Federal Practitioner

TOPLINE:

Among US veterans with type 2 diabetes (T2D), adherence to 6 to 8 healthy lifestyle factors combined with GLP‑1 receptor agonist (RA) use was associated with a notably lower risk for major adverse cardiovascular events (MACE) than adherence to three or fewer lifestyle factors without GLP‑1 therapy.

METHODOLOGY:

• GLP-1 RAs help manage cardiovascular risk in patients with T2D; however, lifestyle change remains the foundation of diabetes care. The long-term combined effect of these drugs together with a healthy lifestyle on MACE is not fully understood.
• Researchers conducted a prospective cohort study of 98,261 US veterans with T2D between January 2011 and September 2023, with a follow-up duration of 632,543 person-years, to examine the combined impact of GLP-1 RA use and adherence to eight lifestyle habits on cardiovascular outcomes.
• The 8 low-risk lifestyle habits assessed were healthy eating, regular physical activity (≥ 7.5 metabolic equivalent hours/week), nonsmoking, restful sleep (7-9 hours/day), no or moderate alcohol intake (absence of frequent heavy drinking), good stress management, strong social connection and support, and no opioid use disorder.
• GLP‑1 RA use was ascertained from Veterans Health Administration pharmacy records. The primary outcome was MACE, defined as nonfatal stroke, nonfatal myocardial infarction, or cardiovascular death.

TAKEAWAY:

• Participants adhering to all 8 low-risk lifestyle habits had a 60% lower risk for MACE than those adhering to ≤ 1 (multivariable-adjusted hazard ratio [HR], 0.40; P < .0001).
• All 8 low-risk lifestyle factors were independently associated with a lower risk for MACE, with no opioid use disorder showing the strongest association (HR, 0.77; 95% CI, 0.66-0.89).
• Participants using GLP-1 RAs had a 16% lower risk for MACE than those not receiving GLP-1 therapy and receiving usual care (multivariable-adjusted HR, 0.84; 95% CI, 0.76-0.92).
• Participants using GLP-1 RAs who also adhered to 6 to 8 low-risk lifestyle factors had a 43% lower risk for MACE than those not receiving GLP-1 therapy who adhered to three or fewer lifestyle factors (HR, 0.57; 95% CI, 0.46-0.71).

IN PRACTICE:

"In a healthcare landscape, in which GLP-1 [RAs] remain costly and access is uneven, the additive benefit of lifestyle adherence highlighted by this study has important implications for health equity, resource allocation, and the long-term sustainability of diabetes care," experts noted in an accompanying editorial.

SOURCE:

The study was led by Xuan-Mai T. Nguyen, MD, Department of Medicine, UCLA David Geffen School of Medicine in Los Angeles. It was published online in The Lancet Diabetes & Endocrinology.

LIMITATIONS:

The analyses were based on Veterans Health Administration electronic health record data, and healthcare use outside this system was only incompletely captured. The estimation was based on observational data in which lifestyle factors were assessed at baseline. The cohort consisted of predominantly male veterans, which might limit generalizability to other populations.

DISCLOSURES:

The study used data from the Million Veteran Program (MVP) and was supported by Veterans Affairs MVP awards, along with additional support from other sources. One author reported receiving consulting fees, speaker honoraria, meeting/travel support; participation on advisory boards; and ownership of stock or stock options from certain companies in the healthcare and life sciences sectors. Another author reported receiving a research grant from a consulting/analysis firm.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.

A version of this article first appeared on Medscape.com.

TOPLINE:

Among US veterans with type 2 diabetes (T2D), adherence to 6 to 8 healthy lifestyle factors combined with GLP‑1 receptor agonist (RA) use was associated with a notably lower risk for major adverse cardiovascular events (MACE) than adherence to three or fewer lifestyle factors without GLP‑1 therapy.

METHODOLOGY:

• GLP-1 RAs help manage cardiovascular risk in patients with T2D; however, lifestyle change remains the foundation of diabetes care. The long-term combined effect of these drugs together with a healthy lifestyle on MACE is not fully understood.
• Researchers conducted a prospective cohort study of 98,261 US veterans with T2D between January 2011 and September 2023, with a follow-up duration of 632,543 person-years, to examine the combined impact of GLP-1 RA use and adherence to eight lifestyle habits on cardiovascular outcomes.
• The 8 low-risk lifestyle habits assessed were healthy eating, regular physical activity (≥ 7.5 metabolic equivalent hours/week), nonsmoking, restful sleep (7-9 hours/day), no or moderate alcohol intake (absence of frequent heavy drinking), good stress management, strong social connection and support, and no opioid use disorder.
• GLP‑1 RA use was ascertained from Veterans Health Administration pharmacy records. The primary outcome was MACE, defined as nonfatal stroke, nonfatal myocardial infarction, or cardiovascular death.

TAKEAWAY:

• Participants adhering to all 8 low-risk lifestyle habits had a 60% lower risk for MACE than those adhering to ≤ 1 (multivariable-adjusted hazard ratio [HR], 0.40; P < .0001).
• All 8 low-risk lifestyle factors were independently associated with a lower risk for MACE, with no opioid use disorder showing the strongest association (HR, 0.77; 95% CI, 0.66-0.89).
• Participants using GLP-1 RAs had a 16% lower risk for MACE than those not receiving GLP-1 therapy and receiving usual care (multivariable-adjusted HR, 0.84; 95% CI, 0.76-0.92).
• Participants using GLP-1 RAs who also adhered to 6 to 8 low-risk lifestyle factors had a 43% lower risk for MACE than those not receiving GLP-1 therapy who adhered to three or fewer lifestyle factors (HR, 0.57; 95% CI, 0.46-0.71).

IN PRACTICE:

"In a healthcare landscape, in which GLP-1 [RAs] remain costly and access is uneven, the additive benefit of lifestyle adherence highlighted by this study has important implications for health equity, resource allocation, and the long-term sustainability of diabetes care," experts noted in an accompanying editorial.

SOURCE:

The study was led by Xuan-Mai T. Nguyen, MD, Department of Medicine, UCLA David Geffen School of Medicine in Los Angeles. It was published online in The Lancet Diabetes & Endocrinology.

LIMITATIONS:

The analyses were based on Veterans Health Administration electronic health record data, and healthcare use outside this system was only incompletely captured. The estimation was based on observational data in which lifestyle factors were assessed at baseline. The cohort consisted of predominantly male veterans, which might limit generalizability to other populations.

DISCLOSURES:

The study used data from the Million Veteran Program (MVP) and was supported by Veterans Affairs MVP awards, along with additional support from other sources. One author reported receiving consulting fees, speaker honoraria, meeting/travel support; participation on advisory boards; and ownership of stock or stock options from certain companies in the healthcare and life sciences sectors. Another author reported receiving a research grant from a consulting/analysis firm.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.

A version of this article first appeared on Medscape.com.

TOPLINE:

Among US veterans with type 2 diabetes (T2D), adherence to 6 to 8 healthy lifestyle factors combined with GLP‑1 receptor agonist (RA) use was associated with a notably lower risk for major adverse cardiovascular events (MACE) than adherence to three or fewer lifestyle factors without GLP‑1 therapy.

METHODOLOGY:

• GLP-1 RAs help manage cardiovascular risk in patients with T2D; however, lifestyle change remains the foundation of diabetes care. The long-term combined effect of these drugs together with a healthy lifestyle on MACE is not fully understood.
• Researchers conducted a prospective cohort study of 98,261 US veterans with T2D between January 2011 and September 2023, with a follow-up duration of 632,543 person-years, to examine the combined impact of GLP-1 RA use and adherence to eight lifestyle habits on cardiovascular outcomes.
• The 8 low-risk lifestyle habits assessed were healthy eating, regular physical activity (≥ 7.5 metabolic equivalent hours/week), nonsmoking, restful sleep (7-9 hours/day), no or moderate alcohol intake (absence of frequent heavy drinking), good stress management, strong social connection and support, and no opioid use disorder.
• GLP‑1 RA use was ascertained from Veterans Health Administration pharmacy records. The primary outcome was MACE, defined as nonfatal stroke, nonfatal myocardial infarction, or cardiovascular death.

TAKEAWAY:

• Participants adhering to all 8 low-risk lifestyle habits had a 60% lower risk for MACE than those adhering to ≤ 1 (multivariable-adjusted hazard ratio [HR], 0.40; P < .0001).
• All 8 low-risk lifestyle factors were independently associated with a lower risk for MACE, with no opioid use disorder showing the strongest association (HR, 0.77; 95% CI, 0.66-0.89).
• Participants using GLP-1 RAs had a 16% lower risk for MACE than those not receiving GLP-1 therapy and receiving usual care (multivariable-adjusted HR, 0.84; 95% CI, 0.76-0.92).
• Participants using GLP-1 RAs who also adhered to 6 to 8 low-risk lifestyle factors had a 43% lower risk for MACE than those not receiving GLP-1 therapy who adhered to three or fewer lifestyle factors (HR, 0.57; 95% CI, 0.46-0.71).

IN PRACTICE:

"In a healthcare landscape, in which GLP-1 [RAs] remain costly and access is uneven, the additive benefit of lifestyle adherence highlighted by this study has important implications for health equity, resource allocation, and the long-term sustainability of diabetes care," experts noted in an accompanying editorial.

SOURCE:

The study was led by Xuan-Mai T. Nguyen, MD, Department of Medicine, UCLA David Geffen School of Medicine in Los Angeles. It was published online in The Lancet Diabetes & Endocrinology.

LIMITATIONS:

The analyses were based on Veterans Health Administration electronic health record data, and healthcare use outside this system was only incompletely captured. The estimation was based on observational data in which lifestyle factors were assessed at baseline. The cohort consisted of predominantly male veterans, which might limit generalizability to other populations.

DISCLOSURES:

The study used data from the Million Veteran Program (MVP) and was supported by Veterans Affairs MVP awards, along with additional support from other sources. One author reported receiving consulting fees, speaker honoraria, meeting/travel support; participation on advisory boards; and ownership of stock or stock options from certain companies in the healthcare and life sciences sectors. Another author reported receiving a research grant from a consulting/analysis firm.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.

A version of this article first appeared on Medscape.com.

Women with epithelial ovarian cancer treated in the US Department of Defense (DoD) universal health care system demonstrate better 5-year survival compared with similar patients from the national population. The survival advantage persists across multiple age groups and disease stages, with particularly notable improvements in patients aged 35-49 years and those with stage III disease.

METHODOLOGY:

• Researchers compared 1504 patients with invasive stage I-IV epithelial ovarian carcinoma from the Automated Center Tumor Registry (ACTUR) for the DoD with 6016 matched patients from the 18-region Surveillance, Epidemiology, and End Results (SEER) program between 1987 and 2013.
• Patients from ACTUR were matched in a 1:4 ratio with SEER patients stratified for age, race, year of diagnosis, and histology, including serous carcinoma, clear cell carcinoma, mucinous carcinoma, and endometrioid carcinoma with adenocarcinoma subtypes.
• Five-year overall survival was evaluated using the Kaplan-Meier method and compared using log-rank test, with median follow-up time of 46 months in ACTUR and 44 months in SEER.
• Adjusted hazard ratio (AHR) and 95% CI for all-cause mortality were estimated from multivariable Cox proportional regression modeling controlling for age, race, year of diagnosis, region of diagnosis, stage, histology, and grade.

TAKEAWAY:

• Overall survival differs between registries: 5-year survival of 53.2% in ACTUR vs 47.7% in matched SEER cohort (log-rank P = .001).
• In the primary adjusted model, ACTUR is associated with a lower risk for all-cause mortality vs SEER (AHR, 0.83; 95% CI, 0.76-0.91; P < .0001).
• Subset results retain lower adjusted risk for death for ACTUR vs SEER among ages 35-49 years (AHR, 0.66; 95% CI, 0.52-0.83; P = .0005), ages ≥ 65 years (AHR, 0.82; 95% CI, 0.70-0.96; P = .016), and stage III cancer (AHR, 0.79; 95% CI, 0.69-0.91; P = .0015).
• Histology-stratified findings show lower adjusted risk for death in ACTUR vs SEER for clear cell carcinoma (AHR, 0.63; 95% CI, 0.43-0.93; P =.02) and for endometrioid and other adenocarcinomas (AHR, 0.68; 95% CI, 0.56-0.81; P < .0001).

IN PRACTICE:

"This study is envisioned to be a stepping stone to further investigations of survival and other cancer health outcomes starting with patients diagnosed between 2014 and 2024 with epithelial carcinoma of the ovary, fallopian tube, or primary peritoneum in the DoD Healthcare System versus the national population or other Healthcare Systems,” wrote the authors of the study. “Dedicated funding and support in the [Military Health System] are needed to invest in infrastructure, technology, security, education, and research.”

SOURCE:

The study was led by Kathleen M. Darcy, PhD, and Christopher M. Tarney, MD, from the Gynecologic Cancer Center of Excellence, Department of Gynecologic Surgery & Obstetrics, Uniformed Services University, Walter Reed National Military Medical Center in Bethesda, Maryland. It was published online in Military Medicine.

LIMITATIONS:

The retrospective cohort study design limits causal inference. Although groups were balanced by age, race, year, and region of diagnosis, other demographic factors and socioeconomic variables such as patient comorbidities, educational attainment, household income, and health insurance status were not available and may have affected results. The databases fundamentally differ in how data are acquired, with ACTUR following hospital-based Facility Oncology Registry Data Standards and SEER being a national population-based registry, potentially affecting data quality, consistency, and reliability of survival outcome comparisons. The inclusion of patients diagnosed only through 2013 represents a limitation as it does not allow for contemporary evaluation of survival outcomes, particularly given advances over the past decade including maximal cytoreductive effort to no residual disease, increased adoption of neoadjuvant chemotherapy, and introduction of targeted maintenance agents. The study could not incorporate details regarding residual disease status or control for specifics regarding surgical and medical management, including primary vs interval debulking surgery or the type and timing of agents utilized in first-line, maintenance, and recurrent disease settings. Data regarding circulating biomarkers including CA125, molecular subtypes or alterations, and stratification by homologous recombination deficiency vs proficiency status were not available. Epithelial carcinomas of the fallopian tube and primary peritoneum were excluded from this study, which now are commonly incorporated with ovarian carcinomas. Results may not be generalizable to other populations given the unique characteristics of the Military Health System beneficiary population.

DISCLOSURES:

This research received funding from the Uniformed Services University from the Defense Health Program to the Henry M. Jackson Foundation for the Advancement of Military Medicine Inc., including award HU0001-18-2-0032 to the Murtha Cancer Center Research Program and awards HU0001-19-2-0031 and HU0001-24-2-0047 to the Gynecologic Cancer Center of Excellence Program. All coauthors disclosed no conflicts of interest.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.

Women with epithelial ovarian cancer treated in the US Department of Defense (DoD) universal health care system demonstrate better 5-year survival compared with similar patients from the national population. The survival advantage persists across multiple age groups and disease stages, with particularly notable improvements in patients aged 35-49 years and those with stage III disease.

METHODOLOGY:

• Researchers compared 1504 patients with invasive stage I-IV epithelial ovarian carcinoma from the Automated Center Tumor Registry (ACTUR) for the DoD with 6016 matched patients from the 18-region Surveillance, Epidemiology, and End Results (SEER) program between 1987 and 2013.
• Patients from ACTUR were matched in a 1:4 ratio with SEER patients stratified for age, race, year of diagnosis, and histology, including serous carcinoma, clear cell carcinoma, mucinous carcinoma, and endometrioid carcinoma with adenocarcinoma subtypes.
• Five-year overall survival was evaluated using the Kaplan-Meier method and compared using log-rank test, with median follow-up time of 46 months in ACTUR and 44 months in SEER.
• Adjusted hazard ratio (AHR) and 95% CI for all-cause mortality were estimated from multivariable Cox proportional regression modeling controlling for age, race, year of diagnosis, region of diagnosis, stage, histology, and grade.

TAKEAWAY:

• Overall survival differs between registries: 5-year survival of 53.2% in ACTUR vs 47.7% in matched SEER cohort (log-rank P = .001).
• In the primary adjusted model, ACTUR is associated with a lower risk for all-cause mortality vs SEER (AHR, 0.83; 95% CI, 0.76-0.91; P < .0001).
• Subset results retain lower adjusted risk for death for ACTUR vs SEER among ages 35-49 years (AHR, 0.66; 95% CI, 0.52-0.83; P = .0005), ages ≥ 65 years (AHR, 0.82; 95% CI, 0.70-0.96; P = .016), and stage III cancer (AHR, 0.79; 95% CI, 0.69-0.91; P = .0015).
• Histology-stratified findings show lower adjusted risk for death in ACTUR vs SEER for clear cell carcinoma (AHR, 0.63; 95% CI, 0.43-0.93; P =.02) and for endometrioid and other adenocarcinomas (AHR, 0.68; 95% CI, 0.56-0.81; P < .0001).

IN PRACTICE:

"This study is envisioned to be a stepping stone to further investigations of survival and other cancer health outcomes starting with patients diagnosed between 2014 and 2024 with epithelial carcinoma of the ovary, fallopian tube, or primary peritoneum in the DoD Healthcare System versus the national population or other Healthcare Systems,” wrote the authors of the study. “Dedicated funding and support in the [Military Health System] are needed to invest in infrastructure, technology, security, education, and research.”

SOURCE:

The study was led by Kathleen M. Darcy, PhD, and Christopher M. Tarney, MD, from the Gynecologic Cancer Center of Excellence, Department of Gynecologic Surgery & Obstetrics, Uniformed Services University, Walter Reed National Military Medical Center in Bethesda, Maryland. It was published online in Military Medicine.

LIMITATIONS:

The retrospective cohort study design limits causal inference. Although groups were balanced by age, race, year, and region of diagnosis, other demographic factors and socioeconomic variables such as patient comorbidities, educational attainment, household income, and health insurance status were not available and may have affected results. The databases fundamentally differ in how data are acquired, with ACTUR following hospital-based Facility Oncology Registry Data Standards and SEER being a national population-based registry, potentially affecting data quality, consistency, and reliability of survival outcome comparisons. The inclusion of patients diagnosed only through 2013 represents a limitation as it does not allow for contemporary evaluation of survival outcomes, particularly given advances over the past decade including maximal cytoreductive effort to no residual disease, increased adoption of neoadjuvant chemotherapy, and introduction of targeted maintenance agents. The study could not incorporate details regarding residual disease status or control for specifics regarding surgical and medical management, including primary vs interval debulking surgery or the type and timing of agents utilized in first-line, maintenance, and recurrent disease settings. Data regarding circulating biomarkers including CA125, molecular subtypes or alterations, and stratification by homologous recombination deficiency vs proficiency status were not available. Epithelial carcinomas of the fallopian tube and primary peritoneum were excluded from this study, which now are commonly incorporated with ovarian carcinomas. Results may not be generalizable to other populations given the unique characteristics of the Military Health System beneficiary population.

DISCLOSURES:

This research received funding from the Uniformed Services University from the Defense Health Program to the Henry M. Jackson Foundation for the Advancement of Military Medicine Inc., including award HU0001-18-2-0032 to the Murtha Cancer Center Research Program and awards HU0001-19-2-0031 and HU0001-24-2-0047 to the Gynecologic Cancer Center of Excellence Program. All coauthors disclosed no conflicts of interest.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.

Women with epithelial ovarian cancer treated in the US Department of Defense (DoD) universal health care system demonstrate better 5-year survival compared with similar patients from the national population. The survival advantage persists across multiple age groups and disease stages, with particularly notable improvements in patients aged 35-49 years and those with stage III disease.

METHODOLOGY:

• Researchers compared 1504 patients with invasive stage I-IV epithelial ovarian carcinoma from the Automated Center Tumor Registry (ACTUR) for the DoD with 6016 matched patients from the 18-region Surveillance, Epidemiology, and End Results (SEER) program between 1987 and 2013.
• Patients from ACTUR were matched in a 1:4 ratio with SEER patients stratified for age, race, year of diagnosis, and histology, including serous carcinoma, clear cell carcinoma, mucinous carcinoma, and endometrioid carcinoma with adenocarcinoma subtypes.
• Five-year overall survival was evaluated using the Kaplan-Meier method and compared using log-rank test, with median follow-up time of 46 months in ACTUR and 44 months in SEER.
• Adjusted hazard ratio (AHR) and 95% CI for all-cause mortality were estimated from multivariable Cox proportional regression modeling controlling for age, race, year of diagnosis, region of diagnosis, stage, histology, and grade.

TAKEAWAY:

• Overall survival differs between registries: 5-year survival of 53.2% in ACTUR vs 47.7% in matched SEER cohort (log-rank P = .001).
• In the primary adjusted model, ACTUR is associated with a lower risk for all-cause mortality vs SEER (AHR, 0.83; 95% CI, 0.76-0.91; P < .0001).
• Subset results retain lower adjusted risk for death for ACTUR vs SEER among ages 35-49 years (AHR, 0.66; 95% CI, 0.52-0.83; P = .0005), ages ≥ 65 years (AHR, 0.82; 95% CI, 0.70-0.96; P = .016), and stage III cancer (AHR, 0.79; 95% CI, 0.69-0.91; P = .0015).
• Histology-stratified findings show lower adjusted risk for death in ACTUR vs SEER for clear cell carcinoma (AHR, 0.63; 95% CI, 0.43-0.93; P =.02) and for endometrioid and other adenocarcinomas (AHR, 0.68; 95% CI, 0.56-0.81; P < .0001).

IN PRACTICE:

"This study is envisioned to be a stepping stone to further investigations of survival and other cancer health outcomes starting with patients diagnosed between 2014 and 2024 with epithelial carcinoma of the ovary, fallopian tube, or primary peritoneum in the DoD Healthcare System versus the national population or other Healthcare Systems,” wrote the authors of the study. “Dedicated funding and support in the [Military Health System] are needed to invest in infrastructure, technology, security, education, and research.”

SOURCE:

The study was led by Kathleen M. Darcy, PhD, and Christopher M. Tarney, MD, from the Gynecologic Cancer Center of Excellence, Department of Gynecologic Surgery & Obstetrics, Uniformed Services University, Walter Reed National Military Medical Center in Bethesda, Maryland. It was published online in Military Medicine.

LIMITATIONS:

The retrospective cohort study design limits causal inference. Although groups were balanced by age, race, year, and region of diagnosis, other demographic factors and socioeconomic variables such as patient comorbidities, educational attainment, household income, and health insurance status were not available and may have affected results. The databases fundamentally differ in how data are acquired, with ACTUR following hospital-based Facility Oncology Registry Data Standards and SEER being a national population-based registry, potentially affecting data quality, consistency, and reliability of survival outcome comparisons. The inclusion of patients diagnosed only through 2013 represents a limitation as it does not allow for contemporary evaluation of survival outcomes, particularly given advances over the past decade including maximal cytoreductive effort to no residual disease, increased adoption of neoadjuvant chemotherapy, and introduction of targeted maintenance agents. The study could not incorporate details regarding residual disease status or control for specifics regarding surgical and medical management, including primary vs interval debulking surgery or the type and timing of agents utilized in first-line, maintenance, and recurrent disease settings. Data regarding circulating biomarkers including CA125, molecular subtypes or alterations, and stratification by homologous recombination deficiency vs proficiency status were not available. Epithelial carcinomas of the fallopian tube and primary peritoneum were excluded from this study, which now are commonly incorporated with ovarian carcinomas. Results may not be generalizable to other populations given the unique characteristics of the Military Health System beneficiary population.

DISCLOSURES:

This research received funding from the Uniformed Services University from the Defense Health Program to the Henry M. Jackson Foundation for the Advancement of Military Medicine Inc., including award HU0001-18-2-0032 to the Murtha Cancer Center Research Program and awards HU0001-19-2-0031 and HU0001-24-2-0047 to the Gynecologic Cancer Center of Excellence Program. All coauthors disclosed no conflicts of interest.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.

Wildfire smoke exposure may be associated with increased risks for multiple types of cancer, suggests an analysis of prospective cohort data from over 90,000 individuals.

