Background: Over 1.6 million US service members have served in Afghanistan or Iraq as part of Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF), and up to 15% of them report significant mental health symptoms. Failure to engage in treatment remains a significant obstacle and one that can lead to devastating consequences including exacerbation of psychiatric symptoms, deteriorating social and vocational functioning, homelessness, substance abuse, and suicide (2,3,6-8). Because disengagement from mental health treatment may reflect the OEF/OIF veteran's perspective that treatment is not meeting his/her needs or not being provided in a collaborative manner, there is a growing imperative to develop and implement veteran- centered strategies for fostering treatment engagement with the longer-term goal of improving treatment outcomes for newly returning veterans. This imperative is reflected in the mandates specified in the so-called VA Action Agenda (9) to create a system of care that is recovery-oriented and patient centered. Despite the mounting evidence suggesting that computer-mediated technologies designed to help structure and enhance patient-clinician communication can lead to improved patient health and functioning across a variety of medical conditions (10), their implementation in mental health service delivery has occurred only recently. Providing mental health clinicians with a tool to ensure delivery of mandated patient-centered care and affording veterans an opportunity to more meaningfully participate in the identification of treatment priorities will have significant impact on improving treatment engagement and related outcomes for OEF/OIF veterans.
The specific aims for this proposed two year pilot are to: 1) Modify an existing computerized structured communication tool called DIALOG to reflect the mental health treatment needs of OEF/OIF veterans and enhance implementation procedures based on principles and strategies of Cognitive Behavioral Therapy (CBT);and 2) Complete a randomized pilot for 32 OEF/OIF veterans and their mental providers to generate preliminary data supporting our hypotheses that use of the modified and enhanced DIALOG tool will: a) improve mental health treatment engagement as defined by increased likelihood of attending a subsequent mental health appointment following index use of the tool;and b) result in a decrease in veteran reported unmet needs, more positive ratings of treatment satisfaction, and improved ratings of quality of life. Methods: Our proposal includes a two-stage effort that parallels our Specific Aims. Stage One will be completed during year one and will focus on modifying and enhancing the DIALOG tool. In addition to convening multiple meetings with an advisory group of experts and OEF/OIF veterans, we will also beta-test modifications and complete interviews and focus groups with veteran and mental health provider users of the tool to evaluate acceptability and feasibility. Stage Two, completed during the second year, will involve a carefully monitored randomized pilot. OEF/OIF veterans will be randomized to either the experimental condition (defined by use of the DIALOG structured communication tool) or the control condition (defined by delivery of standard treatment without use of the DIALOG tool). Using a pre-post design over a 3-month period, outcomes assessed will include: rates of attending a subsequent mental health appointment following index use of the DIALOG tool, and veteran ratings of unmet needs, treatment satisfaction and quality of life. Impact: The development of the proposed computerized structured communication tool and innovative implementation enhancements drawing on the principles and strategies of CBT will contribute to the VA mandate to deliver patient-centered services to OEF/OIF veterans to better meet their pressing treatment needs. Providing clinicians with a simple tool to consistently and effectively delivery patient-centered mental health services could have significant impact on improving treatment engagement and related outcomes for OEF/OIF veterans.
Over 1.6 million US service members have served in the Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) conflicts, and up to 15% of them report significant mental health symptoms. Failure to engage in treatment remains a significant obstacle and one that can lead to devastating consequences including exacerbation of psychiatric symptoms, deteriorating functioning, substance abuse, and suicide. The goals of this research are to: 1) modify an innovative computerized structured communication tool designed to help deliver VA mandated veteran-centered care by ensuring that mental health providers consistently address the self-identified treatment needs of OEF/OIF veterans;and 2) evaluate the tools ability to improve rates of treatment engagement and veteran outcomes.