reported sleep problems, drug misuse and low levels of social support. The other-than-honorably discharged were also more likely than other vets to meet the criteria for major depressive disorder (Military Medicine, online first publication, 2018opens in new window).
Improving access for SMI patients
The VA Capitol Healthcare Netword MIRECC
The motto at the VA Capitol Healthcare Network MIRECC is "Putting recovery into practice." The research at this Baltimore-based center is focused on serious mental illness (SMI) and is divided into five areas: health and wellness, family-oriented service, stigma, psychopharmacology and neurobiology, and treatment and community engagement.
As that list might indicate, ensuring that veterans with SMI receive effective services is a big part of this MIRECC's mission. One major project, led by program director and psychologist Richard Goldberg, PhD, focuses on implementing a self-management program in which veterans participate in a group curriculum led by a mental health professional and a peer specialist. The goal is to help the veterans manage critical aspects of their health, from sleep quality to stress reduction to managing pain and diet.
The peer specialist is key, Goldberg says, because that person provides a model for the kind of change the program hopes to encourage. The results of a large trial of the program are under review in a leading journal, Goldberg says, but the research team found that the program spurred positive functional, attitudinal and behavioral changes.
Another successful evidence-based program developed at this MIRECC focuses on reducing internalized stigma among vets with SMI. The center's Ending Self Stigma program is a nine-session group psycho-education intervention in which participants learn to disassociate themselves from myths about mental illness and shift their thinking about their own conditions (Psychiatric Rehabilitation Journal, Vol. 35, No. 1, 2011opens in new window). It's taken off in clinical settings, Goldberg says.
"There was so much interest in this that we offered consultation in supporting the intervention in nonresearch settings in over 70 programs across the country," he says.
Reaching out to rural vets
The South Central MIRECC
Access to care is a key focus of the South Central MIRECC in Houston, where Tracey L. Smith, PhD, the AVAPL president, works as the associate director for improving clinical care. Long wait times for care and high demand for psychological services have been notorious problems for the VA in the past. To help ease access to care, Smith and her team are studying how to improve patient flow by identifying those who are ready to transition back to primary care within the VA setting after being seen by mental health specialists.
"When we looked at the data, about 13 percent of the veterans identified were transferred to primary care, and of those, only 2 percent came back to mental health," Smith says. That low return rate suggests that the identification methods were catching vets who were ready for a less-intensive level of care, she says. Veterans are told that the road between primary care and mental health services is a two-way street, she says, and that they should be able to move between the two depending on their evolving needs.
Despite the MIRECC's urban location, research is also focused on pushing care out toward rural areas for veterans far from VA facilities. Each VA medical center has eight to 10 community-based outpatient clinics associated with it, Smith says, and these smaller clinics are often more conveniently placed for rural vets. To better meet the need for psychological services, South Central MIRECC researchers and clinicians are working to implement brief psychotherapy programs at these community clinics.
Improving integrated care
The Center for Integrated Healthcare
There are also entire VA research programs devoted to implementation studies, such as one at the Center for Integrated Healthcare, headquartered in Buffalo, New York. The goal of this center is to bring mental health care into primary care to improve access for vets.
Research shows that even when patients feel comfortable enough to ask their primary-care physicians about mental health issues, they often fail to follow up with the referral to a mental health professional if there's a delay in scheduling an appointment, says Executive Director Laura Wray, PhD, a clinical psychologist.
"We need to make sure we're providing availability," Wray says. To that end, the goal is to have a mental health practitioner, whether a psychologist, psychiatrist or social worker, embedded with the primary-care team to triage patients. These changes are currently being implemented and studied by the center, Wray says. Veterans who are experiencing severe problems can be quickly assessed and, if willing, sent to specialist care, while those with less serious issues can receive brief mental health interventions, such as a short series of counseling sessions, on the spot.
The integrated nature of the VA system makes this possible, Wray says. "If I go to my primary-care doc and say, ‘I haven't been eating, sleeping, my mood is terrible,' they're going to refer me out to someplace in the community. Here in the VA, the primary-care doc is going to say to you, ‘I have somebody on my team and she can talk to you for a few minutes and help you figure out what to do. Would you be willing to talk to her?'"
Wray and her team are now testing the efficacy of short mental health sessions in primary care. The interventions are scaled-down versions of longer evidence-based treatments, Wray says, and the researchers want to find out if they work and if they boost patients' willingness to get more intensive help.
The VA is a one-of-a-kind place for this type of work, Wray says, in part because its nationally linked electronic health-care records make it possible to pull out the data researchers need to test these programs at multiple sites. And driving this work, Wray says, is the sense of obligation to veterans. "We all have this shared mission to take care of the people who have protected us," she says.