To determine how this widespread pollution might be affecting cancer risk, senior author Shuguang Leng, MBBS, PhD, and colleagues analyzed data from the Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial. That prospective national study enrolled approximately 154,000 participants between 1993 and 2001 and tracked cancer incidence through 2018. Of these, 91,460 participants had wildfire smoke exposure data and were included in the analysis.

During the 2006-2018 exposure period, the investigators identified incident cases of 242 ovarian, 800 colorectal, 896 bladder, 1696 hematopoietic, 1739 breast, and 1758 lung cancers, as well as 1127 melanoma cases. The median 36-month moving average for wildfire smoke PM_2.5 (fine particulate matter) across the cohort was 0.37 µg/m³.

Wildfire smoke exposure was significantly associated with increased risks for lung, colorectal, breast, bladder, and hematopoietic cancer, according to the results of the study presented by Leng at American Association for Cancer Research (AACR) Annual Meeting 2026.

Each 1 µg/m³ increase in the 36-month moving average of wildfire smoke PM_2.5 was associated with a 63% higher risk for hematopoietic cancer (HR, 1.63; 95% CI, 1.02-2.60), a nearly twofold higher risk for lung cancer (hazard ratio [HR], 1.92; 95% CI, 1.18-3.15), more than twofold higher risks for breast cancer (HR, 2.09; 95% CI, 1.34-3.26) and colorectal cancer (HR, 2.31; 95% CI, 1.11-4.81), and a more than threefold higher risk for bladder cancer (HR, 3.49; 95% CI, 1.66-7.34). No significant associations were observed for ovarian cancer or melanoma.

The investigators quantified wildfire smoke exposure at each participant’s residence on a monthly basis using three measures: near-ground wildfire smoke PM_2.5, wildfire smoke black carbon, and satellite-derived wildfire smoke plume-day counts, with measurements available from 2006 until first cancer diagnosis or last contact.

Given evidence that 3 years of air pollution exposure can influence the development of epidermal growth factor receptor-positive lung adenocarcinoma, the team modeled exposure as a time-varying variable using 36-month moving averages preceding each month. HRs were estimated using Cox proportional hazards models stratified by study center, with restricted cubic splines applied to evaluate dose-response relationships. Models were adjusted for age, sex, race and ethnicity, education, smoking history, BMI, and trial arm.

All five cancer types linked with wildfire smoke exposure showed linear dose-response relationships, Leng noted, “which means the higher the exposure, the higher the cancer risk.”

Results based on wildfire smoke plume-day counts were generally consistent with those for PM_2.5, while associations for black carbon exposure were observed only for breast and bladder cancers.

With wildfires on the rise, these findings suggest that the resulting smoke may become a “major driver for cancer burden in the US in the coming decades,” said Leng, of the University of New Mexico Comprehensive Cancer Center, Albuquerque, New Mexico.

“Wildfire smoke has become a major source of air pollution in the United States,” he continued. Large fires in the US are three times more common than they were 50 years ago, and the “tons of toxicants and particles” released by these fires “can travel hundreds of miles to affect communities far away.”

The investigators also conducted histology-specific analyses, finding that adenocarcinoma showed the strongest association with wildfire smoke among lung cancer subtypes. Among colorectal cancers, proximal tumors appeared more sensitive to wildfire smoke exposure, while among bladder cancers, the association was strongest for muscle-invasive disease.

Wildfire Smoke Exposure Expected to Rise

Under even the most conservative climate projections, wildfire smoke exposure in the US is expected to rise over the next 20-30 years, Leng said.

Annual average wildfire smoke PM_2.5 levels, currently estimated at around 0.5 µg/m³, could rise to 1 µg/m³. Based on the study’s dose-response data, this would correspond to substantially greater cancer risk.

There will be “a much larger area” of the US exposed “at a much higher dose,” Leng predicted.

Mitigating the Risks of Wildfire Smoke

This is a “strong hypothesis-generating study,” Jun Wu, PhD, professor of environmental and occupational health at the UC Irvine Program in Public Health, Irvine, California, told Medscape Medical News.

“This is one of the first large, prospective US cohort studies to examine wildfire smoke specifically in relation to cancer risk, especially cancer sites beyond the lung,” Wu said. “A major strength is that the PLCO platform has around 91,000 participants with longitudinal follow-up and detailed covariate data, including smoking history, which is often a weak point in previous air pollution-cancer studies.”

According to Wu, who was not involved in the analysis but recently published data linking wildfire smoke exposure to preterm birth, the reported risks for colorectal, breast, bladder, and hematopoietic cancers represent novel contributions to the literature. However, she cautioned against viewing the specific HRs as a precise estimates of risk due to wide confidence intervals.

The findings should encourage individuals, public health officials, and clinicians to mitigate the risks of wildfire smoke, Wu said.

Specifically, she suggested that public health assessments expand beyond acute outcomes like emergency department visits to include long-term endpoints such as cancer, while community clean-air shelters need to be made more widely available.

She advised clinicians to incorporate wildfire exposure into routine patient histories and to provide vulnerable patients — such as those with asthma, chronic obstructive pulmonary disease, heart failure, or pregnancy — with smoke-season action plans.

Risk mitigation begins with awareness, according to Wu, who advised individuals check their local air quality index on AirNow.gov or PurpleAir.

On smoky days, she suggested prioritizing indoor air quality by keeping windows closed and running air purifiers. If going outside on such days is necessary, she suggested an N95 or KN95 mask, as these offer “meaningful protection,” while cloth and surgical masks do not.

These preventive steps may have once been out of the ordinary, Wu said, but the risk for wildfire smoke exposure is becoming a part of everyday life.

“The common thread is a shift in framing,” Wu said. “Wildfire smoke has traditionally been treated as an acute event, but the emerging evidence points to a chronic environmental exposure. Both our clinical and public health systems have room to grow into that reality.”

The analysis was funded by the National Institutes of Health. The investigators and Wu reported having no conflicts of interest.

This article was previously published on Medscape.

Wildfire smoke exposure may be associated with increased risks for multiple types of cancer, suggests an analysis of prospective cohort data from over 90,000 individuals.

To determine how this widespread pollution might be affecting cancer risk, senior author Shuguang Leng, MBBS, PhD, and colleagues analyzed data from the Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial. That prospective national study enrolled approximately 154,000 participants between 1993 and 2001 and tracked cancer incidence through 2018. Of these, 91,460 participants had wildfire smoke exposure data and were included in the analysis.

During the 2006-2018 exposure period, the investigators identified incident cases of 242 ovarian, 800 colorectal, 896 bladder, 1696 hematopoietic, 1739 breast, and 1758 lung cancers, as well as 1127 melanoma cases. The median 36-month moving average for wildfire smoke PM_2.5 (fine particulate matter) across the cohort was 0.37 µg/m³.

Wildfire smoke exposure was significantly associated with increased risks for lung, colorectal, breast, bladder, and hematopoietic cancer, according to the results of the study presented by Leng at American Association for Cancer Research (AACR) Annual Meeting 2026.

Each 1 µg/m³ increase in the 36-month moving average of wildfire smoke PM_2.5 was associated with a 63% higher risk for hematopoietic cancer (HR, 1.63; 95% CI, 1.02-2.60), a nearly twofold higher risk for lung cancer (hazard ratio [HR], 1.92; 95% CI, 1.18-3.15), more than twofold higher risks for breast cancer (HR, 2.09; 95% CI, 1.34-3.26) and colorectal cancer (HR, 2.31; 95% CI, 1.11-4.81), and a more than threefold higher risk for bladder cancer (HR, 3.49; 95% CI, 1.66-7.34). No significant associations were observed for ovarian cancer or melanoma.

The investigators quantified wildfire smoke exposure at each participant’s residence on a monthly basis using three measures: near-ground wildfire smoke PM_2.5, wildfire smoke black carbon, and satellite-derived wildfire smoke plume-day counts, with measurements available from 2006 until first cancer diagnosis or last contact.

Given evidence that 3 years of air pollution exposure can influence the development of epidermal growth factor receptor-positive lung adenocarcinoma, the team modeled exposure as a time-varying variable using 36-month moving averages preceding each month. HRs were estimated using Cox proportional hazards models stratified by study center, with restricted cubic splines applied to evaluate dose-response relationships. Models were adjusted for age, sex, race and ethnicity, education, smoking history, BMI, and trial arm.

All five cancer types linked with wildfire smoke exposure showed linear dose-response relationships, Leng noted, “which means the higher the exposure, the higher the cancer risk.”

Results based on wildfire smoke plume-day counts were generally consistent with those for PM_2.5, while associations for black carbon exposure were observed only for breast and bladder cancers.

With wildfires on the rise, these findings suggest that the resulting smoke may become a “major driver for cancer burden in the US in the coming decades,” said Leng, of the University of New Mexico Comprehensive Cancer Center, Albuquerque, New Mexico.

“Wildfire smoke has become a major source of air pollution in the United States,” he continued. Large fires in the US are three times more common than they were 50 years ago, and the “tons of toxicants and particles” released by these fires “can travel hundreds of miles to affect communities far away.”

The investigators also conducted histology-specific analyses, finding that adenocarcinoma showed the strongest association with wildfire smoke among lung cancer subtypes. Among colorectal cancers, proximal tumors appeared more sensitive to wildfire smoke exposure, while among bladder cancers, the association was strongest for muscle-invasive disease.

Wildfire Smoke Exposure Expected to Rise

Under even the most conservative climate projections, wildfire smoke exposure in the US is expected to rise over the next 20-30 years, Leng said.

Annual average wildfire smoke PM_2.5 levels, currently estimated at around 0.5 µg/m³, could rise to 1 µg/m³. Based on the study’s dose-response data, this would correspond to substantially greater cancer risk.

There will be “a much larger area” of the US exposed “at a much higher dose,” Leng predicted.

Mitigating the Risks of Wildfire Smoke

This is a “strong hypothesis-generating study,” Jun Wu, PhD, professor of environmental and occupational health at the UC Irvine Program in Public Health, Irvine, California, told Medscape Medical News.

“This is one of the first large, prospective US cohort studies to examine wildfire smoke specifically in relation to cancer risk, especially cancer sites beyond the lung,” Wu said. “A major strength is that the PLCO platform has around 91,000 participants with longitudinal follow-up and detailed covariate data, including smoking history, which is often a weak point in previous air pollution-cancer studies.”

According to Wu, who was not involved in the analysis but recently published data linking wildfire smoke exposure to preterm birth, the reported risks for colorectal, breast, bladder, and hematopoietic cancers represent novel contributions to the literature. However, she cautioned against viewing the specific HRs as a precise estimates of risk due to wide confidence intervals.

The findings should encourage individuals, public health officials, and clinicians to mitigate the risks of wildfire smoke, Wu said.

Specifically, she suggested that public health assessments expand beyond acute outcomes like emergency department visits to include long-term endpoints such as cancer, while community clean-air shelters need to be made more widely available.

She advised clinicians to incorporate wildfire exposure into routine patient histories and to provide vulnerable patients — such as those with asthma, chronic obstructive pulmonary disease, heart failure, or pregnancy — with smoke-season action plans.

Risk mitigation begins with awareness, according to Wu, who advised individuals check their local air quality index on AirNow.gov or PurpleAir.

On smoky days, she suggested prioritizing indoor air quality by keeping windows closed and running air purifiers. If going outside on such days is necessary, she suggested an N95 or KN95 mask, as these offer “meaningful protection,” while cloth and surgical masks do not.

These preventive steps may have once been out of the ordinary, Wu said, but the risk for wildfire smoke exposure is becoming a part of everyday life.

“The common thread is a shift in framing,” Wu said. “Wildfire smoke has traditionally been treated as an acute event, but the emerging evidence points to a chronic environmental exposure. Both our clinical and public health systems have room to grow into that reality.”

The analysis was funded by the National Institutes of Health. The investigators and Wu reported having no conflicts of interest.

This article was previously published on Medscape.

Wildfire smoke exposure may be associated with increased risks for multiple types of cancer, suggests an analysis of prospective cohort data from over 90,000 individuals.

To determine how this widespread pollution might be affecting cancer risk, senior author Shuguang Leng, MBBS, PhD, and colleagues analyzed data from the Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial. That prospective national study enrolled approximately 154,000 participants between 1993 and 2001 and tracked cancer incidence through 2018. Of these, 91,460 participants had wildfire smoke exposure data and were included in the analysis.

During the 2006-2018 exposure period, the investigators identified incident cases of 242 ovarian, 800 colorectal, 896 bladder, 1696 hematopoietic, 1739 breast, and 1758 lung cancers, as well as 1127 melanoma cases. The median 36-month moving average for wildfire smoke PM_2.5 (fine particulate matter) across the cohort was 0.37 µg/m³.

Wildfire smoke exposure was significantly associated with increased risks for lung, colorectal, breast, bladder, and hematopoietic cancer, according to the results of the study presented by Leng at American Association for Cancer Research (AACR) Annual Meeting 2026.

Each 1 µg/m³ increase in the 36-month moving average of wildfire smoke PM_2.5 was associated with a 63% higher risk for hematopoietic cancer (HR, 1.63; 95% CI, 1.02-2.60), a nearly twofold higher risk for lung cancer (hazard ratio [HR], 1.92; 95% CI, 1.18-3.15), more than twofold higher risks for breast cancer (HR, 2.09; 95% CI, 1.34-3.26) and colorectal cancer (HR, 2.31; 95% CI, 1.11-4.81), and a more than threefold higher risk for bladder cancer (HR, 3.49; 95% CI, 1.66-7.34). No significant associations were observed for ovarian cancer or melanoma.

The investigators quantified wildfire smoke exposure at each participant’s residence on a monthly basis using three measures: near-ground wildfire smoke PM_2.5, wildfire smoke black carbon, and satellite-derived wildfire smoke plume-day counts, with measurements available from 2006 until first cancer diagnosis or last contact.

Given evidence that 3 years of air pollution exposure can influence the development of epidermal growth factor receptor-positive lung adenocarcinoma, the team modeled exposure as a time-varying variable using 36-month moving averages preceding each month. HRs were estimated using Cox proportional hazards models stratified by study center, with restricted cubic splines applied to evaluate dose-response relationships. Models were adjusted for age, sex, race and ethnicity, education, smoking history, BMI, and trial arm.

All five cancer types linked with wildfire smoke exposure showed linear dose-response relationships, Leng noted, “which means the higher the exposure, the higher the cancer risk.”

Results based on wildfire smoke plume-day counts were generally consistent with those for PM_2.5, while associations for black carbon exposure were observed only for breast and bladder cancers.

With wildfires on the rise, these findings suggest that the resulting smoke may become a “major driver for cancer burden in the US in the coming decades,” said Leng, of the University of New Mexico Comprehensive Cancer Center, Albuquerque, New Mexico.

“Wildfire smoke has become a major source of air pollution in the United States,” he continued. Large fires in the US are three times more common than they were 50 years ago, and the “tons of toxicants and particles” released by these fires “can travel hundreds of miles to affect communities far away.”

The investigators also conducted histology-specific analyses, finding that adenocarcinoma showed the strongest association with wildfire smoke among lung cancer subtypes. Among colorectal cancers, proximal tumors appeared more sensitive to wildfire smoke exposure, while among bladder cancers, the association was strongest for muscle-invasive disease.

Wildfire Smoke Exposure Expected to Rise

Under even the most conservative climate projections, wildfire smoke exposure in the US is expected to rise over the next 20-30 years, Leng said.

Annual average wildfire smoke PM_2.5 levels, currently estimated at around 0.5 µg/m³, could rise to 1 µg/m³. Based on the study’s dose-response data, this would correspond to substantially greater cancer risk.

There will be “a much larger area” of the US exposed “at a much higher dose,” Leng predicted.

Mitigating the Risks of Wildfire Smoke

This is a “strong hypothesis-generating study,” Jun Wu, PhD, professor of environmental and occupational health at the UC Irvine Program in Public Health, Irvine, California, told Medscape Medical News.

“This is one of the first large, prospective US cohort studies to examine wildfire smoke specifically in relation to cancer risk, especially cancer sites beyond the lung,” Wu said. “A major strength is that the PLCO platform has around 91,000 participants with longitudinal follow-up and detailed covariate data, including smoking history, which is often a weak point in previous air pollution-cancer studies.”

According to Wu, who was not involved in the analysis but recently published data linking wildfire smoke exposure to preterm birth, the reported risks for colorectal, breast, bladder, and hematopoietic cancers represent novel contributions to the literature. However, she cautioned against viewing the specific HRs as a precise estimates of risk due to wide confidence intervals.

The findings should encourage individuals, public health officials, and clinicians to mitigate the risks of wildfire smoke, Wu said.

Specifically, she suggested that public health assessments expand beyond acute outcomes like emergency department visits to include long-term endpoints such as cancer, while community clean-air shelters need to be made more widely available.

She advised clinicians to incorporate wildfire exposure into routine patient histories and to provide vulnerable patients — such as those with asthma, chronic obstructive pulmonary disease, heart failure, or pregnancy — with smoke-season action plans.

Risk mitigation begins with awareness, according to Wu, who advised individuals check their local air quality index on AirNow.gov or PurpleAir.

On smoky days, she suggested prioritizing indoor air quality by keeping windows closed and running air purifiers. If going outside on such days is necessary, she suggested an N95 or KN95 mask, as these offer “meaningful protection,” while cloth and surgical masks do not.

These preventive steps may have once been out of the ordinary, Wu said, but the risk for wildfire smoke exposure is becoming a part of everyday life.

“The common thread is a shift in framing,” Wu said. “Wildfire smoke has traditionally been treated as an acute event, but the emerging evidence points to a chronic environmental exposure. Both our clinical and public health systems have room to grow into that reality.”

The analysis was funded by the National Institutes of Health. The investigators and Wu reported having no conflicts of interest.

This article was previously published on Medscape.

Veterans are at higher risk for suicide compared with civilian populations.¹ Firearms are the most frequent cause of death in veteran deaths by suicide, likely because about 51% of veterans own ≥ 1 firearms and firearms are the most lethal and readily available mechanism.^1-3 Unsecure firearm storage practices (eg, storing firearms unlocked, in an unsecure location, or loaded with ammunition) are associated with increased suicide risk.⁴ Conversely, secure firearm storage (ie, storing firearms locked and unloaded) is associated with lower suicide risk.⁵

A 2019 study of veterans who own firearms found that only 22.2% store all their firearms unloaded and locked, while 32.7% store ≥ 1 firearm unlocked and loaded, and 45.2% store firearms both unlocked and loaded or locked and unloaded. Only 6.3% of veterans strongly agreed that having a firearm at home increased suicide risk among household members; however, 77.2% indicated they would ensure a household member could not access firearms if they were concerned about their suicidal ideation.⁶

Another study found that 9.2% of veterans receive lethal means safety counseling from their US Department of Veterans Affairs (VA)-affiliated or non-VA health care professional.⁷ These data highlight a need to educate veterans about the increased risk for suicide associated with storing an unsecured firearm in the household and to connect this understanding to their values of service and protection of others, while simultaneously preparing them and their family members for a potential mental health crisis.

Consistent with the government’s public health approach to suicide prevention, prevention efforts should also enlist the participation of individuals outside health care.⁸ For example, prior research has found that family members are considered highly credible, and engaging them could expand the reach of lethal means safety conversations. A qualitative analysis of 29 veterans found that 17 (57%) said they preferred having a concerned significant other (CSO) (eg, spouse, adult friend, or relative) involved in their suicide prevention care, while 21 (72%) said they would prefer having a CSO assisting in the secure storage of firearms.^9,10 Some veterans may be more amenable to a conversation about firearm access and suicide risk concerns initiated by a CSO rather than by a clinician, indicating the potential benefits of educating and involving CSOs in suicide prevention.¹¹ Involving CSOs in secure firearm storage planning may also strengthen the veteran’s sense of social support, a key protective factor against suicidal ideation.¹²

CSO involvement in secure firearm storage can provide the following benefits: (1) helping the veteran create a secure storage plan, including developing approaches to secure storage; (2) understanding warning signs of suicide; (3) helping the veteran limit access to firearms during a suicidal crisis; (4) helping the veteran remember the secure storage plan; (5) helping the veteran connect with mental health services; and (6) enhancing social support. In most instances, CSOs are physically close to the veteran (eg, live in the same household) and have a greater practical ability to support and affect change with respect to changes in firearm storage practices.

This article describes the development of an intervention that incorporates CSO involvement in firearms safety efforts for veterans with guidance from VA mental health care practitioners (HCPs). The goal is to provide HCPs and other key stakeholders with a detailed description of the intervention and to suggest potential strategies for how to involve CSOs in suicide prevention.

This article follows the Guideline for Reporting Evidence-based Practice Educational interventions and Teaching checklist, which was developed to facilitate standardized reporting and replication for education interventions.¹³ Applicable portions of the checklist are outlined, with others (ie, incentives, planned/unplanned changes, attendance, and other outcomes) to be addressed in future research.

FFAST INTERVENTION

Training (FFAST) intervention promotes voluntary secure firearm storage, engages CSOs in veteran mental health care, and provides psychoeducation and skills to support crisis management. The intervention was developed for all veterans who do not securely store firearms.

Theory

The intervention incorporates motivational interviewing techniques, as ambivalence about changing firearm storage behaviors is common, particularly when veterans own firearms for safety or protection.^6,14 Motivational interviewing is a collaborative approach that addresses a client’s ambivalence to change by eliciting and exploring the client’s own arguments related to change.¹⁴ An important aspect of developing this intervention was to ensure it would be culturally relevant to veteran firearm owners and their CSOs.¹⁵ Further, involvement of the CSO is intentional and meant to boost social support, a known buffering factor against suicide risk.¹²

Objectives

This intervention’s primary objective was for veteran participants to identify secure firearm storage practices and develop a plan for implementing them, including when a veteran or other household member experiences a mental health crisis. For CSOs, the primary objective is to learn how to help the veteran connect with mental health resources if needed and support secure firearm storage as necessary. The overall goal is to learn how to identify warning signs for suicide and how to respond to a mental health crisis through a collaborative process, including securing firearms in a crisis situation.

Materials, Educational Strategies, and Instructors

Training for delivering the intervention was provided via direct consultation with the developer of the intervention and manual. The manual contains pertinent background information to provide context for the intervention’s significance and rationale, including the role of firearms in suicides and current lethal means safety initiatives. It also describes the purpose and objective of each intervention component in detail in addition to providing a script for interventionists to follow to complete each objective.

Training materials for veterans and CSOs include a single Firearms Secure Storage Planning worksheet completed during the intervention, with which the interventionist guides participants through the creation of a secure firearm storage plan (Table). Educational strategies include psychoeducation and Socratic questioning (eg, questioning focused on guiding participants toward the intervention goals) delivered verbally by the interventionist.

The intervention is delivered in person or virtually during a single 90-minute session with a veteran and CSO. Veterans and CSOs work with the interventionist to complete collaborative activities during the session and have self-directive learning activities or homework.

The intervention has 4 primary components: (1) CSO involvement; (2) psychoeducation; (3) secure firearm storage; and (4) how to respond to a mental health crisis. Each CSO should have an established relationship with the veteran, be willing and able to be present during the intervention, and remain an encouraging support person for the veteran. The interventionist emphasizes that it is part of the VA mission for staff to care about the veteran, and that initiating such contact with a CSO is meant to prioritize veteran safety and the safety of their family. Psychoeducation on mental health symptoms, suicide warning signs, veteran suicide rates and lethal means, and the benefits of secure firearm storage, is incorporated in the intervention.

The secure firearm storage component consists of 7 subcomponents: (1) general lethal means secure storage; (2) warning signs; (3) dyad communication; (4) lethal means safety when symptoms emerge; (5) coping strategies; (6) social support; and (7) emergency contacts. A lethal means safety worksheet rooted in the Stanley and Brown suicide safety plan model and implemented in VA health care settings is used to facilitate discussions of secure storage (Appendix).¹⁶

CSOs typically have little or no suicidal crisis response training, yet they likely have more interaction with the veteran on a daily basis than HCPs, putting them in a vital position to identify a crisis early and connect the veteran with the proper care. The crisis component prepares the CSO and veteran to navigate a crisis scenario so they can practice their newly developed safety plan and increase their comfort in discussing mental health and suicidal crisis.

FICTIONAL CASE STUDY

Cole, aged 59 years, is a Persian Gulf War veteran and retired police officer. His medical history includes hypothyroidism, hypertension, type 2 diabetes mellitus, chronic posttraumatic stress disorder, major depressive disorder, and insomnia.

Cole's wife of > 30 years, Sheila, joined him for the FFAST intervention. They report having 4 firearms in the home, 3 of which are loaded but stored in a lockbox and 1 that Cole reports is kept on his person for protection. Cole reports passive suicidal ideation, but no plans or intent. When discussing warning signs that a mental health crisis is building, Cole describes feeling anxious, having a change in his speech patterns, and isolating himself. Sheila agrees, but also mentions that Cole is easily angered and becomes nonverbal. Cole and Sheila express difficulty communicating and appear to have a breakthrough moment when Cole says he does not like when Sheila repeats herself, as he feels like she is “poking” at him. Sheila shares concerns for his safety and that she only repeats herself because he refuses to talk.

Cole agrees to verbalize that he is safe but needs time to process his thoughts. Sheila agrees to give him space with a plan to revisit the conversation within an agreed upon timeline. When discussing an updated secure storage plan for their firearms when a mental health crisis is building, Cole commits to allowing Sheila to store the firearm currently on his person in their gun safe, with the ammunition stored separately, and to giving her the gun safe key. They agree to implement this practice until the mental health crisis has passed.

To mitigate a potential crisis, the interventionist discusses possible internal coping strategies for Cole, including writing, reading, walking the dog, listening to music, and baking. People and social settings that could provide distraction involve going to the gym, talking to his friend Carl or his daughter Kelly, and attending the men’s ministry at church. The intervention concludes by discussing professionals or agencies that Cole and Sheila could contact during a crisis. After the intervention, Cole and Sheila are asked to rate their likelihood of using the plan they established during the conversation on a scale of 0 to 10, with 0 being highly unlikely and 10 being extremely likely. Cole responds with 9 and Sheila responds with 10.

DISCUSSION

Lethal means safety remains a critical component of veteran suicide prevention. However, lethal means safety discussions are often implemented after suicide risk has been identified, which may be too late. Thus, having these conversations early and before a crisis may be imperative. Veterans have expressed a desire to have CSOs involved in their suicide prevention treatment, and CSOs can play a key role in recognizing risk factors during everyday life. The FFAST intervention addresses many of these gaps.

Having discussions in advance of a crisis allows veterans to consider an effective secure firearm storage plan outside of the context of a crisis. Including a CSO galvanizes another person to understand a veteran’s needs and assist with secure firearm storage, identify warning signs, and support them during a crisis. These discussions occur in a context where there is less pressure than during a crisis. Features that were more appealing to veterans and their CSOs were also incorporated, such as having the dyad build a plan that is conceptually similar to other public safety initiatives (eg, a fire safety plan, tornado plan, or hurricane plan). Previous research demonstrates that veterans appreciated the nonjudgmental approach and some preferred that clinicians approach the discussion of secure firearm storage within the context of general home and family safety.¹⁷ Additionally, this intervention can build on veterans’ prior military training in preparedness.

Other potential benefits associated with the FFAST intervention include creating an opportunity to strengthen communication between the veteran and CSO. While FFAST is intended to be used with all types of CSOs, this work is consistent with preliminary data from a couples-based suicide prevention study that indicated veterans and their partners reported increases in relationship functioning and marginal decreases in suicidal ideation.¹⁸ It is possible that communication strategies gained from the current intervention could improve veterans’ relationships with their CSOs, which are associated with a greater sense of social support and reduced suicide risk.¹²

The intervention is a brief, single session that may be appealing to veterans and CSOs with full schedules. Evidence suggests that even brief, single-session interventions have a significant impact on beliefs about secure firearm storage, knowledge of lethal means safety, and confidence in having secure firearm storage conversations.¹⁹ However, clinicians should be cautious when extrapolating from the findings of the current case example, which was a one-time intervention with no follow-up.

Future Directions

Pilot testing of the proposed intervention is underway, and future research will include feedback from veterans and CSOs, as well as feasibility and acceptability data collected during the pilot process. The pilot study uses a successive cohort design with an initial 2 sets of 5 veteran and CSO dyads, and subsequent funding has expanded the pilot study to include an additional 30 dyads. Qualitative interviews will be conducted separately with each veteran and CSO, and additional constructs such as feasibility, acceptability, barriers and facilitators to implementation, and changes in secure storage will be examined. This future research may provide a deeper understanding of the broader acceptability, feasibility, and satisfaction associated with a suicide prevention intervention focused on securing firearms and involving veterans and their CSOs. These data could be used to inform future implementation trials and inform the development of an implementation strategy. In the interim, the nature of the manual is summarized in the context of the urgency of suicide prevention in this at-risk population.

Conclusions

FFAST is a novel approach to veteran firearm suicide prevention. By involving CSOs and emphasizing mental health crisis preparedness between them and veterans, the dyad can work in association with HCPs to establish and exercise secure firearm storage practices as part of an at-home safety plan. Implementation of FFAST may be beneficial for all veterans, not only those who have been identified as being at high suicide risk.

Veterans are at higher risk for suicide compared with civilian populations.¹ Firearms are the most frequent cause of death in veteran deaths by suicide, likely because about 51% of veterans own ≥ 1 firearms and firearms are the most lethal and readily available mechanism.^1-3 Unsecure firearm storage practices (eg, storing firearms unlocked, in an unsecure location, or loaded with ammunition) are associated with increased suicide risk.⁴ Conversely, secure firearm storage (ie, storing firearms locked and unloaded) is associated with lower suicide risk.⁵

A 2019 study of veterans who own firearms found that only 22.2% store all their firearms unloaded and locked, while 32.7% store ≥ 1 firearm unlocked and loaded, and 45.2% store firearms both unlocked and loaded or locked and unloaded. Only 6.3% of veterans strongly agreed that having a firearm at home increased suicide risk among household members; however, 77.2% indicated they would ensure a household member could not access firearms if they were concerned about their suicidal ideation.⁶

Another study found that 9.2% of veterans receive lethal means safety counseling from their US Department of Veterans Affairs (VA)-affiliated or non-VA health care professional.⁷ These data highlight a need to educate veterans about the increased risk for suicide associated with storing an unsecured firearm in the household and to connect this understanding to their values of service and protection of others, while simultaneously preparing them and their family members for a potential mental health crisis.

Consistent with the government’s public health approach to suicide prevention, prevention efforts should also enlist the participation of individuals outside health care.⁸ For example, prior research has found that family members are considered highly credible, and engaging them could expand the reach of lethal means safety conversations. A qualitative analysis of 29 veterans found that 17 (57%) said they preferred having a concerned significant other (CSO) (eg, spouse, adult friend, or relative) involved in their suicide prevention care, while 21 (72%) said they would prefer having a CSO assisting in the secure storage of firearms.^9,10 Some veterans may be more amenable to a conversation about firearm access and suicide risk concerns initiated by a CSO rather than by a clinician, indicating the potential benefits of educating and involving CSOs in suicide prevention.¹¹ Involving CSOs in secure firearm storage planning may also strengthen the veteran’s sense of social support, a key protective factor against suicidal ideation.¹²

CSO involvement in secure firearm storage can provide the following benefits: (1) helping the veteran create a secure storage plan, including developing approaches to secure storage; (2) understanding warning signs of suicide; (3) helping the veteran limit access to firearms during a suicidal crisis; (4) helping the veteran remember the secure storage plan; (5) helping the veteran connect with mental health services; and (6) enhancing social support. In most instances, CSOs are physically close to the veteran (eg, live in the same household) and have a greater practical ability to support and affect change with respect to changes in firearm storage practices.

This article describes the development of an intervention that incorporates CSO involvement in firearms safety efforts for veterans with guidance from VA mental health care practitioners (HCPs). The goal is to provide HCPs and other key stakeholders with a detailed description of the intervention and to suggest potential strategies for how to involve CSOs in suicide prevention.

This article follows the Guideline for Reporting Evidence-based Practice Educational interventions and Teaching checklist, which was developed to facilitate standardized reporting and replication for education interventions.¹³ Applicable portions of the checklist are outlined, with others (ie, incentives, planned/unplanned changes, attendance, and other outcomes) to be addressed in future research.

FFAST INTERVENTION

Training (FFAST) intervention promotes voluntary secure firearm storage, engages CSOs in veteran mental health care, and provides psychoeducation and skills to support crisis management. The intervention was developed for all veterans who do not securely store firearms.

Theory

The intervention incorporates motivational interviewing techniques, as ambivalence about changing firearm storage behaviors is common, particularly when veterans own firearms for safety or protection.^6,14 Motivational interviewing is a collaborative approach that addresses a client’s ambivalence to change by eliciting and exploring the client’s own arguments related to change.¹⁴ An important aspect of developing this intervention was to ensure it would be culturally relevant to veteran firearm owners and their CSOs.¹⁵ Further, involvement of the CSO is intentional and meant to boost social support, a known buffering factor against suicide risk.¹²

Objectives

This intervention’s primary objective was for veteran participants to identify secure firearm storage practices and develop a plan for implementing them, including when a veteran or other household member experiences a mental health crisis. For CSOs, the primary objective is to learn how to help the veteran connect with mental health resources if needed and support secure firearm storage as necessary. The overall goal is to learn how to identify warning signs for suicide and how to respond to a mental health crisis through a collaborative process, including securing firearms in a crisis situation.

Materials, Educational Strategies, and Instructors

Training for delivering the intervention was provided via direct consultation with the developer of the intervention and manual. The manual contains pertinent background information to provide context for the intervention’s significance and rationale, including the role of firearms in suicides and current lethal means safety initiatives. It also describes the purpose and objective of each intervention component in detail in addition to providing a script for interventionists to follow to complete each objective.

Training materials for veterans and CSOs include a single Firearms Secure Storage Planning worksheet completed during the intervention, with which the interventionist guides participants through the creation of a secure firearm storage plan (Table). Educational strategies include psychoeducation and Socratic questioning (eg, questioning focused on guiding participants toward the intervention goals) delivered verbally by the interventionist.

The intervention is delivered in person or virtually during a single 90-minute session with a veteran and CSO. Veterans and CSOs work with the interventionist to complete collaborative activities during the session and have self-directive learning activities or homework.

The intervention has 4 primary components: (1) CSO involvement; (2) psychoeducation; (3) secure firearm storage; and (4) how to respond to a mental health crisis. Each CSO should have an established relationship with the veteran, be willing and able to be present during the intervention, and remain an encouraging support person for the veteran. The interventionist emphasizes that it is part of the VA mission for staff to care about the veteran, and that initiating such contact with a CSO is meant to prioritize veteran safety and the safety of their family. Psychoeducation on mental health symptoms, suicide warning signs, veteran suicide rates and lethal means, and the benefits of secure firearm storage, is incorporated in the intervention.

The secure firearm storage component consists of 7 subcomponents: (1) general lethal means secure storage; (2) warning signs; (3) dyad communication; (4) lethal means safety when symptoms emerge; (5) coping strategies; (6) social support; and (7) emergency contacts. A lethal means safety worksheet rooted in the Stanley and Brown suicide safety plan model and implemented in VA health care settings is used to facilitate discussions of secure storage (Appendix).¹⁶

CSOs typically have little or no suicidal crisis response training, yet they likely have more interaction with the veteran on a daily basis than HCPs, putting them in a vital position to identify a crisis early and connect the veteran with the proper care. The crisis component prepares the CSO and veteran to navigate a crisis scenario so they can practice their newly developed safety plan and increase their comfort in discussing mental health and suicidal crisis.

FICTIONAL CASE STUDY

Cole, aged 59 years, is a Persian Gulf War veteran and retired police officer. His medical history includes hypothyroidism, hypertension, type 2 diabetes mellitus, chronic posttraumatic stress disorder, major depressive disorder, and insomnia.

Cole's wife of > 30 years, Sheila, joined him for the FFAST intervention. They report having 4 firearms in the home, 3 of which are loaded but stored in a lockbox and 1 that Cole reports is kept on his person for protection. Cole reports passive suicidal ideation, but no plans or intent. When discussing warning signs that a mental health crisis is building, Cole describes feeling anxious, having a change in his speech patterns, and isolating himself. Sheila agrees, but also mentions that Cole is easily angered and becomes nonverbal. Cole and Sheila express difficulty communicating and appear to have a breakthrough moment when Cole says he does not like when Sheila repeats herself, as he feels like she is “poking” at him. Sheila shares concerns for his safety and that she only repeats herself because he refuses to talk.

Cole agrees to verbalize that he is safe but needs time to process his thoughts. Sheila agrees to give him space with a plan to revisit the conversation within an agreed upon timeline. When discussing an updated secure storage plan for their firearms when a mental health crisis is building, Cole commits to allowing Sheila to store the firearm currently on his person in their gun safe, with the ammunition stored separately, and to giving her the gun safe key. They agree to implement this practice until the mental health crisis has passed.

To mitigate a potential crisis, the interventionist discusses possible internal coping strategies for Cole, including writing, reading, walking the dog, listening to music, and baking. People and social settings that could provide distraction involve going to the gym, talking to his friend Carl or his daughter Kelly, and attending the men’s ministry at church. The intervention concludes by discussing professionals or agencies that Cole and Sheila could contact during a crisis. After the intervention, Cole and Sheila are asked to rate their likelihood of using the plan they established during the conversation on a scale of 0 to 10, with 0 being highly unlikely and 10 being extremely likely. Cole responds with 9 and Sheila responds with 10.

DISCUSSION

Lethal means safety remains a critical component of veteran suicide prevention. However, lethal means safety discussions are often implemented after suicide risk has been identified, which may be too late. Thus, having these conversations early and before a crisis may be imperative. Veterans have expressed a desire to have CSOs involved in their suicide prevention treatment, and CSOs can play a key role in recognizing risk factors during everyday life. The FFAST intervention addresses many of these gaps.

Having discussions in advance of a crisis allows veterans to consider an effective secure firearm storage plan outside of the context of a crisis. Including a CSO galvanizes another person to understand a veteran’s needs and assist with secure firearm storage, identify warning signs, and support them during a crisis. These discussions occur in a context where there is less pressure than during a crisis. Features that were more appealing to veterans and their CSOs were also incorporated, such as having the dyad build a plan that is conceptually similar to other public safety initiatives (eg, a fire safety plan, tornado plan, or hurricane plan). Previous research demonstrates that veterans appreciated the nonjudgmental approach and some preferred that clinicians approach the discussion of secure firearm storage within the context of general home and family safety.¹⁷ Additionally, this intervention can build on veterans’ prior military training in preparedness.

Other potential benefits associated with the FFAST intervention include creating an opportunity to strengthen communication between the veteran and CSO. While FFAST is intended to be used with all types of CSOs, this work is consistent with preliminary data from a couples-based suicide prevention study that indicated veterans and their partners reported increases in relationship functioning and marginal decreases in suicidal ideation.¹⁸ It is possible that communication strategies gained from the current intervention could improve veterans’ relationships with their CSOs, which are associated with a greater sense of social support and reduced suicide risk.¹²

The intervention is a brief, single session that may be appealing to veterans and CSOs with full schedules. Evidence suggests that even brief, single-session interventions have a significant impact on beliefs about secure firearm storage, knowledge of lethal means safety, and confidence in having secure firearm storage conversations.¹⁹ However, clinicians should be cautious when extrapolating from the findings of the current case example, which was a one-time intervention with no follow-up.

Future Directions

Pilot testing of the proposed intervention is underway, and future research will include feedback from veterans and CSOs, as well as feasibility and acceptability data collected during the pilot process. The pilot study uses a successive cohort design with an initial 2 sets of 5 veteran and CSO dyads, and subsequent funding has expanded the pilot study to include an additional 30 dyads. Qualitative interviews will be conducted separately with each veteran and CSO, and additional constructs such as feasibility, acceptability, barriers and facilitators to implementation, and changes in secure storage will be examined. This future research may provide a deeper understanding of the broader acceptability, feasibility, and satisfaction associated with a suicide prevention intervention focused on securing firearms and involving veterans and their CSOs. These data could be used to inform future implementation trials and inform the development of an implementation strategy. In the interim, the nature of the manual is summarized in the context of the urgency of suicide prevention in this at-risk population.

Conclusions

FFAST is a novel approach to veteran firearm suicide prevention. By involving CSOs and emphasizing mental health crisis preparedness between them and veterans, the dyad can work in association with HCPs to establish and exercise secure firearm storage practices as part of an at-home safety plan. Implementation of FFAST may be beneficial for all veterans, not only those who have been identified as being at high suicide risk.

Veterans are at higher risk for suicide compared with civilian populations.¹ Firearms are the most frequent cause of death in veteran deaths by suicide, likely because about 51% of veterans own ≥ 1 firearms and firearms are the most lethal and readily available mechanism.^1-3 Unsecure firearm storage practices (eg, storing firearms unlocked, in an unsecure location, or loaded with ammunition) are associated with increased suicide risk.⁴ Conversely, secure firearm storage (ie, storing firearms locked and unloaded) is associated with lower suicide risk.⁵

A 2019 study of veterans who own firearms found that only 22.2% store all their firearms unloaded and locked, while 32.7% store ≥ 1 firearm unlocked and loaded, and 45.2% store firearms both unlocked and loaded or locked and unloaded. Only 6.3% of veterans strongly agreed that having a firearm at home increased suicide risk among household members; however, 77.2% indicated they would ensure a household member could not access firearms if they were concerned about their suicidal ideation.⁶

Another study found that 9.2% of veterans receive lethal means safety counseling from their US Department of Veterans Affairs (VA)-affiliated or non-VA health care professional.⁷ These data highlight a need to educate veterans about the increased risk for suicide associated with storing an unsecured firearm in the household and to connect this understanding to their values of service and protection of others, while simultaneously preparing them and their family members for a potential mental health crisis.

Consistent with the government’s public health approach to suicide prevention, prevention efforts should also enlist the participation of individuals outside health care.⁸ For example, prior research has found that family members are considered highly credible, and engaging them could expand the reach of lethal means safety conversations. A qualitative analysis of 29 veterans found that 17 (57%) said they preferred having a concerned significant other (CSO) (eg, spouse, adult friend, or relative) involved in their suicide prevention care, while 21 (72%) said they would prefer having a CSO assisting in the secure storage of firearms.^9,10 Some veterans may be more amenable to a conversation about firearm access and suicide risk concerns initiated by a CSO rather than by a clinician, indicating the potential benefits of educating and involving CSOs in suicide prevention.¹¹ Involving CSOs in secure firearm storage planning may also strengthen the veteran’s sense of social support, a key protective factor against suicidal ideation.¹²

CSO involvement in secure firearm storage can provide the following benefits: (1) helping the veteran create a secure storage plan, including developing approaches to secure storage; (2) understanding warning signs of suicide; (3) helping the veteran limit access to firearms during a suicidal crisis; (4) helping the veteran remember the secure storage plan; (5) helping the veteran connect with mental health services; and (6) enhancing social support. In most instances, CSOs are physically close to the veteran (eg, live in the same household) and have a greater practical ability to support and affect change with respect to changes in firearm storage practices.

This article describes the development of an intervention that incorporates CSO involvement in firearms safety efforts for veterans with guidance from VA mental health care practitioners (HCPs). The goal is to provide HCPs and other key stakeholders with a detailed description of the intervention and to suggest potential strategies for how to involve CSOs in suicide prevention.

This article follows the Guideline for Reporting Evidence-based Practice Educational interventions and Teaching checklist, which was developed to facilitate standardized reporting and replication for education interventions.¹³ Applicable portions of the checklist are outlined, with others (ie, incentives, planned/unplanned changes, attendance, and other outcomes) to be addressed in future research.

FFAST INTERVENTION

Training (FFAST) intervention promotes voluntary secure firearm storage, engages CSOs in veteran mental health care, and provides psychoeducation and skills to support crisis management. The intervention was developed for all veterans who do not securely store firearms.

Theory

The intervention incorporates motivational interviewing techniques, as ambivalence about changing firearm storage behaviors is common, particularly when veterans own firearms for safety or protection.^6,14 Motivational interviewing is a collaborative approach that addresses a client’s ambivalence to change by eliciting and exploring the client’s own arguments related to change.¹⁴ An important aspect of developing this intervention was to ensure it would be culturally relevant to veteran firearm owners and their CSOs.¹⁵ Further, involvement of the CSO is intentional and meant to boost social support, a known buffering factor against suicide risk.¹²

Objectives

This intervention’s primary objective was for veteran participants to identify secure firearm storage practices and develop a plan for implementing them, including when a veteran or other household member experiences a mental health crisis. For CSOs, the primary objective is to learn how to help the veteran connect with mental health resources if needed and support secure firearm storage as necessary. The overall goal is to learn how to identify warning signs for suicide and how to respond to a mental health crisis through a collaborative process, including securing firearms in a crisis situation.

Materials, Educational Strategies, and Instructors

Training for delivering the intervention was provided via direct consultation with the developer of the intervention and manual. The manual contains pertinent background information to provide context for the intervention’s significance and rationale, including the role of firearms in suicides and current lethal means safety initiatives. It also describes the purpose and objective of each intervention component in detail in addition to providing a script for interventionists to follow to complete each objective.

Training materials for veterans and CSOs include a single Firearms Secure Storage Planning worksheet completed during the intervention, with which the interventionist guides participants through the creation of a secure firearm storage plan (Table). Educational strategies include psychoeducation and Socratic questioning (eg, questioning focused on guiding participants toward the intervention goals) delivered verbally by the interventionist.

The intervention is delivered in person or virtually during a single 90-minute session with a veteran and CSO. Veterans and CSOs work with the interventionist to complete collaborative activities during the session and have self-directive learning activities or homework.

The intervention has 4 primary components: (1) CSO involvement; (2) psychoeducation; (3) secure firearm storage; and (4) how to respond to a mental health crisis. Each CSO should have an established relationship with the veteran, be willing and able to be present during the intervention, and remain an encouraging support person for the veteran. The interventionist emphasizes that it is part of the VA mission for staff to care about the veteran, and that initiating such contact with a CSO is meant to prioritize veteran safety and the safety of their family. Psychoeducation on mental health symptoms, suicide warning signs, veteran suicide rates and lethal means, and the benefits of secure firearm storage, is incorporated in the intervention.

The secure firearm storage component consists of 7 subcomponents: (1) general lethal means secure storage; (2) warning signs; (3) dyad communication; (4) lethal means safety when symptoms emerge; (5) coping strategies; (6) social support; and (7) emergency contacts. A lethal means safety worksheet rooted in the Stanley and Brown suicide safety plan model and implemented in VA health care settings is used to facilitate discussions of secure storage (Appendix).¹⁶

CSOs typically have little or no suicidal crisis response training, yet they likely have more interaction with the veteran on a daily basis than HCPs, putting them in a vital position to identify a crisis early and connect the veteran with the proper care. The crisis component prepares the CSO and veteran to navigate a crisis scenario so they can practice their newly developed safety plan and increase their comfort in discussing mental health and suicidal crisis.

FICTIONAL CASE STUDY

Cole, aged 59 years, is a Persian Gulf War veteran and retired police officer. His medical history includes hypothyroidism, hypertension, type 2 diabetes mellitus, chronic posttraumatic stress disorder, major depressive disorder, and insomnia.

Cole's wife of > 30 years, Sheila, joined him for the FFAST intervention. They report having 4 firearms in the home, 3 of which are loaded but stored in a lockbox and 1 that Cole reports is kept on his person for protection. Cole reports passive suicidal ideation, but no plans or intent. When discussing warning signs that a mental health crisis is building, Cole describes feeling anxious, having a change in his speech patterns, and isolating himself. Sheila agrees, but also mentions that Cole is easily angered and becomes nonverbal. Cole and Sheila express difficulty communicating and appear to have a breakthrough moment when Cole says he does not like when Sheila repeats herself, as he feels like she is “poking” at him. Sheila shares concerns for his safety and that she only repeats herself because he refuses to talk.

Cole agrees to verbalize that he is safe but needs time to process his thoughts. Sheila agrees to give him space with a plan to revisit the conversation within an agreed upon timeline. When discussing an updated secure storage plan for their firearms when a mental health crisis is building, Cole commits to allowing Sheila to store the firearm currently on his person in their gun safe, with the ammunition stored separately, and to giving her the gun safe key. They agree to implement this practice until the mental health crisis has passed.

To mitigate a potential crisis, the interventionist discusses possible internal coping strategies for Cole, including writing, reading, walking the dog, listening to music, and baking. People and social settings that could provide distraction involve going to the gym, talking to his friend Carl or his daughter Kelly, and attending the men’s ministry at church. The intervention concludes by discussing professionals or agencies that Cole and Sheila could contact during a crisis. After the intervention, Cole and Sheila are asked to rate their likelihood of using the plan they established during the conversation on a scale of 0 to 10, with 0 being highly unlikely and 10 being extremely likely. Cole responds with 9 and Sheila responds with 10.

DISCUSSION

Lethal means safety remains a critical component of veteran suicide prevention. However, lethal means safety discussions are often implemented after suicide risk has been identified, which may be too late. Thus, having these conversations early and before a crisis may be imperative. Veterans have expressed a desire to have CSOs involved in their suicide prevention treatment, and CSOs can play a key role in recognizing risk factors during everyday life. The FFAST intervention addresses many of these gaps.

Having discussions in advance of a crisis allows veterans to consider an effective secure firearm storage plan outside of the context of a crisis. Including a CSO galvanizes another person to understand a veteran’s needs and assist with secure firearm storage, identify warning signs, and support them during a crisis. These discussions occur in a context where there is less pressure than during a crisis. Features that were more appealing to veterans and their CSOs were also incorporated, such as having the dyad build a plan that is conceptually similar to other public safety initiatives (eg, a fire safety plan, tornado plan, or hurricane plan). Previous research demonstrates that veterans appreciated the nonjudgmental approach and some preferred that clinicians approach the discussion of secure firearm storage within the context of general home and family safety.¹⁷ Additionally, this intervention can build on veterans’ prior military training in preparedness.

Other potential benefits associated with the FFAST intervention include creating an opportunity to strengthen communication between the veteran and CSO. While FFAST is intended to be used with all types of CSOs, this work is consistent with preliminary data from a couples-based suicide prevention study that indicated veterans and their partners reported increases in relationship functioning and marginal decreases in suicidal ideation.¹⁸ It is possible that communication strategies gained from the current intervention could improve veterans’ relationships with their CSOs, which are associated with a greater sense of social support and reduced suicide risk.¹²

The intervention is a brief, single session that may be appealing to veterans and CSOs with full schedules. Evidence suggests that even brief, single-session interventions have a significant impact on beliefs about secure firearm storage, knowledge of lethal means safety, and confidence in having secure firearm storage conversations.¹⁹ However, clinicians should be cautious when extrapolating from the findings of the current case example, which was a one-time intervention with no follow-up.

Future Directions

Pilot testing of the proposed intervention is underway, and future research will include feedback from veterans and CSOs, as well as feasibility and acceptability data collected during the pilot process. The pilot study uses a successive cohort design with an initial 2 sets of 5 veteran and CSO dyads, and subsequent funding has expanded the pilot study to include an additional 30 dyads. Qualitative interviews will be conducted separately with each veteran and CSO, and additional constructs such as feasibility, acceptability, barriers and facilitators to implementation, and changes in secure storage will be examined. This future research may provide a deeper understanding of the broader acceptability, feasibility, and satisfaction associated with a suicide prevention intervention focused on securing firearms and involving veterans and their CSOs. These data could be used to inform future implementation trials and inform the development of an implementation strategy. In the interim, the nature of the manual is summarized in the context of the urgency of suicide prevention in this at-risk population.

Conclusions

FFAST is a novel approach to veteran firearm suicide prevention. By involving CSOs and emphasizing mental health crisis preparedness between them and veterans, the dyad can work in association with HCPs to establish and exercise secure firearm storage practices as part of an at-home safety plan. Implementation of FFAST may be beneficial for all veterans, not only those who have been identified as being at high suicide risk.

T he US Census Bureau projects that the number of older adults (aged ≥ 65 years) will exceed 49 million by 2030, and an estimated 20% (nearly 10 million) of this population will experience cognitive or mental health disorders.^1,2 The mental health workforce is not equipped to address the specialized mental health care needs of many older adults.^2,3 For example, geriatric psychiatrists specialize in the diagnosis and treatment of mental illness and cognitive disorders in the later stages of life, but their numbers are few and declining. Only 33.5% of geriatric psychiatry fellowship training slots were filled from 2017 to 2021, and only 62 fellows trained during the 2021-2022 academic year.⁴ Board-certified geriatric psychiatrists also tend to be concentrated in larger, urban, academically-affiliated medical centers, often leaving rural areas and smaller facilities without access, including facilities in the Veterans Health Administration (VHA).⁵

The VHA has been optimizing access to specialty geriatric mental health services via regional and national virtual consultation services. Seven of 19 Veterans Integrated Service Network (VISN) Clinical Resource Hubs (CRHs) have geriatric mental health teams.⁶ These provide interdisciplinary geriatric mental telehealth services, including geriatric psychiatry, for older veterans with complex care needs.^7,8 Likewise, the VHA National Expert Consultation & Specialized Services-Mental Health (NEXCSS- MH, formerly known as the National Telemental Health Center) sponsors video teleconsultations with board-certified geriatric psychiatrists and an Ask the Expert email consultation program.

This article describes the Ask the Expert Geriatric Psychiatry email program (one of several similar programs at NEXCSS-MH), building upon a symposium presented at the American Association for Geriatric Psychiatry (AAGP) annual meeting in March 2022.⁹ The program was initiated in June 2021 as a result of discussions between the National Mental Health Director, Geriatric Mental Health in the VHA Office of Mental Health and Suicide Prevention (now known as the Office of Mental Health [OMH]), and National Telemental Health Center leadership. VHA board certified geriatric psychiatrists were recruited to serve as expert consultants and respond to email questions submitted by VHA clinicians regarding the psychiatric care of older adult veterans. The results of this program identify educational needs among clinical staff and may inform the development of program materials for a range of clinicians.

Program Description

The national geriatric mental health director recruited prospective experts and met with each to assess interest and qualifications, consulting with OMH psychiatrist leaders before making selections. Five experts were initially selected; 1 later stepped down and was replaced by another, who also stepped down. The experts were board certified in psychiatry and geriatric psychiatry and held a variety of local and national leadership positions, including geriatric psychiatry fellowship director, US Department of Veterans Affairs (VA) research and clinical leader, and various roles in the AAGP; some had received teaching awards.

Operations

The national geriatric mental health director announced the program in June 2021 to VHA mental health and geriatric program email groups with reminders sent every few months. The announcement included information about the types of questions appropriate to submit, including examples of general clinical management questions that did not share patient-specific protected health information, and clarified that experts would not be conducting chart reviews because the time required for detailed chart reviews was not feasible for volunteer experts to integrate into their otherwise full-time jobs at their respective VA medical centers. The announcement also included brief biographies of the experts.

The Figure describes the daily operations of the Ask the Expert Geriatric Psychiatry email consultation program. The NEXCSS- MH developed a Microsoft Outlook mailbox and group email address where clinicians from across the VHA could submit questions. The experts, as well as the national geriatric mental health director and NEXCSS-MH staff, had access to this mailbox to track and/or respond to questions. One expert volunteered to be the program’s primary mailbox coordinator. The coordinator checked the inbox daily and assigned each question to one of the experts on a rotating basis using the color-coding feature in Outlook. The other experts were advised to check the email account at least once weekly and reply to any assigned questions.

Responding to a question entailed first determining whether the question was appropriate for the service. For example, if a question requested a chart review, the expert replied that experts could not provide chart reviews and requested that the question be reframed. Next, the expert often needed to define a specific clinical question from the information provided, as email questions often touched upon several topics. The expert provided personalized advice on diagnostic testing, nonpharmacologic treatment strategies, and/or pharmacologic treatment options. Experts also often attached relevant guidelines or review articles. The goal was to provide a response within 7 business days.

All email responses included a disclaimer indicating that the program was not intended for urgent or immediate medical advice and that the information provided was for VHA clinician education purposes only. The disclaimer explained that email communication did not establish a doctor-patient relationship between the expert and a specific veteran and that, if desired, a request for a clinical consultation could be submitted on a specific case (ie, a video teleconsultation).

Methods for Reviewing Questions

Descriptive statistics, including frequencies, means, and minimum and maximum ranges, were used to capture the number of questions the program received, type of requester, and length of time prior to response for emailed questions.⁹ Conventional content analysis procedures were used between January and October 2024 to analyze clinicians’ questions.¹⁰ Four subject matter experts (3 geriatric psychiatrists and 1 geropsychologist) served as coders, assigned in groups of 2 to review questions. Each coder independently reviewed assigned questions and identified preliminary themes. Themes were reviewed and revised using an iterative process during regular team meetings with coders to clarify and confirm interpretations. Discrepancies were discussed within team meetings to achieve consensus.

Questions received. Between February 2022 and December 2023, the program received 101 email questions. Requesters included 39 physicians, 17 nurse practitioners or physician assistants, 15 social workers, 14 psychologists, 9 nurses, 5 pharmacists, 1 dietitian, and 1 who was undetermined. Experts responded to the questions an average of 6 days after receipt (range, < 1-19); 73 responses (72%) met the 7-day goal.

Iterative changes to coded themes were made during group discussions. Multiple clinical questions were often posed within the same email. Initially, some coders identified themes solely based on reported symptoms; others identified themes based on reported and/or potential diagnostic conditions attributed to the symptom(s) described within the email. For example, some coders selected a primary theme of behavioral and psychological symptoms of dementia (BPSD) only if a behavior contributing to distress in the veteran or others was described, while others selected this theme when any psychiatric symptom (eg, psychosis) was present in the context of dementia. The group identified 1 primary theme per question based on the main clinical symptom or main concern presented. Co-occurring diagnostic conditions highlighted in the email requests were included as secondary themes, and each question could have > 1 secondary theme.

The most frequent requests related to clinical symptoms included questions about agitated behaviors, sleep and/or nightmares, and depression symptoms (Table 1). Twenty-seven of 33 email requests on agitated behaviors were related to a dementia diagnosis, as were several questions about sleep/nightmares, depression, psychosis/mania, and anxiety. Many diagnostic conditions were described in the email requests (Table 2). The most frequent condition was dementia, followed by a medical condition, depressive disorder, posttraumatic stress disorder, and/or serious mental illness.

Request for Feedback. In February 2022, an email request was sent to the 64 clinicians who asked email questions from the start of the program in June 2021 through December 2021. A second request included 11 clinicians who asked questions from January through February 2022. These requests were sent as part of preparations for the symposium on the program presented at the AAGP annual meeting in March 2022.⁹ In May 2024, feedback was requested from 37 clinicians who submitted questions from May 1, 2023, through May 15, 2024.

Requests for feedback included 6 closed-ended and 1 open-ended question: (1) Did the answer you received help inform clinical practice? (2) Did you receive a timely response? (3) What type of information was useful to you in addressing your question (ie, direct/specific answer to a clinical scenario, guidelines, articles, VA resources)? (4) Do you have access to a geriatric psychiatrist at your facility? (5) Are you likely to use Ask the Expert Geriatric Psychiatry in the future? (6) Would you use a geriatric psychiatry teleconsultation service? (7) Share suggestions for improvement. Frequencies of response selection were obtained for each question. Text responses to the open-ended question asking for suggestions for improvement were reviewed and summarized.

Responses

Thirty users responded to the feedback request (27% response rate). Respondents considered the answers received extremely (n = 14; 47%) or very much (n = 12; 40%) helpful for their clinical practice. Twenty-three respondents (77%) felt an answer was provided promptly, 7 respondents (23%) felt the answer was not timely but still useful, and none felt that the answer was too late. Respondents reported that the most useful type of information in addressing their questions was a direct/specific answer to a clinical scenario (n = 27; 90%), followed by guidelines (n = 12; 40%), articles (n = 7; 23%), and VA resources (n = 4; 13%).

Sixteen respondents (53%) reported that they rarely had ready access to a geriatric psychiatrist at their facility, 3 (10%) had access sometimes, 4 (14%) had access usually, 3 (10%) had access regularly, and 3 (10%) never had access. Twenty-seven respondents (90%) indicated they would be very likely to use the service again. If geriatric psychiatry teleconsultation and/or e-consultation were offered, many respondents indicated they would be extremely (n = 10; 33%) or very (n = 12; 40%) likely to use teleconsultation and/or e-consultation.

Suggestions for improvement included supporting experts to perform chart reviews for email questions, developing a template or consult form, holding a biweekly drop-in meeting to present questions to and discuss cases with a panel of experts, and providing further help addressing complex decisional capacity issues, delirium, and care or placement for veterans with severe behavioral issues in a rural setting.

Discussion

Although many older adults experience cognitive and mental health disorders that may benefit from management by a geriatric psychiatrist, the number of trained geriatric psychiatrists available is insufficient to allow for direct care for each patient. The Ask the Expert Geriatric Psychiatry email consultation program is one aspect of a multicomponent strategy within the VHA to increase access to specialty geriatric mental health services for veterans. A key advantage of the program is that it is not resource intensive. Experts can participate voluntarily, providing timely feedback to clinicians around the country while continuing other duties at their respective VA medical centers. Email replies to the experts’ answers elicited positive feedback on the program, include: “I found this service to be extremely helpful and I have shared the information they sent me with several other coworkers!”, “It was great!”, and “I endorsed the service to our VISN Rehabilitation and Extended Care group.”

The coding of primary and secondary themes from 101 email questions that were retained revealed the range and relative frequencies of clinical and administrative topics with which clinicians needed help. The most common (33%) theme was agitated behaviors. Nearly half of the questions (48%) were related to underlying dementia, and 29% were related to a patient’s medical comorbidities. These findings suggest that the expertise of a geriatric psychiatrist is particularly relevant when caring for older patients experiencing BPSD or patients with complex, overlapping psychiatric and medical conditions.

Despite a 27% response rate, participant feedback has been helpful. The program reached its intended audience of clinicians in rural areas and at smaller facilities with 53% of requesters reporting they rarely had access to a geriatric psychiatrist. Suggestions for improvement indicated that some clinicians desired additional support, including chart reviews, meetings with experts, and a video teleconsultation service (available through NEXCSS-MH).

Many clinicians without training in specialty geriatric mental health may require help with complex clinical presentations. For example, 39 clinicians who submitted questions to the program were physicians. Accreditation Council for Graduate Medical Education program requirements for general psychiatry residency include 4 weeks of geriatric psychiatry.¹¹ The findings of this study suggest that this level of training may not be adequate to independently care for every patient who experiences dementia or multimorbidity. Several training and mentoring initiatives have been developed to address the professional development need for psychiatrists.^12-14

The need for geriatric workforce development is significant across health care, including other mental health professions.^15,16 The VHA Geriatric Scholars program trains rural primary care practitioners, psychologists, and psychiatrists.^17,18 Likewise, consultative geriatric specialty support for primary care practitioners in rural areas is provided via the Geriatric Research Education and Clinical Center Connect program.¹⁹ The Ask the Expert Geriatric Psychiatry email program is an additional economical model to support clinician educational development and provide rapid educational responses to inform patient care.

Ask the Expert received fewer email questions than anticipated. Enhanced optimization may require more frequent and widespread announcements about the program. Clinical staff may not be aware of the program due to an overload of email communications. Likewise, it may be challenging for busy clinicians to take the time to seek consultation or recognize a potential gap in their knowledge or skills. Had more questions been submitted, the 5 volunteer experts may have had more difficulty addressing the demand. Feedback from this project may inform development of a frequently asked questions document to share with VHA teams and a drop-in office hour to pose clinical questions of geriatric psychiatry experts, as recommended by a clinician who participated in the program.

Limitations

Not all requesters were sent a request for feedback, and the response rate for the request for feedback was only 27%. As the program has evolved, it began sending a request for feedback immediately after answering each question, which may increase the odds of response. The goal of experts answering questions within 7 business days was met 72% of the time, likely an artifact of experts integrating question answering with many other duties. The mailbox coordinator has since provided email prompts to experts immediately upon being assigned a question with the goal of improving timeliness. The program did not include chart reviews or patient consultations, as neither was feasible for volunteer experts. The email consultation service is a single component of virtual consultative specialty geriatric mental health services within the VHA, including video consultations via NEXCSS-MH and regional geriatric mental health teams.

Conclusions

The need for specialty geriatric mental health services is increasing in the VHA and across the US. However, there are too few board-certified geriatric psychiatrists to provide direct patient care to all older adults with cognitive and mental health disorders. The VHA has leveraged telehealth to improve access to geriatric mental health care. The VHA Ask the Expert Geriatric Psychiatry email consultation program is a low-resource service which provides rapid feedback to clinicians nationwide on challenging clinical scenarios, many of which are dementia-related. Most users of the service who responded to requests for feedback reported that answers to their questions were helpful and timely. The email consultation program should continue to be supplemented by more comprehensive geriatric telemental health services for particularly complex cases to meet the needs of older veterans.

T he US Census Bureau projects that the number of older adults (aged ≥ 65 years) will exceed 49 million by 2030, and an estimated 20% (nearly 10 million) of this population will experience cognitive or mental health disorders.^1,2 The mental health workforce is not equipped to address the specialized mental health care needs of many older adults.^2,3 For example, geriatric psychiatrists specialize in the diagnosis and treatment of mental illness and cognitive disorders in the later stages of life, but their numbers are few and declining. Only 33.5% of geriatric psychiatry fellowship training slots were filled from 2017 to 2021, and only 62 fellows trained during the 2021-2022 academic year.⁴ Board-certified geriatric psychiatrists also tend to be concentrated in larger, urban, academically-affiliated medical centers, often leaving rural areas and smaller facilities without access, including facilities in the Veterans Health Administration (VHA).⁵

The VHA has been optimizing access to specialty geriatric mental health services via regional and national virtual consultation services. Seven of 19 Veterans Integrated Service Network (VISN) Clinical Resource Hubs (CRHs) have geriatric mental health teams.⁶ These provide interdisciplinary geriatric mental telehealth services, including geriatric psychiatry, for older veterans with complex care needs.^7,8 Likewise, the VHA National Expert Consultation & Specialized Services-Mental Health (NEXCSS- MH, formerly known as the National Telemental Health Center) sponsors video teleconsultations with board-certified geriatric psychiatrists and an Ask the Expert email consultation program.

This article describes the Ask the Expert Geriatric Psychiatry email program (one of several similar programs at NEXCSS-MH), building upon a symposium presented at the American Association for Geriatric Psychiatry (AAGP) annual meeting in March 2022.⁹ The program was initiated in June 2021 as a result of discussions between the National Mental Health Director, Geriatric Mental Health in the VHA Office of Mental Health and Suicide Prevention (now known as the Office of Mental Health [OMH]), and National Telemental Health Center leadership. VHA board certified geriatric psychiatrists were recruited to serve as expert consultants and respond to email questions submitted by VHA clinicians regarding the psychiatric care of older adult veterans. The results of this program identify educational needs among clinical staff and may inform the development of program materials for a range of clinicians.

Program Description

The national geriatric mental health director recruited prospective experts and met with each to assess interest and qualifications, consulting with OMH psychiatrist leaders before making selections. Five experts were initially selected; 1 later stepped down and was replaced by another, who also stepped down. The experts were board certified in psychiatry and geriatric psychiatry and held a variety of local and national leadership positions, including geriatric psychiatry fellowship director, US Department of Veterans Affairs (VA) research and clinical leader, and various roles in the AAGP; some had received teaching awards.

Operations

The national geriatric mental health director announced the program in June 2021 to VHA mental health and geriatric program email groups with reminders sent every few months. The announcement included information about the types of questions appropriate to submit, including examples of general clinical management questions that did not share patient-specific protected health information, and clarified that experts would not be conducting chart reviews because the time required for detailed chart reviews was not feasible for volunteer experts to integrate into their otherwise full-time jobs at their respective VA medical centers. The announcement also included brief biographies of the experts.

The Figure describes the daily operations of the Ask the Expert Geriatric Psychiatry email consultation program. The NEXCSS- MH developed a Microsoft Outlook mailbox and group email address where clinicians from across the VHA could submit questions. The experts, as well as the national geriatric mental health director and NEXCSS-MH staff, had access to this mailbox to track and/or respond to questions. One expert volunteered to be the program’s primary mailbox coordinator. The coordinator checked the inbox daily and assigned each question to one of the experts on a rotating basis using the color-coding feature in Outlook. The other experts were advised to check the email account at least once weekly and reply to any assigned questions.

Responding to a question entailed first determining whether the question was appropriate for the service. For example, if a question requested a chart review, the expert replied that experts could not provide chart reviews and requested that the question be reframed. Next, the expert often needed to define a specific clinical question from the information provided, as email questions often touched upon several topics. The expert provided personalized advice on diagnostic testing, nonpharmacologic treatment strategies, and/or pharmacologic treatment options. Experts also often attached relevant guidelines or review articles. The goal was to provide a response within 7 business days.

All email responses included a disclaimer indicating that the program was not intended for urgent or immediate medical advice and that the information provided was for VHA clinician education purposes only. The disclaimer explained that email communication did not establish a doctor-patient relationship between the expert and a specific veteran and that, if desired, a request for a clinical consultation could be submitted on a specific case (ie, a video teleconsultation).

Methods for Reviewing Questions

Descriptive statistics, including frequencies, means, and minimum and maximum ranges, were used to capture the number of questions the program received, type of requester, and length of time prior to response for emailed questions.⁹ Conventional content analysis procedures were used between January and October 2024 to analyze clinicians’ questions.¹⁰ Four subject matter experts (3 geriatric psychiatrists and 1 geropsychologist) served as coders, assigned in groups of 2 to review questions. Each coder independently reviewed assigned questions and identified preliminary themes. Themes were reviewed and revised using an iterative process during regular team meetings with coders to clarify and confirm interpretations. Discrepancies were discussed within team meetings to achieve consensus.

Questions received. Between February 2022 and December 2023, the program received 101 email questions. Requesters included 39 physicians, 17 nurse practitioners or physician assistants, 15 social workers, 14 psychologists, 9 nurses, 5 pharmacists, 1 dietitian, and 1 who was undetermined. Experts responded to the questions an average of 6 days after receipt (range, < 1-19); 73 responses (72%) met the 7-day goal.

Iterative changes to coded themes were made during group discussions. Multiple clinical questions were often posed within the same email. Initially, some coders identified themes solely based on reported symptoms; others identified themes based on reported and/or potential diagnostic conditions attributed to the symptom(s) described within the email. For example, some coders selected a primary theme of behavioral and psychological symptoms of dementia (BPSD) only if a behavior contributing to distress in the veteran or others was described, while others selected this theme when any psychiatric symptom (eg, psychosis) was present in the context of dementia. The group identified 1 primary theme per question based on the main clinical symptom or main concern presented. Co-occurring diagnostic conditions highlighted in the email requests were included as secondary themes, and each question could have > 1 secondary theme.

The most frequent requests related to clinical symptoms included questions about agitated behaviors, sleep and/or nightmares, and depression symptoms (Table 1). Twenty-seven of 33 email requests on agitated behaviors were related to a dementia diagnosis, as were several questions about sleep/nightmares, depression, psychosis/mania, and anxiety. Many diagnostic conditions were described in the email requests (Table 2). The most frequent condition was dementia, followed by a medical condition, depressive disorder, posttraumatic stress disorder, and/or serious mental illness.

Request for Feedback. In February 2022, an email request was sent to the 64 clinicians who asked email questions from the start of the program in June 2021 through December 2021. A second request included 11 clinicians who asked questions from January through February 2022. These requests were sent as part of preparations for the symposium on the program presented at the AAGP annual meeting in March 2022.⁹ In May 2024, feedback was requested from 37 clinicians who submitted questions from May 1, 2023, through May 15, 2024.

Requests for feedback included 6 closed-ended and 1 open-ended question: (1) Did the answer you received help inform clinical practice? (2) Did you receive a timely response? (3) What type of information was useful to you in addressing your question (ie, direct/specific answer to a clinical scenario, guidelines, articles, VA resources)? (4) Do you have access to a geriatric psychiatrist at your facility? (5) Are you likely to use Ask the Expert Geriatric Psychiatry in the future? (6) Would you use a geriatric psychiatry teleconsultation service? (7) Share suggestions for improvement. Frequencies of response selection were obtained for each question. Text responses to the open-ended question asking for suggestions for improvement were reviewed and summarized.

Responses

Thirty users responded to the feedback request (27% response rate). Respondents considered the answers received extremely (n = 14; 47%) or very much (n = 12; 40%) helpful for their clinical practice. Twenty-three respondents (77%) felt an answer was provided promptly, 7 respondents (23%) felt the answer was not timely but still useful, and none felt that the answer was too late. Respondents reported that the most useful type of information in addressing their questions was a direct/specific answer to a clinical scenario (n = 27; 90%), followed by guidelines (n = 12; 40%), articles (n = 7; 23%), and VA resources (n = 4; 13%).

Sixteen respondents (53%) reported that they rarely had ready access to a geriatric psychiatrist at their facility, 3 (10%) had access sometimes, 4 (14%) had access usually, 3 (10%) had access regularly, and 3 (10%) never had access. Twenty-seven respondents (90%) indicated they would be very likely to use the service again. If geriatric psychiatry teleconsultation and/or e-consultation were offered, many respondents indicated they would be extremely (n = 10; 33%) or very (n = 12; 40%) likely to use teleconsultation and/or e-consultation.

Suggestions for improvement included supporting experts to perform chart reviews for email questions, developing a template or consult form, holding a biweekly drop-in meeting to present questions to and discuss cases with a panel of experts, and providing further help addressing complex decisional capacity issues, delirium, and care or placement for veterans with severe behavioral issues in a rural setting.

Discussion

Although many older adults experience cognitive and mental health disorders that may benefit from management by a geriatric psychiatrist, the number of trained geriatric psychiatrists available is insufficient to allow for direct care for each patient. The Ask the Expert Geriatric Psychiatry email consultation program is one aspect of a multicomponent strategy within the VHA to increase access to specialty geriatric mental health services for veterans. A key advantage of the program is that it is not resource intensive. Experts can participate voluntarily, providing timely feedback to clinicians around the country while continuing other duties at their respective VA medical centers. Email replies to the experts’ answers elicited positive feedback on the program, include: “I found this service to be extremely helpful and I have shared the information they sent me with several other coworkers!”, “It was great!”, and “I endorsed the service to our VISN Rehabilitation and Extended Care group.”

The coding of primary and secondary themes from 101 email questions that were retained revealed the range and relative frequencies of clinical and administrative topics with which clinicians needed help. The most common (33%) theme was agitated behaviors. Nearly half of the questions (48%) were related to underlying dementia, and 29% were related to a patient’s medical comorbidities. These findings suggest that the expertise of a geriatric psychiatrist is particularly relevant when caring for older patients experiencing BPSD or patients with complex, overlapping psychiatric and medical conditions.

Despite a 27% response rate, participant feedback has been helpful. The program reached its intended audience of clinicians in rural areas and at smaller facilities with 53% of requesters reporting they rarely had access to a geriatric psychiatrist. Suggestions for improvement indicated that some clinicians desired additional support, including chart reviews, meetings with experts, and a video teleconsultation service (available through NEXCSS-MH).

Many clinicians without training in specialty geriatric mental health may require help with complex clinical presentations. For example, 39 clinicians who submitted questions to the program were physicians. Accreditation Council for Graduate Medical Education program requirements for general psychiatry residency include 4 weeks of geriatric psychiatry.¹¹ The findings of this study suggest that this level of training may not be adequate to independently care for every patient who experiences dementia or multimorbidity. Several training and mentoring initiatives have been developed to address the professional development need for psychiatrists.^12-14

The need for geriatric workforce development is significant across health care, including other mental health professions.^15,16 The VHA Geriatric Scholars program trains rural primary care practitioners, psychologists, and psychiatrists.^17,18 Likewise, consultative geriatric specialty support for primary care practitioners in rural areas is provided via the Geriatric Research Education and Clinical Center Connect program.¹⁹ The Ask the Expert Geriatric Psychiatry email program is an additional economical model to support clinician educational development and provide rapid educational responses to inform patient care.

Ask the Expert received fewer email questions than anticipated. Enhanced optimization may require more frequent and widespread announcements about the program. Clinical staff may not be aware of the program due to an overload of email communications. Likewise, it may be challenging for busy clinicians to take the time to seek consultation or recognize a potential gap in their knowledge or skills. Had more questions been submitted, the 5 volunteer experts may have had more difficulty addressing the demand. Feedback from this project may inform development of a frequently asked questions document to share with VHA teams and a drop-in office hour to pose clinical questions of geriatric psychiatry experts, as recommended by a clinician who participated in the program.

Limitations

Not all requesters were sent a request for feedback, and the response rate for the request for feedback was only 27%. As the program has evolved, it began sending a request for feedback immediately after answering each question, which may increase the odds of response. The goal of experts answering questions within 7 business days was met 72% of the time, likely an artifact of experts integrating question answering with many other duties. The mailbox coordinator has since provided email prompts to experts immediately upon being assigned a question with the goal of improving timeliness. The program did not include chart reviews or patient consultations, as neither was feasible for volunteer experts. The email consultation service is a single component of virtual consultative specialty geriatric mental health services within the VHA, including video consultations via NEXCSS-MH and regional geriatric mental health teams.

Conclusions

The need for specialty geriatric mental health services is increasing in the VHA and across the US. However, there are too few board-certified geriatric psychiatrists to provide direct patient care to all older adults with cognitive and mental health disorders. The VHA has leveraged telehealth to improve access to geriatric mental health care. The VHA Ask the Expert Geriatric Psychiatry email consultation program is a low-resource service which provides rapid feedback to clinicians nationwide on challenging clinical scenarios, many of which are dementia-related. Most users of the service who responded to requests for feedback reported that answers to their questions were helpful and timely. The email consultation program should continue to be supplemented by more comprehensive geriatric telemental health services for particularly complex cases to meet the needs of older veterans.

T he US Census Bureau projects that the number of older adults (aged ≥ 65 years) will exceed 49 million by 2030, and an estimated 20% (nearly 10 million) of this population will experience cognitive or mental health disorders.^1,2 The mental health workforce is not equipped to address the specialized mental health care needs of many older adults.^2,3 For example, geriatric psychiatrists specialize in the diagnosis and treatment of mental illness and cognitive disorders in the later stages of life, but their numbers are few and declining. Only 33.5% of geriatric psychiatry fellowship training slots were filled from 2017 to 2021, and only 62 fellows trained during the 2021-2022 academic year.⁴ Board-certified geriatric psychiatrists also tend to be concentrated in larger, urban, academically-affiliated medical centers, often leaving rural areas and smaller facilities without access, including facilities in the Veterans Health Administration (VHA).⁵

The VHA has been optimizing access to specialty geriatric mental health services via regional and national virtual consultation services. Seven of 19 Veterans Integrated Service Network (VISN) Clinical Resource Hubs (CRHs) have geriatric mental health teams.⁶ These provide interdisciplinary geriatric mental telehealth services, including geriatric psychiatry, for older veterans with complex care needs.^7,8 Likewise, the VHA National Expert Consultation & Specialized Services-Mental Health (NEXCSS- MH, formerly known as the National Telemental Health Center) sponsors video teleconsultations with board-certified geriatric psychiatrists and an Ask the Expert email consultation program.

This article describes the Ask the Expert Geriatric Psychiatry email program (one of several similar programs at NEXCSS-MH), building upon a symposium presented at the American Association for Geriatric Psychiatry (AAGP) annual meeting in March 2022.⁹ The program was initiated in June 2021 as a result of discussions between the National Mental Health Director, Geriatric Mental Health in the VHA Office of Mental Health and Suicide Prevention (now known as the Office of Mental Health [OMH]), and National Telemental Health Center leadership. VHA board certified geriatric psychiatrists were recruited to serve as expert consultants and respond to email questions submitted by VHA clinicians regarding the psychiatric care of older adult veterans. The results of this program identify educational needs among clinical staff and may inform the development of program materials for a range of clinicians.

Program Description

The national geriatric mental health director recruited prospective experts and met with each to assess interest and qualifications, consulting with OMH psychiatrist leaders before making selections. Five experts were initially selected; 1 later stepped down and was replaced by another, who also stepped down. The experts were board certified in psychiatry and geriatric psychiatry and held a variety of local and national leadership positions, including geriatric psychiatry fellowship director, US Department of Veterans Affairs (VA) research and clinical leader, and various roles in the AAGP; some had received teaching awards.

Operations

The national geriatric mental health director announced the program in June 2021 to VHA mental health and geriatric program email groups with reminders sent every few months. The announcement included information about the types of questions appropriate to submit, including examples of general clinical management questions that did not share patient-specific protected health information, and clarified that experts would not be conducting chart reviews because the time required for detailed chart reviews was not feasible for volunteer experts to integrate into their otherwise full-time jobs at their respective VA medical centers. The announcement also included brief biographies of the experts.

The Figure describes the daily operations of the Ask the Expert Geriatric Psychiatry email consultation program. The NEXCSS- MH developed a Microsoft Outlook mailbox and group email address where clinicians from across the VHA could submit questions. The experts, as well as the national geriatric mental health director and NEXCSS-MH staff, had access to this mailbox to track and/or respond to questions. One expert volunteered to be the program’s primary mailbox coordinator. The coordinator checked the inbox daily and assigned each question to one of the experts on a rotating basis using the color-coding feature in Outlook. The other experts were advised to check the email account at least once weekly and reply to any assigned questions.

Responding to a question entailed first determining whether the question was appropriate for the service. For example, if a question requested a chart review, the expert replied that experts could not provide chart reviews and requested that the question be reframed. Next, the expert often needed to define a specific clinical question from the information provided, as email questions often touched upon several topics. The expert provided personalized advice on diagnostic testing, nonpharmacologic treatment strategies, and/or pharmacologic treatment options. Experts also often attached relevant guidelines or review articles. The goal was to provide a response within 7 business days.

All email responses included a disclaimer indicating that the program was not intended for urgent or immediate medical advice and that the information provided was for VHA clinician education purposes only. The disclaimer explained that email communication did not establish a doctor-patient relationship between the expert and a specific veteran and that, if desired, a request for a clinical consultation could be submitted on a specific case (ie, a video teleconsultation).

Methods for Reviewing Questions

Descriptive statistics, including frequencies, means, and minimum and maximum ranges, were used to capture the number of questions the program received, type of requester, and length of time prior to response for emailed questions.⁹ Conventional content analysis procedures were used between January and October 2024 to analyze clinicians’ questions.¹⁰ Four subject matter experts (3 geriatric psychiatrists and 1 geropsychologist) served as coders, assigned in groups of 2 to review questions. Each coder independently reviewed assigned questions and identified preliminary themes. Themes were reviewed and revised using an iterative process during regular team meetings with coders to clarify and confirm interpretations. Discrepancies were discussed within team meetings to achieve consensus.

Questions received. Between February 2022 and December 2023, the program received 101 email questions. Requesters included 39 physicians, 17 nurse practitioners or physician assistants, 15 social workers, 14 psychologists, 9 nurses, 5 pharmacists, 1 dietitian, and 1 who was undetermined. Experts responded to the questions an average of 6 days after receipt (range, < 1-19); 73 responses (72%) met the 7-day goal.

Iterative changes to coded themes were made during group discussions. Multiple clinical questions were often posed within the same email. Initially, some coders identified themes solely based on reported symptoms; others identified themes based on reported and/or potential diagnostic conditions attributed to the symptom(s) described within the email. For example, some coders selected a primary theme of behavioral and psychological symptoms of dementia (BPSD) only if a behavior contributing to distress in the veteran or others was described, while others selected this theme when any psychiatric symptom (eg, psychosis) was present in the context of dementia. The group identified 1 primary theme per question based on the main clinical symptom or main concern presented. Co-occurring diagnostic conditions highlighted in the email requests were included as secondary themes, and each question could have > 1 secondary theme.

The most frequent requests related to clinical symptoms included questions about agitated behaviors, sleep and/or nightmares, and depression symptoms (Table 1). Twenty-seven of 33 email requests on agitated behaviors were related to a dementia diagnosis, as were several questions about sleep/nightmares, depression, psychosis/mania, and anxiety. Many diagnostic conditions were described in the email requests (Table 2). The most frequent condition was dementia, followed by a medical condition, depressive disorder, posttraumatic stress disorder, and/or serious mental illness.

Request for Feedback. In February 2022, an email request was sent to the 64 clinicians who asked email questions from the start of the program in June 2021 through December 2021. A second request included 11 clinicians who asked questions from January through February 2022. These requests were sent as part of preparations for the symposium on the program presented at the AAGP annual meeting in March 2022.⁹ In May 2024, feedback was requested from 37 clinicians who submitted questions from May 1, 2023, through May 15, 2024.

Requests for feedback included 6 closed-ended and 1 open-ended question: (1) Did the answer you received help inform clinical practice? (2) Did you receive a timely response? (3) What type of information was useful to you in addressing your question (ie, direct/specific answer to a clinical scenario, guidelines, articles, VA resources)? (4) Do you have access to a geriatric psychiatrist at your facility? (5) Are you likely to use Ask the Expert Geriatric Psychiatry in the future? (6) Would you use a geriatric psychiatry teleconsultation service? (7) Share suggestions for improvement. Frequencies of response selection were obtained for each question. Text responses to the open-ended question asking for suggestions for improvement were reviewed and summarized.

Responses

Thirty users responded to the feedback request (27% response rate). Respondents considered the answers received extremely (n = 14; 47%) or very much (n = 12; 40%) helpful for their clinical practice. Twenty-three respondents (77%) felt an answer was provided promptly, 7 respondents (23%) felt the answer was not timely but still useful, and none felt that the answer was too late. Respondents reported that the most useful type of information in addressing their questions was a direct/specific answer to a clinical scenario (n = 27; 90%), followed by guidelines (n = 12; 40%), articles (n = 7; 23%), and VA resources (n = 4; 13%).

Sixteen respondents (53%) reported that they rarely had ready access to a geriatric psychiatrist at their facility, 3 (10%) had access sometimes, 4 (14%) had access usually, 3 (10%) had access regularly, and 3 (10%) never had access. Twenty-seven respondents (90%) indicated they would be very likely to use the service again. If geriatric psychiatry teleconsultation and/or e-consultation were offered, many respondents indicated they would be extremely (n = 10; 33%) or very (n = 12; 40%) likely to use teleconsultation and/or e-consultation.

Suggestions for improvement included supporting experts to perform chart reviews for email questions, developing a template or consult form, holding a biweekly drop-in meeting to present questions to and discuss cases with a panel of experts, and providing further help addressing complex decisional capacity issues, delirium, and care or placement for veterans with severe behavioral issues in a rural setting.

Discussion

Although many older adults experience cognitive and mental health disorders that may benefit from management by a geriatric psychiatrist, the number of trained geriatric psychiatrists available is insufficient to allow for direct care for each patient. The Ask the Expert Geriatric Psychiatry email consultation program is one aspect of a multicomponent strategy within the VHA to increase access to specialty geriatric mental health services for veterans. A key advantage of the program is that it is not resource intensive. Experts can participate voluntarily, providing timely feedback to clinicians around the country while continuing other duties at their respective VA medical centers. Email replies to the experts’ answers elicited positive feedback on the program, include: “I found this service to be extremely helpful and I have shared the information they sent me with several other coworkers!”, “It was great!”, and “I endorsed the service to our VISN Rehabilitation and Extended Care group.”

The coding of primary and secondary themes from 101 email questions that were retained revealed the range and relative frequencies of clinical and administrative topics with which clinicians needed help. The most common (33%) theme was agitated behaviors. Nearly half of the questions (48%) were related to underlying dementia, and 29% were related to a patient’s medical comorbidities. These findings suggest that the expertise of a geriatric psychiatrist is particularly relevant when caring for older patients experiencing BPSD or patients with complex, overlapping psychiatric and medical conditions.

Despite a 27% response rate, participant feedback has been helpful. The program reached its intended audience of clinicians in rural areas and at smaller facilities with 53% of requesters reporting they rarely had access to a geriatric psychiatrist. Suggestions for improvement indicated that some clinicians desired additional support, including chart reviews, meetings with experts, and a video teleconsultation service (available through NEXCSS-MH).

Many clinicians without training in specialty geriatric mental health may require help with complex clinical presentations. For example, 39 clinicians who submitted questions to the program were physicians. Accreditation Council for Graduate Medical Education program requirements for general psychiatry residency include 4 weeks of geriatric psychiatry.¹¹ The findings of this study suggest that this level of training may not be adequate to independently care for every patient who experiences dementia or multimorbidity. Several training and mentoring initiatives have been developed to address the professional development need for psychiatrists.^12-14

The need for geriatric workforce development is significant across health care, including other mental health professions.^15,16 The VHA Geriatric Scholars program trains rural primary care practitioners, psychologists, and psychiatrists.^17,18 Likewise, consultative geriatric specialty support for primary care practitioners in rural areas is provided via the Geriatric Research Education and Clinical Center Connect program.¹⁹ The Ask the Expert Geriatric Psychiatry email program is an additional economical model to support clinician educational development and provide rapid educational responses to inform patient care.

Ask the Expert received fewer email questions than anticipated. Enhanced optimization may require more frequent and widespread announcements about the program. Clinical staff may not be aware of the program due to an overload of email communications. Likewise, it may be challenging for busy clinicians to take the time to seek consultation or recognize a potential gap in their knowledge or skills. Had more questions been submitted, the 5 volunteer experts may have had more difficulty addressing the demand. Feedback from this project may inform development of a frequently asked questions document to share with VHA teams and a drop-in office hour to pose clinical questions of geriatric psychiatry experts, as recommended by a clinician who participated in the program.

Limitations

Not all requesters were sent a request for feedback, and the response rate for the request for feedback was only 27%. As the program has evolved, it began sending a request for feedback immediately after answering each question, which may increase the odds of response. The goal of experts answering questions within 7 business days was met 72% of the time, likely an artifact of experts integrating question answering with many other duties. The mailbox coordinator has since provided email prompts to experts immediately upon being assigned a question with the goal of improving timeliness. The program did not include chart reviews or patient consultations, as neither was feasible for volunteer experts. The email consultation service is a single component of virtual consultative specialty geriatric mental health services within the VHA, including video consultations via NEXCSS-MH and regional geriatric mental health teams.

Conclusions

The need for specialty geriatric mental health services is increasing in the VHA and across the US. However, there are too few board-certified geriatric psychiatrists to provide direct patient care to all older adults with cognitive and mental health disorders. The VHA has leveraged telehealth to improve access to geriatric mental health care. The VHA Ask the Expert Geriatric Psychiatry email consultation program is a low-resource service which provides rapid feedback to clinicians nationwide on challenging clinical scenarios, many of which are dementia-related. Most users of the service who responded to requests for feedback reported that answers to their questions were helpful and timely. The email consultation program should continue to be supplemented by more comprehensive geriatric telemental health services for particularly complex cases to meet the needs of older veterans.

Accessible and effective mental health services are a vital component of the Veterans Health Administration (VHA) mission to provide exceptional care that improves veterans’ health and well-being. Veterans are seeking mental health care at the VHA at significantly higher rates than in previous years. From 2009 through 2024, the number of veterans who received direct mental health care from the VHA increased 78%.¹ The proportion of veterans enrolled in the VHA who also received direct mental health care expanded from 23% of total enrollees in 2009 to 33% in 2024. The increase in VHA mental health care delivery is also reflected in the number of outpatient mental health care and treatment visits at the VHA, which increased from 12.7 million to 21.5 million over the same period.

The Sergeant First Class (SFC) Heath Robinson Honoring Our Promise to Address Comprehensive Toxics (PACT) Act of 2022 expanded eligibility for VHA services, including mental health care and counseling, to new cohorts of toxic-exposed veterans. From 2022 to 2024, > 680,000 veterans enrolled in VHA care, and 45% of those were PACT Act-eligible cohorts.² Research highlighted the high prevalence of physical and psychiatric comorbidities in toxic-exposed veterans.³ As such, the VHA may face greater demand for direct mental health care with these newly eligible cohorts of veterans.

Veterans often have mental health conditions (eg, depression, posttraumatic stress disorder [PTSD]), substance use disorders (SUDs), unique military experiences (eg, deployments), and injuries and illnesses (eg, traumatic brain injury [TBI]) that increase the complexity of their clinical presentation. The varied nature of these mental health conditions, as well as veterans’ unique military-related experiences, necessitates specialized centers focused on distinct high-priority areas of mental health in the VHA.

A series of public laws charged the US Department of Veterans Affairs (VA) with developing specialized mental health Centers of Excellence (CoEs) focused on high-priority areas of veteran mental health. The first of these laws, Public Law 98- 528, established the National Center for PTSD (NCPTSD), which opened in 1989.⁴ In 1996, Congress established specialized mental health CoEs known as Mental Illness Research, Education, and Clinical Centers (MIRECCs) across the VHA.⁵ To address the unique needs of post-9/11 veterans, 3 additional specialized centers were established in 2005.⁶ Finally, under the authority of the Secretary of the VA, specialized mental health CoEs were established to focus on SUD and integrated health care.

There are 17 geographically diverse mental health CoEs and MIRECCs across the VA (Table). CoEs are embedded in VA medical centers (VAMCs) with strong medical school academic affiliations. Organizational oversight of the CoEs is provided by the VA Office of Mental Health and Office of Suicide Prevention, respectively. As part of the oversight process, CoEs submit annual reports detailing their advancements in research, education and training, and clinical activities, as well as participate in a peer-reviewed renewal process.

These specialized centers are united in a shared tripartite mission to generate new knowledge about the causes and treatments of mental health conditions, to educate and train VHA clinicians and personnel, and to develop and implement innovative clinical programs within the VHA. This combined focus on research, education, and improved clinical care reduces the time from discovery to implementation and improves the health and well-being of veterans.

Examples of this acceleration translation from scientific discovery to clinical practice are evident throughout mental health CoEs. The NCPTSD is a leader in research on PTSD and traumatic stress. Its work led to the development of national training programs for VHA clinicians, facilitating the broad dissemination of efficacious PTSD treatments across the enterprise.⁷ Researchers at the Veterans Integrated Service Network (VISN) 21 Sierra Pacific MIRECC identified depression as a significant risk factor for dementia and subsequently launched the first multisite trial of repetitive transcranial magnetic stimulation (rTMS) in the VHA in 2012 (CSP #556: the effectiveness of rTMS in depressed VA patients).⁸ This project laid the groundwork for the national clinical rTMS program launched in 2017, which is now clinically available at 60 VAMCs. In the largest pragmatic randomized clinical trial of its kind, the VISN 4 Philadelphia and Pittsburgh MIRECC found that pharmacogenomic testing significantly reduced the number of prescription medications with predicted drug-gene interactions and improved clinical outcomes among veterans with depression.⁹

Mental health CoEs are also leaders in suicide prevention, a top clinical priority for the VHA. The VISN 2 New York MIRECC developed Project Life Force, a safety planning skills group for veterans with suicidal ideation, now implemented across 10 VAMCs, including telehealth hubs, outpatient settings, and veteran peer programs.¹⁰ The VISN 2 CoE for Suicide Prevention and VISN 19 Rocky Mountain MIRECC coordinate key suicide prevention services for VA, including the analysis of suicide surveillance data; evaluation of national VA suicide prevention initiatives; the support of veterans, families, and clinicians; and enhanced access to evidence-based treatments for at-risk veterans.

Mental health CoEs are a key operational partner in VHA treatment of SUDs. The CoEs in Substance Addiction Treatment and Education (CESATEs) are national resources dedicated to improving the quality, clinical outcomes, and cost-effectiveness of VHA SUD treatment. CESATEs developed and implemented a national rollout of an effective treatment for stimulant use disorders, training staff at > 120 VA programs. The VISN 1 Mid-Atlantic MIRECC’s focus on SUD and comorbid/co-occurring mental health conditions has highlighted the significant prevalence of these conditions and the impact they have on treatment response.¹¹

Serious mental illness (SMI) (eg, schizophrenia, schizoaffective disorder) impacts up to 5% of veterans.¹² VISN 22 Desert Pacific MIRECC has developed interventions to improve the lives of veterans with SMI. Its research established supported employment as an effective intervention to improve outcomes in veterans with psychotic disorders and supported its implementation in the VHA.¹³ Peer specialists are a cornerstone in the VHA commitment to recovery-oriented services for veterans with SMI. VISN 5 Capitol MIRECC has long championed research, clinical training, and educational activities that contributed to the effective deployment of peer specialists across the VHA enterprise.

Veterans have unique military-related experiences (eg, deployment, traumatic stress, transition to civilian status) and injuries and illnesses (eg, TBI, posttraumatic headaches) that significantly impact their mental health and quality of life.

The period between active duty and transition to civilian status is a critical time in a veteran’s life. The VISN 17 CoE Veteran Sponsorship Initiative connects veterans with VA care within 30 days postdischarge, with the option of additional support in the community. The VISN 22 CoE for Stress and Mental Health (CESAMH) develops, evaluates, and disseminates diagnostics and treatments for veterans affected by traumatic events and brain injuries, with a unique focus on supporting their whole health needs. The VISN 6 Mid-Atlantic MIRECC leads the ongoing VISN-6 Post-Deployment Mental Health (PDMH) study, the largest biorepository of post-9/11 veterans. PDMH has greatly expanded the understanding of the unique needs of post-9/11 veterans, with > 100 peer-reviewed publications to date. Veterans with mild TBI frequently experience chronic posttraumatic headaches that can be disabling and nonresponsive to treatment. The VISN 20 Northwest MIRECC demonstrated that prazosin, a repurposed, low-cost, widely available, nonaddictive medication, can safely and effectively reduce the frequency of these headaches and improve functional impairment in veterans and active-duty service members.¹⁴

Increased and enhanced access to effective mental health treatment is a priority for VA. In 2007, the VA launched the National Primary Care Mental Health Integration program, which integrated mental health services into primary care settings. The Center for Integrated Healthcare (CIH) has supported the VA in these efforts. In 2024, CIH trained > 5000 health care staff on high-fidelity integration of behavioral health and medical care. VA has also focused on increasing access to mental health services via expanded telehealth offerings. The VISN 16 MIRECC, with its unique focus on increasing access to care for rural veterans via distance-based and digital health technology, supported the VA Offices of Mental Health and Connected Care to virtualize mental health care and promote adoption and sustained use of VA Video Connect across the enterprise.

Specialized MH CoEs are uniquely equipped to support the VHA in providing training and education to VA clinicians, veterans, care partners and family members, and the community on high-priority mental health topics. Education is a core component of the MH CoEs tripartite mission. As such, MH CoEs offer national trainings, conferences, consultation services, clinical demonstration projects, development of clinical dashboards and toolkits, and public awareness campaigns. Researchers, educators, and clinicians at the CoEs frequently serve as subject matter experts on topics aligned with their respective missions. Several national rollout programs that disseminated evidence-based treatments for mental health conditions to the field (eg, cognitive behavioral therapy for depression, cognitive behavioral therapy for insomnia, and prolonged exposure) were developed at specialized CoEs.

The VHA provides advanced training, residencies, and fellowships to > 120,000 trainees annually. Many of these trainees choose to remain at the VA. Seven of 10 VHA psychologists and 6 of 10 VHA physicians trained within the VHA prior to their employment.¹⁵ The MH CoEs and MIRECCs play an important role in preparing these trainees for VHA mental health careers. These centers are funded to provide advanced postdoctoral training to physicians as well as allied health professionals in clinical and counseling psychology, social work, pharmacy, and nursing. Training is not limited to postdoctoral fellows: graduate students, residents, and interns from affiliated accredited training programs may rotate through mental health CoEs each academic year.

Conclusions

For > 30 years, mental health CoEs have brought thousands of veterans advanced treatments for their mental health needs and helped reduce death by suicide. The centers have a bright future ahead, harnessing advances in artificial intelligence and genomics to permit the matching of the individual veterans to the treatment most likely to benefit them. Precision medicine, as espoused by the Hannon Act, will not only encourage the efficient use of health care resources but also rapidly reduce pain in veterans with mental health and SUDs.

Accessible and effective mental health services are a vital component of the Veterans Health Administration (VHA) mission to provide exceptional care that improves veterans’ health and well-being. Veterans are seeking mental health care at the VHA at significantly higher rates than in previous years. From 2009 through 2024, the number of veterans who received direct mental health care from the VHA increased 78%.¹ The proportion of veterans enrolled in the VHA who also received direct mental health care expanded from 23% of total enrollees in 2009 to 33% in 2024. The increase in VHA mental health care delivery is also reflected in the number of outpatient mental health care and treatment visits at the VHA, which increased from 12.7 million to 21.5 million over the same period.

The Sergeant First Class (SFC) Heath Robinson Honoring Our Promise to Address Comprehensive Toxics (PACT) Act of 2022 expanded eligibility for VHA services, including mental health care and counseling, to new cohorts of toxic-exposed veterans. From 2022 to 2024, > 680,000 veterans enrolled in VHA care, and 45% of those were PACT Act-eligible cohorts.² Research highlighted the high prevalence of physical and psychiatric comorbidities in toxic-exposed veterans.³ As such, the VHA may face greater demand for direct mental health care with these newly eligible cohorts of veterans.

Veterans often have mental health conditions (eg, depression, posttraumatic stress disorder [PTSD]), substance use disorders (SUDs), unique military experiences (eg, deployments), and injuries and illnesses (eg, traumatic brain injury [TBI]) that increase the complexity of their clinical presentation. The varied nature of these mental health conditions, as well as veterans’ unique military-related experiences, necessitates specialized centers focused on distinct high-priority areas of mental health in the VHA.

A series of public laws charged the US Department of Veterans Affairs (VA) with developing specialized mental health Centers of Excellence (CoEs) focused on high-priority areas of veteran mental health. The first of these laws, Public Law 98- 528, established the National Center for PTSD (NCPTSD), which opened in 1989.⁴ In 1996, Congress established specialized mental health CoEs known as Mental Illness Research, Education, and Clinical Centers (MIRECCs) across the VHA.⁵ To address the unique needs of post-9/11 veterans, 3 additional specialized centers were established in 2005.⁶ Finally, under the authority of the Secretary of the VA, specialized mental health CoEs were established to focus on SUD and integrated health care.

There are 17 geographically diverse mental health CoEs and MIRECCs across the VA (Table). CoEs are embedded in VA medical centers (VAMCs) with strong medical school academic affiliations. Organizational oversight of the CoEs is provided by the VA Office of Mental Health and Office of Suicide Prevention, respectively. As part of the oversight process, CoEs submit annual reports detailing their advancements in research, education and training, and clinical activities, as well as participate in a peer-reviewed renewal process.

These specialized centers are united in a shared tripartite mission to generate new knowledge about the causes and treatments of mental health conditions, to educate and train VHA clinicians and personnel, and to develop and implement innovative clinical programs within the VHA. This combined focus on research, education, and improved clinical care reduces the time from discovery to implementation and improves the health and well-being of veterans.

Examples of this acceleration translation from scientific discovery to clinical practice are evident throughout mental health CoEs. The NCPTSD is a leader in research on PTSD and traumatic stress. Its work led to the development of national training programs for VHA clinicians, facilitating the broad dissemination of efficacious PTSD treatments across the enterprise.⁷ Researchers at the Veterans Integrated Service Network (VISN) 21 Sierra Pacific MIRECC identified depression as a significant risk factor for dementia and subsequently launched the first multisite trial of repetitive transcranial magnetic stimulation (rTMS) in the VHA in 2012 (CSP #556: the effectiveness of rTMS in depressed VA patients).⁸ This project laid the groundwork for the national clinical rTMS program launched in 2017, which is now clinically available at 60 VAMCs. In the largest pragmatic randomized clinical trial of its kind, the VISN 4 Philadelphia and Pittsburgh MIRECC found that pharmacogenomic testing significantly reduced the number of prescription medications with predicted drug-gene interactions and improved clinical outcomes among veterans with depression.⁹

Mental health CoEs are also leaders in suicide prevention, a top clinical priority for the VHA. The VISN 2 New York MIRECC developed Project Life Force, a safety planning skills group for veterans with suicidal ideation, now implemented across 10 VAMCs, including telehealth hubs, outpatient settings, and veteran peer programs.¹⁰ The VISN 2 CoE for Suicide Prevention and VISN 19 Rocky Mountain MIRECC coordinate key suicide prevention services for VA, including the analysis of suicide surveillance data; evaluation of national VA suicide prevention initiatives; the support of veterans, families, and clinicians; and enhanced access to evidence-based treatments for at-risk veterans.

Mental health CoEs are a key operational partner in VHA treatment of SUDs. The CoEs in Substance Addiction Treatment and Education (CESATEs) are national resources dedicated to improving the quality, clinical outcomes, and cost-effectiveness of VHA SUD treatment. CESATEs developed and implemented a national rollout of an effective treatment for stimulant use disorders, training staff at > 120 VA programs. The VISN 1 Mid-Atlantic MIRECC’s focus on SUD and comorbid/co-occurring mental health conditions has highlighted the significant prevalence of these conditions and the impact they have on treatment response.¹¹

Serious mental illness (SMI) (eg, schizophrenia, schizoaffective disorder) impacts up to 5% of veterans.¹² VISN 22 Desert Pacific MIRECC has developed interventions to improve the lives of veterans with SMI. Its research established supported employment as an effective intervention to improve outcomes in veterans with psychotic disorders and supported its implementation in the VHA.¹³ Peer specialists are a cornerstone in the VHA commitment to recovery-oriented services for veterans with SMI. VISN 5 Capitol MIRECC has long championed research, clinical training, and educational activities that contributed to the effective deployment of peer specialists across the VHA enterprise.

Veterans have unique military-related experiences (eg, deployment, traumatic stress, transition to civilian status) and injuries and illnesses (eg, TBI, posttraumatic headaches) that significantly impact their mental health and quality of life.

The period between active duty and transition to civilian status is a critical time in a veteran’s life. The VISN 17 CoE Veteran Sponsorship Initiative connects veterans with VA care within 30 days postdischarge, with the option of additional support in the community. The VISN 22 CoE for Stress and Mental Health (CESAMH) develops, evaluates, and disseminates diagnostics and treatments for veterans affected by traumatic events and brain injuries, with a unique focus on supporting their whole health needs. The VISN 6 Mid-Atlantic MIRECC leads the ongoing VISN-6 Post-Deployment Mental Health (PDMH) study, the largest biorepository of post-9/11 veterans. PDMH has greatly expanded the understanding of the unique needs of post-9/11 veterans, with > 100 peer-reviewed publications to date. Veterans with mild TBI frequently experience chronic posttraumatic headaches that can be disabling and nonresponsive to treatment. The VISN 20 Northwest MIRECC demonstrated that prazosin, a repurposed, low-cost, widely available, nonaddictive medication, can safely and effectively reduce the frequency of these headaches and improve functional impairment in veterans and active-duty service members.¹⁴

Increased and enhanced access to effective mental health treatment is a priority for VA. In 2007, the VA launched the National Primary Care Mental Health Integration program, which integrated mental health services into primary care settings. The Center for Integrated Healthcare (CIH) has supported the VA in these efforts. In 2024, CIH trained > 5000 health care staff on high-fidelity integration of behavioral health and medical care. VA has also focused on increasing access to mental health services via expanded telehealth offerings. The VISN 16 MIRECC, with its unique focus on increasing access to care for rural veterans via distance-based and digital health technology, supported the VA Offices of Mental Health and Connected Care to virtualize mental health care and promote adoption and sustained use of VA Video Connect across the enterprise.

Specialized MH CoEs are uniquely equipped to support the VHA in providing training and education to VA clinicians, veterans, care partners and family members, and the community on high-priority mental health topics. Education is a core component of the MH CoEs tripartite mission. As such, MH CoEs offer national trainings, conferences, consultation services, clinical demonstration projects, development of clinical dashboards and toolkits, and public awareness campaigns. Researchers, educators, and clinicians at the CoEs frequently serve as subject matter experts on topics aligned with their respective missions. Several national rollout programs that disseminated evidence-based treatments for mental health conditions to the field (eg, cognitive behavioral therapy for depression, cognitive behavioral therapy for insomnia, and prolonged exposure) were developed at specialized CoEs.

The VHA provides advanced training, residencies, and fellowships to > 120,000 trainees annually. Many of these trainees choose to remain at the VA. Seven of 10 VHA psychologists and 6 of 10 VHA physicians trained within the VHA prior to their employment.¹⁵ The MH CoEs and MIRECCs play an important role in preparing these trainees for VHA mental health careers. These centers are funded to provide advanced postdoctoral training to physicians as well as allied health professionals in clinical and counseling psychology, social work, pharmacy, and nursing. Training is not limited to postdoctoral fellows: graduate students, residents, and interns from affiliated accredited training programs may rotate through mental health CoEs each academic year.

Conclusions

For > 30 years, mental health CoEs have brought thousands of veterans advanced treatments for their mental health needs and helped reduce death by suicide. The centers have a bright future ahead, harnessing advances in artificial intelligence and genomics to permit the matching of the individual veterans to the treatment most likely to benefit them. Precision medicine, as espoused by the Hannon Act, will not only encourage the efficient use of health care resources but also rapidly reduce pain in veterans with mental health and SUDs.

Accessible and effective mental health services are a vital component of the Veterans Health Administration (VHA) mission to provide exceptional care that improves veterans’ health and well-being. Veterans are seeking mental health care at the VHA at significantly higher rates than in previous years. From 2009 through 2024, the number of veterans who received direct mental health care from the VHA increased 78%.¹ The proportion of veterans enrolled in the VHA who also received direct mental health care expanded from 23% of total enrollees in 2009 to 33% in 2024. The increase in VHA mental health care delivery is also reflected in the number of outpatient mental health care and treatment visits at the VHA, which increased from 12.7 million to 21.5 million over the same period.

The Sergeant First Class (SFC) Heath Robinson Honoring Our Promise to Address Comprehensive Toxics (PACT) Act of 2022 expanded eligibility for VHA services, including mental health care and counseling, to new cohorts of toxic-exposed veterans. From 2022 to 2024, > 680,000 veterans enrolled in VHA care, and 45% of those were PACT Act-eligible cohorts.² Research highlighted the high prevalence of physical and psychiatric comorbidities in toxic-exposed veterans.³ As such, the VHA may face greater demand for direct mental health care with these newly eligible cohorts of veterans.

Veterans often have mental health conditions (eg, depression, posttraumatic stress disorder [PTSD]), substance use disorders (SUDs), unique military experiences (eg, deployments), and injuries and illnesses (eg, traumatic brain injury [TBI]) that increase the complexity of their clinical presentation. The varied nature of these mental health conditions, as well as veterans’ unique military-related experiences, necessitates specialized centers focused on distinct high-priority areas of mental health in the VHA.

A series of public laws charged the US Department of Veterans Affairs (VA) with developing specialized mental health Centers of Excellence (CoEs) focused on high-priority areas of veteran mental health. The first of these laws, Public Law 98- 528, established the National Center for PTSD (NCPTSD), which opened in 1989.⁴ In 1996, Congress established specialized mental health CoEs known as Mental Illness Research, Education, and Clinical Centers (MIRECCs) across the VHA.⁵ To address the unique needs of post-9/11 veterans, 3 additional specialized centers were established in 2005.⁶ Finally, under the authority of the Secretary of the VA, specialized mental health CoEs were established to focus on SUD and integrated health care.

There are 17 geographically diverse mental health CoEs and MIRECCs across the VA (Table). CoEs are embedded in VA medical centers (VAMCs) with strong medical school academic affiliations. Organizational oversight of the CoEs is provided by the VA Office of Mental Health and Office of Suicide Prevention, respectively. As part of the oversight process, CoEs submit annual reports detailing their advancements in research, education and training, and clinical activities, as well as participate in a peer-reviewed renewal process.

These specialized centers are united in a shared tripartite mission to generate new knowledge about the causes and treatments of mental health conditions, to educate and train VHA clinicians and personnel, and to develop and implement innovative clinical programs within the VHA. This combined focus on research, education, and improved clinical care reduces the time from discovery to implementation and improves the health and well-being of veterans.

Examples of this acceleration translation from scientific discovery to clinical practice are evident throughout mental health CoEs. The NCPTSD is a leader in research on PTSD and traumatic stress. Its work led to the development of national training programs for VHA clinicians, facilitating the broad dissemination of efficacious PTSD treatments across the enterprise.⁷ Researchers at the Veterans Integrated Service Network (VISN) 21 Sierra Pacific MIRECC identified depression as a significant risk factor for dementia and subsequently launched the first multisite trial of repetitive transcranial magnetic stimulation (rTMS) in the VHA in 2012 (CSP #556: the effectiveness of rTMS in depressed VA patients).⁸ This project laid the groundwork for the national clinical rTMS program launched in 2017, which is now clinically available at 60 VAMCs. In the largest pragmatic randomized clinical trial of its kind, the VISN 4 Philadelphia and Pittsburgh MIRECC found that pharmacogenomic testing significantly reduced the number of prescription medications with predicted drug-gene interactions and improved clinical outcomes among veterans with depression.⁹

Mental health CoEs are also leaders in suicide prevention, a top clinical priority for the VHA. The VISN 2 New York MIRECC developed Project Life Force, a safety planning skills group for veterans with suicidal ideation, now implemented across 10 VAMCs, including telehealth hubs, outpatient settings, and veteran peer programs.¹⁰ The VISN 2 CoE for Suicide Prevention and VISN 19 Rocky Mountain MIRECC coordinate key suicide prevention services for VA, including the analysis of suicide surveillance data; evaluation of national VA suicide prevention initiatives; the support of veterans, families, and clinicians; and enhanced access to evidence-based treatments for at-risk veterans.

Mental health CoEs are a key operational partner in VHA treatment of SUDs. The CoEs in Substance Addiction Treatment and Education (CESATEs) are national resources dedicated to improving the quality, clinical outcomes, and cost-effectiveness of VHA SUD treatment. CESATEs developed and implemented a national rollout of an effective treatment for stimulant use disorders, training staff at > 120 VA programs. The VISN 1 Mid-Atlantic MIRECC’s focus on SUD and comorbid/co-occurring mental health conditions has highlighted the significant prevalence of these conditions and the impact they have on treatment response.¹¹

Serious mental illness (SMI) (eg, schizophrenia, schizoaffective disorder) impacts up to 5% of veterans.¹² VISN 22 Desert Pacific MIRECC has developed interventions to improve the lives of veterans with SMI. Its research established supported employment as an effective intervention to improve outcomes in veterans with psychotic disorders and supported its implementation in the VHA.¹³ Peer specialists are a cornerstone in the VHA commitment to recovery-oriented services for veterans with SMI. VISN 5 Capitol MIRECC has long championed research, clinical training, and educational activities that contributed to the effective deployment of peer specialists across the VHA enterprise.

Veterans have unique military-related experiences (eg, deployment, traumatic stress, transition to civilian status) and injuries and illnesses (eg, TBI, posttraumatic headaches) that significantly impact their mental health and quality of life.

The period between active duty and transition to civilian status is a critical time in a veteran’s life. The VISN 17 CoE Veteran Sponsorship Initiative connects veterans with VA care within 30 days postdischarge, with the option of additional support in the community. The VISN 22 CoE for Stress and Mental Health (CESAMH) develops, evaluates, and disseminates diagnostics and treatments for veterans affected by traumatic events and brain injuries, with a unique focus on supporting their whole health needs. The VISN 6 Mid-Atlantic MIRECC leads the ongoing VISN-6 Post-Deployment Mental Health (PDMH) study, the largest biorepository of post-9/11 veterans. PDMH has greatly expanded the understanding of the unique needs of post-9/11 veterans, with > 100 peer-reviewed publications to date. Veterans with mild TBI frequently experience chronic posttraumatic headaches that can be disabling and nonresponsive to treatment. The VISN 20 Northwest MIRECC demonstrated that prazosin, a repurposed, low-cost, widely available, nonaddictive medication, can safely and effectively reduce the frequency of these headaches and improve functional impairment in veterans and active-duty service members.¹⁴

Increased and enhanced access to effective mental health treatment is a priority for VA. In 2007, the VA launched the National Primary Care Mental Health Integration program, which integrated mental health services into primary care settings. The Center for Integrated Healthcare (CIH) has supported the VA in these efforts. In 2024, CIH trained > 5000 health care staff on high-fidelity integration of behavioral health and medical care. VA has also focused on increasing access to mental health services via expanded telehealth offerings. The VISN 16 MIRECC, with its unique focus on increasing access to care for rural veterans via distance-based and digital health technology, supported the VA Offices of Mental Health and Connected Care to virtualize mental health care and promote adoption and sustained use of VA Video Connect across the enterprise.

Specialized MH CoEs are uniquely equipped to support the VHA in providing training and education to VA clinicians, veterans, care partners and family members, and the community on high-priority mental health topics. Education is a core component of the MH CoEs tripartite mission. As such, MH CoEs offer national trainings, conferences, consultation services, clinical demonstration projects, development of clinical dashboards and toolkits, and public awareness campaigns. Researchers, educators, and clinicians at the CoEs frequently serve as subject matter experts on topics aligned with their respective missions. Several national rollout programs that disseminated evidence-based treatments for mental health conditions to the field (eg, cognitive behavioral therapy for depression, cognitive behavioral therapy for insomnia, and prolonged exposure) were developed at specialized CoEs.

The VHA provides advanced training, residencies, and fellowships to > 120,000 trainees annually. Many of these trainees choose to remain at the VA. Seven of 10 VHA psychologists and 6 of 10 VHA physicians trained within the VHA prior to their employment.¹⁵ The MH CoEs and MIRECCs play an important role in preparing these trainees for VHA mental health careers. These centers are funded to provide advanced postdoctoral training to physicians as well as allied health professionals in clinical and counseling psychology, social work, pharmacy, and nursing. Training is not limited to postdoctoral fellows: graduate students, residents, and interns from affiliated accredited training programs may rotate through mental health CoEs each academic year.

Conclusions

For > 30 years, mental health CoEs have brought thousands of veterans advanced treatments for their mental health needs and helped reduce death by suicide. The centers have a bright future ahead, harnessing advances in artificial intelligence and genomics to permit the matching of the individual veterans to the treatment most likely to benefit them. Precision medicine, as espoused by the Hannon Act, will not only encourage the efficient use of health care resources but also rapidly reduce pain in veterans with mental health and SUDs.

Cognitive behavioral therapy (CBT) is supported as an effective treatment for depression by clinical practice guidelines from the US Department of Veterans Affairs (VA) and US Department of Defense.^1-3 Despite research supporting the use of evidence-based CBT for anxiety, mood, and emotional disorders, patient access to these interventions is limited.⁴ One barrier to CBT for anxiety, mood, and emotional disorders is the traditional use of single-disorder protocols (SDPs) to separately treat each disorder (eg, major depression, generalized anxiety disorder, panic disorder).

Use of SDPs places a high burden on clinicians, requiring them to learn and competently implement multiple different manualized interventions for each anxiety, mood, or emotional disorder encountered in practice.⁴ It is common for individuals who present with an anxiety, mood, or emotional disorder to experience co-occurring disorders.⁵ Traditional SDP-based CBT may require multiple SDPs to address co-occurring disorders, extending time in treatment and increasing training burden. There is evidence that even when an SDP is used, co-occurring difficulties may decrease in intensity.⁶ Thus, evidence-based CBT for 1 presenting concern may positively affect co-occurring difficulties that are not the primary treatment target.⁶

Unified Protocol (UP) is a transdiagnostic CBT intervention for anxiety and mood disorders. UP targets emotional experiences (eg, negative affect and emotional distress) that are present in multiple anxiety, depression, and emotional disorders. UP is organized into 8 modules and uses interventions present in other CBT SDPs, such as teaching objective assessment methods to clients, motivational enhancement and goal setting, emotion psychoeducation, mindful awareness, cognitive reframing, and exposure principles as mechanisms of change (Table 1).⁴ UP is an ideal intervention for addressing a number of anxiety, mood, and emotional disorders as well as addressing cooccurring disorders within the same course of treatment.

UP has been compared to SDPs; studies illustrate that UP is equivalent to SDPs at the end of treatment and at 6 months posttreatment.^4,7 Additionally, patients who received UP experienced symptom reduction for multiple co-occurring disorders.⁷ Furthermore, patients were less likely to drop out of UP when compared with SDPs.⁴

Studies have reported positive impacts on affective disorders with UP. A 2019 meta-analysis found significant reductions in depression and anxiety-related disorders.⁸ Additionally, UP has been shown to be effective when delivered in person and via telehealth.^9,10 UP has also been successfully used in veterans.¹¹ While traditional models of UP (1-2 sessions weekly) have a lower dropout rate than SDPs, UP and CBT dropout rates still leave room for improvement.^12-14 Specifically, rates of attrition from SDP CBT and transdiagnostic CBT protocols range from 9% to 35%, and dropout reduces the likelihood of attaining a full therapeutic dose of any course of CBT. Notably, accelerated delivery of CBT (ie, ≥ 3 sessions/wk) has been shown to reduce risk of dropout.^14,15

Veterans are at increased risk for suicide, and anxiety and mood disorders are associated with increased risk of suicide attempt and death.^16,17 Very few veterans who could benefit from high-quality CBT interventions, whether SDP or UP, are able to access them. Only 6.3% of veterans received ≥1 session of an evidence-based CBT SDP for posttraumatic stress disorder (PTSD) at 6 clinics evaluated in 2010.¹⁸

We identified 2 strategies to increase access to and completion of an evidence-based CBT course. First, the use of transdiagnostic UP instead of SDPs reduced burden on therapists and allowed them to address presenting and co-occurring disorders within the same course of care. Second, the use of an accelerated model of service delivery reduced dropout risk. Training clinicians to deliver UP is efficient and cost-effective, considering clinicians use core strategies that can be tailored and flexibly applied to a range of emotional difficulties. Thus, implementing UP may decrease barriers to receiving an optimal dose of an evidence-based CBT delivered with fidelity in a time- and cost-efficient manner.⁴ Two studies have found no evidence of differences in outcomes between UP and SDPs, suggesting that training and supervising clinicians in a single transdiagnostic UP intervention may prepare them to treat heterogeneous and co-occurring anxiety, mood, and emotional disorders with less burden than learning multiple SDPs.^7,19

Delivering UP in an accelerated or massed format (≥4 sessions/wk) instead of the traditional spaced model (1 session/wk) has empirical support but has not been widely implemented. This approach, sometimes referred to as a UP-intensive outpatient program (UP-IOP) or UP-intensive outpatient track (UP-IOT), has been shown to be feasible, acceptable, and effective, with increased completion rates compared with traditional UP delivery (1-2 sessions/wk).^20-22

Ragsdale et al describe a 2-week IOP with multiple treatment tracks, including a general track.²⁰ The general track includes massed UP and additional standard services, including case management, wellness services, family services, and a single session effective behaviors group. Additional augmentation services are available when clinically indicated (eg, repetitive transcranial magnetic stimulation, transcranial direct current stimulation, psychoeducation, motivational interviewing, relapse prevention). In other words, this was an UP-IOP.²⁰

Thompson-Brenner et al described a successful implementation of massed UP applied in intensive treatment settings, such as residential and day-hospital programs, for eating disorders. Patients reported improvements in 3 UP targets: experiential avoidance, mindfulness, and anxiety.²¹ Watkins et al evaluated a 2-week IOP using CBT for comorbid substance use and mental health disorders, including prolonged exposure, UP, and relapse prevention for substance use disorders. Participants were post-9/11 veterans and activeduty personnel. Results indicated that UP reduced PTSD and depressive symptoms following treatment. Furthermore, the retention rate (91%) was higher than retention in outpatient treatment (39%-65%), supporting the IOP model as a strategy to reduce dropout.²²

Massed psychotherapy has been extended to IOP programs for PTSD treatment within the Veterans Health Administration (VHA). Yamokoski et al found that patients who completed an IOP that included massed CBT for PTSD had high retention, high satisfaction, and significant reduction in self-reported co-occurring depression symptoms. The authors also found that this model of care could be implemented and sustained within a VHA facility using minimal staffing resources.²³

The UP-IOP models described by Ragsdale et al and Watkins et al included massed UP as the primary evidence-based practice (EBP) with adjunctive groups (eg, wellness and educational groups and access to complementary interventions such as mindfulness and yoga); they found that adding these groups increased retention and patient- reported satisfaction (ie, UP-IOP).^20,22 The addition of wellness education alongside a primary EBP aligns with the VHA focus on whole health well-being and wellness. This includes understanding factors that motivate a patient toward health and well-being, providing health education, and offering access to complementary interventions such as mindfulness.²⁴

Dryden et al described the whole health transformation within VHA as a proactive approach to addressing both employee and patient wellness. Their research found that the whole health model promoted wellbeing in patients and staff and these improvements were sustained during the COVID-19 pandemic. Dryden et al also noted that virtual technologies facilitated continued whole health implementation.²⁵

The literature illustrates that (1) massed UP can be delivered with complementary education and wellness offerings that may increase retention and satisfaction by enriching treatment (eg, delivering UP-IOP); (2) whole health, including wellness education and complementary interventions (eg, mindfulness, motivational enhancement), promotes well-being in patients and clinicians; and (3) whole health education and complementary interventions can be delivered virtually.

IVET

Health Care Need

Veterans Affairs Pacific Islands Health Care System (VAPIHCS) provides medical services to veterans in the Hawaiian Islands, American Samoa, Guam, and Saipan spanning nearly 4000 miles across the Pacific Ocean. Prior to implementation of this program, veterans who received care at VAPIHCS had little to no access to UP in outpatient settings and no access to UP in residential settings. Access to UP depended on the presence of a therapist trained in UP within a given clinic and was geographically limited to the location of the UP-trained therapist. The limited outpatient access to UP was restricted to the traditional UP delivery model (eg, about 1 session/wk); thus, there was no access to accelerated UP for veterans served at VAPIHCS. In the fiscal year prior to implementation of the massed UP program, > 1000 VAPIHCS veterans had been diagnosed with obsessive-compulsive related disorder or anxiety. A massed-UP program with weekly rolling admissions would support access to UP for more veterans over 12 months, and the virtual treatment modality would reduce barriers for diverse and underserved veterans, making care more equitable and inclusive.

Successful implementation and sustainment of an EBP prompted the establishment of this UP program. In 2022, VAPIHCS launched the Intensive Virtual Evidence- Based Psychotherapy Team (iVET) for treatment of PTSD. This clinic and associated EBP project demonstrated that massed (≥3 individual sessions/wk) of prolonged exposure (PE) therapy, delivered virtually to a geographically diverse veteran population with PTSD, resulted in significant reductions in PTSD, depression, and anxiety symptoms and substance use risk factors, with very high retention rates. The iVET for PTSD program was feasible, acceptable, and effective, with veterans reporting significant improvement in quality of life and high satisfaction with their mental health services.¹⁵ Given the known benefits of transdiagnostic UP treatment (vs SDPs), the need for accelerated UP, and success with accelerated PE, our goal was to spread the EBP of massed (≥3 sessions/ wk) virtual psychotherapy to other presenting problems (eg, anxiety disorders with or without co-occurring unipolar depression) using transdiagnostic UP.

Program Description

The program implemented within outpatient mental health services at VAPIHCS was iVET for the treatment of anxiety with or without co-occurring depression. The program model consists of an accelerated course of UP and whole health education provided via VA Video Connect (VVC), the VA video telehealth platform. iVET is a 2- to 4-week program and consists of 3 parts: (1) massed individual UP for transdiagnostic treatment of anxiety and co-occurring depression, (2) group whole health and wellness classes, and (3) individual health coaching to address personal wellness goals. Programming is offered over 10-hour days to increase access across multiple time zones, especially to allow participation from Guam and Saipan.

When a patient is referred to iVET, the first contact is a video (or telephone) appointment with a registered nurse (RN) for a screening session. The screening session is designed to provide education about the program (including interventions, time commitment, and resources required for participation). Following education, the RN completes a safety screening, including screening for suicidal ideation and risk, as well as intimate partner violence risk. If urgent safety concerns are present, a licensed social worker or psychologist joins the screening to complete further risk assessment and address any safety concerns.

Following screening, patients are scheduled for a VVC telehealth intake with a licensed therapist (social worker or psychologist) to complete a diagnostic interview. Patients are sent a secure link to complete a measurement-based care (MBC) battery of self-report measures, including assessments of demographics, anxiety symptoms, depression symptoms, substance use, psychological flexibility, quality of life, and satisfaction with mental health care. The results of the diagnostic interview and self-report measures are discussed with the patient during the intake session to plan next steps and support shared decision-making. This initial VVC intake not only allows for fit assessment but also serves to troubleshoot technical difficulties with the virtual platforms.

Notably, there are minimal exclusion criteria for participation in iVET. These include active unmanaged psychosis or manic symptoms, recent suicidal crises (attempt within 8 weeks), active nonsuicidal self-injury (within 8 weeks), and moderate to severe cognitive impairment. Following intake, patients are scheduled to begin their course of care with iVET. Upon completion of intake, patients receive program materials for individual and group classes and are told they will receive email links for all VVC telehealth appointments. Patients are admitted to the iVET on a rolling basis, thereby increasing access compared with closed group and/or cohort models of care.

Patients receiving iVET attend 2 to 4 telehealth appointments daily and complete exercises between sessions. The primary iVET for Anxiety program EBP intervention is a massed or accelerated individual course of UP, which includes 8 primary components: assessment, goals and motivation, understanding emotions, mindful emotion awareness, cognitive flexibility, countering emotional behaviors, understanding and confronting physical sensations, and emotional exposures. UP is delivered in 4 to 8 individual sessions weekly (60-90 minutes each), allowing completion of the full UP protocol with fidelity in 2 to 4 weeks. In addition to primary EBP intervention, patients participate in 4 group sessions weekly (50 minutes each) of a whole health and wellness education class and have access to 1 individual health coaching session weekly (30- 60 minutes) to set wellness goals and receive coaching. During iVET, patients are invited to complete MBC batteries of self-report measures assessing anxiety symptoms, depression symptoms, substance use, psychological flexibility, quality of life, and satisfaction with mental health care at sessions 1, 5, 9, 13, and the final UP session. Following discharge from the iVET, patients are offered 1-, 3-, and 6-month individual postdischarge check-up sessions with a therapist, during which they are invited to complete MBC measures and review relapse prevention and maintenance of treatment gains. Likewise, patients are offered 1-, 3-, and 6-month individual postdischarge check-up sessions with an RN focused on maintaining wellness gains.

The iVET for Anxiety staff has 3 therapists (psychologists or social workers) and 1 RN. Additionally, the iVET for Anxiety is supported by a program manager and a program support assistant who support 2 programs total (the iVET for Anxiety plus another mental health program). The primary cost of the program is staff salary. Additional resources included computer equipment for staff and supplies (eg, printed materials for patients and office supplies). Due to the virtual environment of care, iVET staff telework and do not require physical space within VAPIHCS.

Outcomes

Veterans receiving iVET for Anxiety are invited to complete MBC multiple times, including pretreatment, during UP treatment (sessions 1, 5, 9, 13, and the final session), and posttreatment (1, 3, and 6 months). MBC measures include self-reported demographics; a 2-item measure of satisfaction with mental health services; the Acceptance and Action Questionnaire II,²⁶ the Brief Addiction Monitor-Intensive Outpatient Program, ²⁷ the Generalized Anxiety Disorder-7,²⁸ the Patient Health Questionnaire (PHQ-9),²⁹ and the Quality of Life Enjoyment and Satisfaction Questionnaire-Short Form.³⁰

Forty-two veterans completed the iVET for Anxiety program, with a retention rate of 87.5% completing . 16 sessions of massed UP (Table 2). Veterans reported reduced anxiety (P < .001), depression (P < .001), and substance use risk (P < .001). Veterans experienced improved acceptance of emotional experiences (P < .001) and quality of life (P < .001), based on paired sample t tests comparing session 1 vs final session scores on the self-reported measures. Veterans also reported high satisfaction with mental health care in iVET for Anxiety.

Veterans experienced reduced thoughts of death or suicidal ideation (SI) based on responses to item 9 of PHQ-9. When SI was categorically analyzed (presence vs absence) using PHQ-9 item 9, there was an association observed between absence of SI and completion of a course of massed UP that does not appear to be due to chance, (X² [1, N = 42) = 3.94; P = .047). In addition, veterans who completed the program showed a significant decrease in SI severity measured continuously (range, 0-3) on PHQ-9 item 9 (P < .05) (Table 3).

Future Directions

The aim of this program is to see sustained patient outcomes as iVET continues to serve more veterans. Another line of inquiry is longer- term follow-up, given that long-term follow- up was not addressed in this project. We also hope that the accelerated model of care can be applied to treatment of other presenting concerns (eg, relationship difficulties, insomnia). Expansion of accelerated mental health treatment into other federal and nonfederal health care settings is another area worthy of future inquiry. Exploration of staff satisfaction and burnout related to providing accelerated UP is another important future direction. Relatedly, assessment of the staff burden to learn 1 transdiagnostic EBP vs learning multiple SDPs is another future direction. Likewise, exploration of institutional benefits of investment in transdiagnostic training, supervision, and consultation for UP vs multiple SDPs may be important. These areas could also result in insightful, beneficial evidence of the effectiveness of massed UP to add to the existing literature.

Conclusions

UP for transdiagnostic treatment of anxiety, depressive, and emotional disorders has demonstrated reduced suffering and improved functioning and is supported by multiple clinical practice guidelines.^1-4 Federal practitioners are positioned to improve access to this intervention, thereby reducing pain and improving lives. Indeed, it is crucial to envision a future state in which access to UP for a range of anxiety and depressive disorders is improved and broad, retention rates are dramatically improved, and clinicians providing UP do not experience the high burden and burnout associated with needing to learn and implement a variety of SDPs. Development of these programs, or similar tracks within existing programs, that provide massed or accelerated UP for transdiagnostic treatment of a range of anxiety and depressive disorders with virtual delivery options, is imperative to advance improved care for patients and clinicians.

Federal health care settings treating patients with anxiety and depression, such as those within the US Department of Defense, Indian Health Services, Bureau of Prisons, and VHA, are positioned to implement programs like iVET. Moreover, at the institutional level, investment in training and supervision in the transdiagnostic UP as opposed to multiple SDPs warrants consideration. We believe this model of care has great merit and foresee a future where all patients seeking treatment for anxiety and depression have the option to complete an accelerated or massed course of transdiagnostic care with UP if they so desire. Our experiences with iVET illustrate the feasibility, acceptability, and sustainability of such programs without requiring substantial staffing and financial resources.

Cognitive behavioral therapy (CBT) is supported as an effective treatment for depression by clinical practice guidelines from the US Department of Veterans Affairs (VA) and US Department of Defense.^1-3 Despite research supporting the use of evidence-based CBT for anxiety, mood, and emotional disorders, patient access to these interventions is limited.⁴ One barrier to CBT for anxiety, mood, and emotional disorders is the traditional use of single-disorder protocols (SDPs) to separately treat each disorder (eg, major depression, generalized anxiety disorder, panic disorder).

Use of SDPs places a high burden on clinicians, requiring them to learn and competently implement multiple different manualized interventions for each anxiety, mood, or emotional disorder encountered in practice.⁴ It is common for individuals who present with an anxiety, mood, or emotional disorder to experience co-occurring disorders.⁵ Traditional SDP-based CBT may require multiple SDPs to address co-occurring disorders, extending time in treatment and increasing training burden. There is evidence that even when an SDP is used, co-occurring difficulties may decrease in intensity.⁶ Thus, evidence-based CBT for 1 presenting concern may positively affect co-occurring difficulties that are not the primary treatment target.⁶

Unified Protocol (UP) is a transdiagnostic CBT intervention for anxiety and mood disorders. UP targets emotional experiences (eg, negative affect and emotional distress) that are present in multiple anxiety, depression, and emotional disorders. UP is organized into 8 modules and uses interventions present in other CBT SDPs, such as teaching objective assessment methods to clients, motivational enhancement and goal setting, emotion psychoeducation, mindful awareness, cognitive reframing, and exposure principles as mechanisms of change (Table 1).⁴ UP is an ideal intervention for addressing a number of anxiety, mood, and emotional disorders as well as addressing cooccurring disorders within the same course of treatment.

UP has been compared to SDPs; studies illustrate that UP is equivalent to SDPs at the end of treatment and at 6 months posttreatment.^4,7 Additionally, patients who received UP experienced symptom reduction for multiple co-occurring disorders.⁷ Furthermore, patients were less likely to drop out of UP when compared with SDPs.⁴

Studies have reported positive impacts on affective disorders with UP. A 2019 meta-analysis found significant reductions in depression and anxiety-related disorders.⁸ Additionally, UP has been shown to be effective when delivered in person and via telehealth.^9,10 UP has also been successfully used in veterans.¹¹ While traditional models of UP (1-2 sessions weekly) have a lower dropout rate than SDPs, UP and CBT dropout rates still leave room for improvement.^12-14 Specifically, rates of attrition from SDP CBT and transdiagnostic CBT protocols range from 9% to 35%, and dropout reduces the likelihood of attaining a full therapeutic dose of any course of CBT. Notably, accelerated delivery of CBT (ie, ≥ 3 sessions/wk) has been shown to reduce risk of dropout.^14,15

Veterans are at increased risk for suicide, and anxiety and mood disorders are associated with increased risk of suicide attempt and death.^16,17 Very few veterans who could benefit from high-quality CBT interventions, whether SDP or UP, are able to access them. Only 6.3% of veterans received ≥1 session of an evidence-based CBT SDP for posttraumatic stress disorder (PTSD) at 6 clinics evaluated in 2010.¹⁸

We identified 2 strategies to increase access to and completion of an evidence-based CBT course. First, the use of transdiagnostic UP instead of SDPs reduced burden on therapists and allowed them to address presenting and co-occurring disorders within the same course of care. Second, the use of an accelerated model of service delivery reduced dropout risk. Training clinicians to deliver UP is efficient and cost-effective, considering clinicians use core strategies that can be tailored and flexibly applied to a range of emotional difficulties. Thus, implementing UP may decrease barriers to receiving an optimal dose of an evidence-based CBT delivered with fidelity in a time- and cost-efficient manner.⁴ Two studies have found no evidence of differences in outcomes between UP and SDPs, suggesting that training and supervising clinicians in a single transdiagnostic UP intervention may prepare them to treat heterogeneous and co-occurring anxiety, mood, and emotional disorders with less burden than learning multiple SDPs.^7,19

Delivering UP in an accelerated or massed format (≥4 sessions/wk) instead of the traditional spaced model (1 session/wk) has empirical support but has not been widely implemented. This approach, sometimes referred to as a UP-intensive outpatient program (UP-IOP) or UP-intensive outpatient track (UP-IOT), has been shown to be feasible, acceptable, and effective, with increased completion rates compared with traditional UP delivery (1-2 sessions/wk).^20-22

Ragsdale et al describe a 2-week IOP with multiple treatment tracks, including a general track.²⁰ The general track includes massed UP and additional standard services, including case management, wellness services, family services, and a single session effective behaviors group. Additional augmentation services are available when clinically indicated (eg, repetitive transcranial magnetic stimulation, transcranial direct current stimulation, psychoeducation, motivational interviewing, relapse prevention). In other words, this was an UP-IOP.²⁰

Thompson-Brenner et al described a successful implementation of massed UP applied in intensive treatment settings, such as residential and day-hospital programs, for eating disorders. Patients reported improvements in 3 UP targets: experiential avoidance, mindfulness, and anxiety.²¹ Watkins et al evaluated a 2-week IOP using CBT for comorbid substance use and mental health disorders, including prolonged exposure, UP, and relapse prevention for substance use disorders. Participants were post-9/11 veterans and activeduty personnel. Results indicated that UP reduced PTSD and depressive symptoms following treatment. Furthermore, the retention rate (91%) was higher than retention in outpatient treatment (39%-65%), supporting the IOP model as a strategy to reduce dropout.²²

Massed psychotherapy has been extended to IOP programs for PTSD treatment within the Veterans Health Administration (VHA). Yamokoski et al found that patients who completed an IOP that included massed CBT for PTSD had high retention, high satisfaction, and significant reduction in self-reported co-occurring depression symptoms. The authors also found that this model of care could be implemented and sustained within a VHA facility using minimal staffing resources.²³

The UP-IOP models described by Ragsdale et al and Watkins et al included massed UP as the primary evidence-based practice (EBP) with adjunctive groups (eg, wellness and educational groups and access to complementary interventions such as mindfulness and yoga); they found that adding these groups increased retention and patient- reported satisfaction (ie, UP-IOP).^20,22 The addition of wellness education alongside a primary EBP aligns with the VHA focus on whole health well-being and wellness. This includes understanding factors that motivate a patient toward health and well-being, providing health education, and offering access to complementary interventions such as mindfulness.²⁴

Dryden et al described the whole health transformation within VHA as a proactive approach to addressing both employee and patient wellness. Their research found that the whole health model promoted wellbeing in patients and staff and these improvements were sustained during the COVID-19 pandemic. Dryden et al also noted that virtual technologies facilitated continued whole health implementation.²⁵

The literature illustrates that (1) massed UP can be delivered with complementary education and wellness offerings that may increase retention and satisfaction by enriching treatment (eg, delivering UP-IOP); (2) whole health, including wellness education and complementary interventions (eg, mindfulness, motivational enhancement), promotes well-being in patients and clinicians; and (3) whole health education and complementary interventions can be delivered virtually.

IVET

Health Care Need

Veterans Affairs Pacific Islands Health Care System (VAPIHCS) provides medical services to veterans in the Hawaiian Islands, American Samoa, Guam, and Saipan spanning nearly 4000 miles across the Pacific Ocean. Prior to implementation of this program, veterans who received care at VAPIHCS had little to no access to UP in outpatient settings and no access to UP in residential settings. Access to UP depended on the presence of a therapist trained in UP within a given clinic and was geographically limited to the location of the UP-trained therapist. The limited outpatient access to UP was restricted to the traditional UP delivery model (eg, about 1 session/wk); thus, there was no access to accelerated UP for veterans served at VAPIHCS. In the fiscal year prior to implementation of the massed UP program, > 1000 VAPIHCS veterans had been diagnosed with obsessive-compulsive related disorder or anxiety. A massed-UP program with weekly rolling admissions would support access to UP for more veterans over 12 months, and the virtual treatment modality would reduce barriers for diverse and underserved veterans, making care more equitable and inclusive.

Successful implementation and sustainment of an EBP prompted the establishment of this UP program. In 2022, VAPIHCS launched the Intensive Virtual Evidence- Based Psychotherapy Team (iVET) for treatment of PTSD. This clinic and associated EBP project demonstrated that massed (≥3 individual sessions/wk) of prolonged exposure (PE) therapy, delivered virtually to a geographically diverse veteran population with PTSD, resulted in significant reductions in PTSD, depression, and anxiety symptoms and substance use risk factors, with very high retention rates. The iVET for PTSD program was feasible, acceptable, and effective, with veterans reporting significant improvement in quality of life and high satisfaction with their mental health services.¹⁵ Given the known benefits of transdiagnostic UP treatment (vs SDPs), the need for accelerated UP, and success with accelerated PE, our goal was to spread the EBP of massed (≥3 sessions/ wk) virtual psychotherapy to other presenting problems (eg, anxiety disorders with or without co-occurring unipolar depression) using transdiagnostic UP.

Program Description

The program implemented within outpatient mental health services at VAPIHCS was iVET for the treatment of anxiety with or without co-occurring depression. The program model consists of an accelerated course of UP and whole health education provided via VA Video Connect (VVC), the VA video telehealth platform. iVET is a 2- to 4-week program and consists of 3 parts: (1) massed individual UP for transdiagnostic treatment of anxiety and co-occurring depression, (2) group whole health and wellness classes, and (3) individual health coaching to address personal wellness goals. Programming is offered over 10-hour days to increase access across multiple time zones, especially to allow participation from Guam and Saipan.

When a patient is referred to iVET, the first contact is a video (or telephone) appointment with a registered nurse (RN) for a screening session. The screening session is designed to provide education about the program (including interventions, time commitment, and resources required for participation). Following education, the RN completes a safety screening, including screening for suicidal ideation and risk, as well as intimate partner violence risk. If urgent safety concerns are present, a licensed social worker or psychologist joins the screening to complete further risk assessment and address any safety concerns.

Following screening, patients are scheduled for a VVC telehealth intake with a licensed therapist (social worker or psychologist) to complete a diagnostic interview. Patients are sent a secure link to complete a measurement-based care (MBC) battery of self-report measures, including assessments of demographics, anxiety symptoms, depression symptoms, substance use, psychological flexibility, quality of life, and satisfaction with mental health care. The results of the diagnostic interview and self-report measures are discussed with the patient during the intake session to plan next steps and support shared decision-making. This initial VVC intake not only allows for fit assessment but also serves to troubleshoot technical difficulties with the virtual platforms.

Notably, there are minimal exclusion criteria for participation in iVET. These include active unmanaged psychosis or manic symptoms, recent suicidal crises (attempt within 8 weeks), active nonsuicidal self-injury (within 8 weeks), and moderate to severe cognitive impairment. Following intake, patients are scheduled to begin their course of care with iVET. Upon completion of intake, patients receive program materials for individual and group classes and are told they will receive email links for all VVC telehealth appointments. Patients are admitted to the iVET on a rolling basis, thereby increasing access compared with closed group and/or cohort models of care.

Patients receiving iVET attend 2 to 4 telehealth appointments daily and complete exercises between sessions. The primary iVET for Anxiety program EBP intervention is a massed or accelerated individual course of UP, which includes 8 primary components: assessment, goals and motivation, understanding emotions, mindful emotion awareness, cognitive flexibility, countering emotional behaviors, understanding and confronting physical sensations, and emotional exposures. UP is delivered in 4 to 8 individual sessions weekly (60-90 minutes each), allowing completion of the full UP protocol with fidelity in 2 to 4 weeks. In addition to primary EBP intervention, patients participate in 4 group sessions weekly (50 minutes each) of a whole health and wellness education class and have access to 1 individual health coaching session weekly (30- 60 minutes) to set wellness goals and receive coaching. During iVET, patients are invited to complete MBC batteries of self-report measures assessing anxiety symptoms, depression symptoms, substance use, psychological flexibility, quality of life, and satisfaction with mental health care at sessions 1, 5, 9, 13, and the final UP session. Following discharge from the iVET, patients are offered 1-, 3-, and 6-month individual postdischarge check-up sessions with a therapist, during which they are invited to complete MBC measures and review relapse prevention and maintenance of treatment gains. Likewise, patients are offered 1-, 3-, and 6-month individual postdischarge check-up sessions with an RN focused on maintaining wellness gains.

The iVET for Anxiety staff has 3 therapists (psychologists or social workers) and 1 RN. Additionally, the iVET for Anxiety is supported by a program manager and a program support assistant who support 2 programs total (the iVET for Anxiety plus another mental health program). The primary cost of the program is staff salary. Additional resources included computer equipment for staff and supplies (eg, printed materials for patients and office supplies). Due to the virtual environment of care, iVET staff telework and do not require physical space within VAPIHCS.

Outcomes

Veterans receiving iVET for Anxiety are invited to complete MBC multiple times, including pretreatment, during UP treatment (sessions 1, 5, 9, 13, and the final session), and posttreatment (1, 3, and 6 months). MBC measures include self-reported demographics; a 2-item measure of satisfaction with mental health services; the Acceptance and Action Questionnaire II,²⁶ the Brief Addiction Monitor-Intensive Outpatient Program, ²⁷ the Generalized Anxiety Disorder-7,²⁸ the Patient Health Questionnaire (PHQ-9),²⁹ and the Quality of Life Enjoyment and Satisfaction Questionnaire-Short Form.³⁰

Forty-two veterans completed the iVET for Anxiety program, with a retention rate of 87.5% completing . 16 sessions of massed UP (Table 2). Veterans reported reduced anxiety (P < .001), depression (P < .001), and substance use risk (P < .001). Veterans experienced improved acceptance of emotional experiences (P < .001) and quality of life (P < .001), based on paired sample t tests comparing session 1 vs final session scores on the self-reported measures. Veterans also reported high satisfaction with mental health care in iVET for Anxiety.

Veterans experienced reduced thoughts of death or suicidal ideation (SI) based on responses to item 9 of PHQ-9. When SI was categorically analyzed (presence vs absence) using PHQ-9 item 9, there was an association observed between absence of SI and completion of a course of massed UP that does not appear to be due to chance, (X² [1, N = 42) = 3.94; P = .047). In addition, veterans who completed the program showed a significant decrease in SI severity measured continuously (range, 0-3) on PHQ-9 item 9 (P < .05) (Table 3).

Future Directions

The aim of this program is to see sustained patient outcomes as iVET continues to serve more veterans. Another line of inquiry is longer- term follow-up, given that long-term follow- up was not addressed in this project. We also hope that the accelerated model of care can be applied to treatment of other presenting concerns (eg, relationship difficulties, insomnia). Expansion of accelerated mental health treatment into other federal and nonfederal health care settings is another area worthy of future inquiry. Exploration of staff satisfaction and burnout related to providing accelerated UP is another important future direction. Relatedly, assessment of the staff burden to learn 1 transdiagnostic EBP vs learning multiple SDPs is another future direction. Likewise, exploration of institutional benefits of investment in transdiagnostic training, supervision, and consultation for UP vs multiple SDPs may be important. These areas could also result in insightful, beneficial evidence of the effectiveness of massed UP to add to the existing literature.

Conclusions

UP for transdiagnostic treatment of anxiety, depressive, and emotional disorders has demonstrated reduced suffering and improved functioning and is supported by multiple clinical practice guidelines.^1-4 Federal practitioners are positioned to improve access to this intervention, thereby reducing pain and improving lives. Indeed, it is crucial to envision a future state in which access to UP for a range of anxiety and depressive disorders is improved and broad, retention rates are dramatically improved, and clinicians providing UP do not experience the high burden and burnout associated with needing to learn and implement a variety of SDPs. Development of these programs, or similar tracks within existing programs, that provide massed or accelerated UP for transdiagnostic treatment of a range of anxiety and depressive disorders with virtual delivery options, is imperative to advance improved care for patients and clinicians.

Federal health care settings treating patients with anxiety and depression, such as those within the US Department of Defense, Indian Health Services, Bureau of Prisons, and VHA, are positioned to implement programs like iVET. Moreover, at the institutional level, investment in training and supervision in the transdiagnostic UP as opposed to multiple SDPs warrants consideration. We believe this model of care has great merit and foresee a future where all patients seeking treatment for anxiety and depression have the option to complete an accelerated or massed course of transdiagnostic care with UP if they so desire. Our experiences with iVET illustrate the feasibility, acceptability, and sustainability of such programs without requiring substantial staffing and financial resources.

Cognitive behavioral therapy (CBT) is supported as an effective treatment for depression by clinical practice guidelines from the US Department of Veterans Affairs (VA) and US Department of Defense.^1-3 Despite research supporting the use of evidence-based CBT for anxiety, mood, and emotional disorders, patient access to these interventions is limited.⁴ One barrier to CBT for anxiety, mood, and emotional disorders is the traditional use of single-disorder protocols (SDPs) to separately treat each disorder (eg, major depression, generalized anxiety disorder, panic disorder).

Use of SDPs places a high burden on clinicians, requiring them to learn and competently implement multiple different manualized interventions for each anxiety, mood, or emotional disorder encountered in practice.⁴ It is common for individuals who present with an anxiety, mood, or emotional disorder to experience co-occurring disorders.⁵ Traditional SDP-based CBT may require multiple SDPs to address co-occurring disorders, extending time in treatment and increasing training burden. There is evidence that even when an SDP is used, co-occurring difficulties may decrease in intensity.⁶ Thus, evidence-based CBT for 1 presenting concern may positively affect co-occurring difficulties that are not the primary treatment target.⁶

Unified Protocol (UP) is a transdiagnostic CBT intervention for anxiety and mood disorders. UP targets emotional experiences (eg, negative affect and emotional distress) that are present in multiple anxiety, depression, and emotional disorders. UP is organized into 8 modules and uses interventions present in other CBT SDPs, such as teaching objective assessment methods to clients, motivational enhancement and goal setting, emotion psychoeducation, mindful awareness, cognitive reframing, and exposure principles as mechanisms of change (Table 1).⁴ UP is an ideal intervention for addressing a number of anxiety, mood, and emotional disorders as well as addressing cooccurring disorders within the same course of treatment.

UP has been compared to SDPs; studies illustrate that UP is equivalent to SDPs at the end of treatment and at 6 months posttreatment.^4,7 Additionally, patients who received UP experienced symptom reduction for multiple co-occurring disorders.⁷ Furthermore, patients were less likely to drop out of UP when compared with SDPs.⁴

Studies have reported positive impacts on affective disorders with UP. A 2019 meta-analysis found significant reductions in depression and anxiety-related disorders.⁸ Additionally, UP has been shown to be effective when delivered in person and via telehealth.^9,10 UP has also been successfully used in veterans.¹¹ While traditional models of UP (1-2 sessions weekly) have a lower dropout rate than SDPs, UP and CBT dropout rates still leave room for improvement.^12-14 Specifically, rates of attrition from SDP CBT and transdiagnostic CBT protocols range from 9% to 35%, and dropout reduces the likelihood of attaining a full therapeutic dose of any course of CBT. Notably, accelerated delivery of CBT (ie, ≥ 3 sessions/wk) has been shown to reduce risk of dropout.^14,15

Veterans are at increased risk for suicide, and anxiety and mood disorders are associated with increased risk of suicide attempt and death.^16,17 Very few veterans who could benefit from high-quality CBT interventions, whether SDP or UP, are able to access them. Only 6.3% of veterans received ≥1 session of an evidence-based CBT SDP for posttraumatic stress disorder (PTSD) at 6 clinics evaluated in 2010.¹⁸

We identified 2 strategies to increase access to and completion of an evidence-based CBT course. First, the use of transdiagnostic UP instead of SDPs reduced burden on therapists and allowed them to address presenting and co-occurring disorders within the same course of care. Second, the use of an accelerated model of service delivery reduced dropout risk. Training clinicians to deliver UP is efficient and cost-effective, considering clinicians use core strategies that can be tailored and flexibly applied to a range of emotional difficulties. Thus, implementing UP may decrease barriers to receiving an optimal dose of an evidence-based CBT delivered with fidelity in a time- and cost-efficient manner.⁴ Two studies have found no evidence of differences in outcomes between UP and SDPs, suggesting that training and supervising clinicians in a single transdiagnostic UP intervention may prepare them to treat heterogeneous and co-occurring anxiety, mood, and emotional disorders with less burden than learning multiple SDPs.^7,19

Delivering UP in an accelerated or massed format (≥4 sessions/wk) instead of the traditional spaced model (1 session/wk) has empirical support but has not been widely implemented. This approach, sometimes referred to as a UP-intensive outpatient program (UP-IOP) or UP-intensive outpatient track (UP-IOT), has been shown to be feasible, acceptable, and effective, with increased completion rates compared with traditional UP delivery (1-2 sessions/wk).^20-22

Ragsdale et al describe a 2-week IOP with multiple treatment tracks, including a general track.²⁰ The general track includes massed UP and additional standard services, including case management, wellness services, family services, and a single session effective behaviors group. Additional augmentation services are available when clinically indicated (eg, repetitive transcranial magnetic stimulation, transcranial direct current stimulation, psychoeducation, motivational interviewing, relapse prevention). In other words, this was an UP-IOP.²⁰

Thompson-Brenner et al described a successful implementation of massed UP applied in intensive treatment settings, such as residential and day-hospital programs, for eating disorders. Patients reported improvements in 3 UP targets: experiential avoidance, mindfulness, and anxiety.²¹ Watkins et al evaluated a 2-week IOP using CBT for comorbid substance use and mental health disorders, including prolonged exposure, UP, and relapse prevention for substance use disorders. Participants were post-9/11 veterans and activeduty personnel. Results indicated that UP reduced PTSD and depressive symptoms following treatment. Furthermore, the retention rate (91%) was higher than retention in outpatient treatment (39%-65%), supporting the IOP model as a strategy to reduce dropout.²²

Massed psychotherapy has been extended to IOP programs for PTSD treatment within the Veterans Health Administration (VHA). Yamokoski et al found that patients who completed an IOP that included massed CBT for PTSD had high retention, high satisfaction, and significant reduction in self-reported co-occurring depression symptoms. The authors also found that this model of care could be implemented and sustained within a VHA facility using minimal staffing resources.²³

The UP-IOP models described by Ragsdale et al and Watkins et al included massed UP as the primary evidence-based practice (EBP) with adjunctive groups (eg, wellness and educational groups and access to complementary interventions such as mindfulness and yoga); they found that adding these groups increased retention and patient- reported satisfaction (ie, UP-IOP).^20,22 The addition of wellness education alongside a primary EBP aligns with the VHA focus on whole health well-being and wellness. This includes understanding factors that motivate a patient toward health and well-being, providing health education, and offering access to complementary interventions such as mindfulness.²⁴

Dryden et al described the whole health transformation within VHA as a proactive approach to addressing both employee and patient wellness. Their research found that the whole health model promoted wellbeing in patients and staff and these improvements were sustained during the COVID-19 pandemic. Dryden et al also noted that virtual technologies facilitated continued whole health implementation.²⁵

The literature illustrates that (1) massed UP can be delivered with complementary education and wellness offerings that may increase retention and satisfaction by enriching treatment (eg, delivering UP-IOP); (2) whole health, including wellness education and complementary interventions (eg, mindfulness, motivational enhancement), promotes well-being in patients and clinicians; and (3) whole health education and complementary interventions can be delivered virtually.

IVET

Health Care Need

Veterans Affairs Pacific Islands Health Care System (VAPIHCS) provides medical services to veterans in the Hawaiian Islands, American Samoa, Guam, and Saipan spanning nearly 4000 miles across the Pacific Ocean. Prior to implementation of this program, veterans who received care at VAPIHCS had little to no access to UP in outpatient settings and no access to UP in residential settings. Access to UP depended on the presence of a therapist trained in UP within a given clinic and was geographically limited to the location of the UP-trained therapist. The limited outpatient access to UP was restricted to the traditional UP delivery model (eg, about 1 session/wk); thus, there was no access to accelerated UP for veterans served at VAPIHCS. In the fiscal year prior to implementation of the massed UP program, > 1000 VAPIHCS veterans had been diagnosed with obsessive-compulsive related disorder or anxiety. A massed-UP program with weekly rolling admissions would support access to UP for more veterans over 12 months, and the virtual treatment modality would reduce barriers for diverse and underserved veterans, making care more equitable and inclusive.

Successful implementation and sustainment of an EBP prompted the establishment of this UP program. In 2022, VAPIHCS launched the Intensive Virtual Evidence- Based Psychotherapy Team (iVET) for treatment of PTSD. This clinic and associated EBP project demonstrated that massed (≥3 individual sessions/wk) of prolonged exposure (PE) therapy, delivered virtually to a geographically diverse veteran population with PTSD, resulted in significant reductions in PTSD, depression, and anxiety symptoms and substance use risk factors, with very high retention rates. The iVET for PTSD program was feasible, acceptable, and effective, with veterans reporting significant improvement in quality of life and high satisfaction with their mental health services.¹⁵ Given the known benefits of transdiagnostic UP treatment (vs SDPs), the need for accelerated UP, and success with accelerated PE, our goal was to spread the EBP of massed (≥3 sessions/ wk) virtual psychotherapy to other presenting problems (eg, anxiety disorders with or without co-occurring unipolar depression) using transdiagnostic UP.

Program Description

The program implemented within outpatient mental health services at VAPIHCS was iVET for the treatment of anxiety with or without co-occurring depression. The program model consists of an accelerated course of UP and whole health education provided via VA Video Connect (VVC), the VA video telehealth platform. iVET is a 2- to 4-week program and consists of 3 parts: (1) massed individual UP for transdiagnostic treatment of anxiety and co-occurring depression, (2) group whole health and wellness classes, and (3) individual health coaching to address personal wellness goals. Programming is offered over 10-hour days to increase access across multiple time zones, especially to allow participation from Guam and Saipan.

When a patient is referred to iVET, the first contact is a video (or telephone) appointment with a registered nurse (RN) for a screening session. The screening session is designed to provide education about the program (including interventions, time commitment, and resources required for participation). Following education, the RN completes a safety screening, including screening for suicidal ideation and risk, as well as intimate partner violence risk. If urgent safety concerns are present, a licensed social worker or psychologist joins the screening to complete further risk assessment and address any safety concerns.

Following screening, patients are scheduled for a VVC telehealth intake with a licensed therapist (social worker or psychologist) to complete a diagnostic interview. Patients are sent a secure link to complete a measurement-based care (MBC) battery of self-report measures, including assessments of demographics, anxiety symptoms, depression symptoms, substance use, psychological flexibility, quality of life, and satisfaction with mental health care. The results of the diagnostic interview and self-report measures are discussed with the patient during the intake session to plan next steps and support shared decision-making. This initial VVC intake not only allows for fit assessment but also serves to troubleshoot technical difficulties with the virtual platforms.

Notably, there are minimal exclusion criteria for participation in iVET. These include active unmanaged psychosis or manic symptoms, recent suicidal crises (attempt within 8 weeks), active nonsuicidal self-injury (within 8 weeks), and moderate to severe cognitive impairment. Following intake, patients are scheduled to begin their course of care with iVET. Upon completion of intake, patients receive program materials for individual and group classes and are told they will receive email links for all VVC telehealth appointments. Patients are admitted to the iVET on a rolling basis, thereby increasing access compared with closed group and/or cohort models of care.

Patients receiving iVET attend 2 to 4 telehealth appointments daily and complete exercises between sessions. The primary iVET for Anxiety program EBP intervention is a massed or accelerated individual course of UP, which includes 8 primary components: assessment, goals and motivation, understanding emotions, mindful emotion awareness, cognitive flexibility, countering emotional behaviors, understanding and confronting physical sensations, and emotional exposures. UP is delivered in 4 to 8 individual sessions weekly (60-90 minutes each), allowing completion of the full UP protocol with fidelity in 2 to 4 weeks. In addition to primary EBP intervention, patients participate in 4 group sessions weekly (50 minutes each) of a whole health and wellness education class and have access to 1 individual health coaching session weekly (30- 60 minutes) to set wellness goals and receive coaching. During iVET, patients are invited to complete MBC batteries of self-report measures assessing anxiety symptoms, depression symptoms, substance use, psychological flexibility, quality of life, and satisfaction with mental health care at sessions 1, 5, 9, 13, and the final UP session. Following discharge from the iVET, patients are offered 1-, 3-, and 6-month individual postdischarge check-up sessions with a therapist, during which they are invited to complete MBC measures and review relapse prevention and maintenance of treatment gains. Likewise, patients are offered 1-, 3-, and 6-month individual postdischarge check-up sessions with an RN focused on maintaining wellness gains.

The iVET for Anxiety staff has 3 therapists (psychologists or social workers) and 1 RN. Additionally, the iVET for Anxiety is supported by a program manager and a program support assistant who support 2 programs total (the iVET for Anxiety plus another mental health program). The primary cost of the program is staff salary. Additional resources included computer equipment for staff and supplies (eg, printed materials for patients and office supplies). Due to the virtual environment of care, iVET staff telework and do not require physical space within VAPIHCS.

Outcomes

Veterans receiving iVET for Anxiety are invited to complete MBC multiple times, including pretreatment, during UP treatment (sessions 1, 5, 9, 13, and the final session), and posttreatment (1, 3, and 6 months). MBC measures include self-reported demographics; a 2-item measure of satisfaction with mental health services; the Acceptance and Action Questionnaire II,²⁶ the Brief Addiction Monitor-Intensive Outpatient Program, ²⁷ the Generalized Anxiety Disorder-7,²⁸ the Patient Health Questionnaire (PHQ-9),²⁹ and the Quality of Life Enjoyment and Satisfaction Questionnaire-Short Form.³⁰

Forty-two veterans completed the iVET for Anxiety program, with a retention rate of 87.5% completing . 16 sessions of massed UP (Table 2). Veterans reported reduced anxiety (P < .001), depression (P < .001), and substance use risk (P < .001). Veterans experienced improved acceptance of emotional experiences (P < .001) and quality of life (P < .001), based on paired sample t tests comparing session 1 vs final session scores on the self-reported measures. Veterans also reported high satisfaction with mental health care in iVET for Anxiety.

Veterans experienced reduced thoughts of death or suicidal ideation (SI) based on responses to item 9 of PHQ-9. When SI was categorically analyzed (presence vs absence) using PHQ-9 item 9, there was an association observed between absence of SI and completion of a course of massed UP that does not appear to be due to chance, (X² [1, N = 42) = 3.94; P = .047). In addition, veterans who completed the program showed a significant decrease in SI severity measured continuously (range, 0-3) on PHQ-9 item 9 (P < .05) (Table 3).

Future Directions

The aim of this program is to see sustained patient outcomes as iVET continues to serve more veterans. Another line of inquiry is longer- term follow-up, given that long-term follow- up was not addressed in this project. We also hope that the accelerated model of care can be applied to treatment of other presenting concerns (eg, relationship difficulties, insomnia). Expansion of accelerated mental health treatment into other federal and nonfederal health care settings is another area worthy of future inquiry. Exploration of staff satisfaction and burnout related to providing accelerated UP is another important future direction. Relatedly, assessment of the staff burden to learn 1 transdiagnostic EBP vs learning multiple SDPs is another future direction. Likewise, exploration of institutional benefits of investment in transdiagnostic training, supervision, and consultation for UP vs multiple SDPs may be important. These areas could also result in insightful, beneficial evidence of the effectiveness of massed UP to add to the existing literature.

Conclusions

UP for transdiagnostic treatment of anxiety, depressive, and emotional disorders has demonstrated reduced suffering and improved functioning and is supported by multiple clinical practice guidelines.^1-4 Federal practitioners are positioned to improve access to this intervention, thereby reducing pain and improving lives. Indeed, it is crucial to envision a future state in which access to UP for a range of anxiety and depressive disorders is improved and broad, retention rates are dramatically improved, and clinicians providing UP do not experience the high burden and burnout associated with needing to learn and implement a variety of SDPs. Development of these programs, or similar tracks within existing programs, that provide massed or accelerated UP for transdiagnostic treatment of a range of anxiety and depressive disorders with virtual delivery options, is imperative to advance improved care for patients and clinicians.

Federal health care settings treating patients with anxiety and depression, such as those within the US Department of Defense, Indian Health Services, Bureau of Prisons, and VHA, are positioned to implement programs like iVET. Moreover, at the institutional level, investment in training and supervision in the transdiagnostic UP as opposed to multiple SDPs warrants consideration. We believe this model of care has great merit and foresee a future where all patients seeking treatment for anxiety and depression have the option to complete an accelerated or massed course of transdiagnostic care with UP if they so desire. Our experiences with iVET illustrate the feasibility, acceptability, and sustainability of such programs without requiring substantial staffing and financial resources.