Background: Veterans have high rates of psychological symptoms and adjustment problems that trouble them, but many go without professional mental health care due to stigma, logistical challenges, and a high value on self-sufficiency. The number of such Veterans is expected to increase in the next two decades as the proportion of Veterans who served in recent wars increases. To meet Veterans' mental health needs, VHA has invested resources in developing evidence-based, computerized self-help tools. Such online tools can be effective if people use them, but many of the tools do not have strong strategies for engaging Veterans to use them. VHA has also funded a peer support (PS) program aimed at improving engagement in MH care, yet there is little empirical data on how peer support can improve Veterans' psychological health. Combining online tools with peer coaching could leverage the unique strengths of these complementary resources to improve VHA mental health care and improve the overall health of the Veteran population. Use of a VHA-DOD developed online problem-solving training called Moving Forward (MF) has been found to improve problem- solving skills and improve mental health in Veterans preliminary studies, but its use has not yet been studied in VHA primary care patients with clinically significant symptoms. Similarly, preliminary research on PS for an online mental health program has shown an impact on use of the program, but no RCT has been conducted. Research Goals: The overall goal of this research program is to improve mental health care in Veterans by increasing the availability of mental health care that is non-stigmatizing and easily available to Veterans who have untreated mental health problems, but choose not to seek or accept face-to-face VHA mental health care services.
The specific aims of this pilot study are preparatory to a large-scale RCT to test the effects of MF with and without peer support on two populations of Veterans who have untreated mental health problems.
Aim 1 : Test feasibility and acceptability of recruitment and data collection strategies to study MF + PS in two populations of Veterans with unmet mental health needs.
Aim 2 : Obtain preliminary efficacy results on the impact of MF and MF+PS on problem-solving skills and psychological health in Veterans with unmet mental health needs. Methods: This pilot study aims to investigate the feasibility and acceptability of methods to study the impact of the online problem-solving training, Moving Forward, with and without peer support, in Veterans with untreated mental health problems. We will study 60 VHA primary care patients who are referred for mental health treatment but decline or do not attend a mental health intake session and 60 Veterans living in the community who have untreated mental health problems. We will adapt an existing guide for peer support for an online mental health program for use with MF, train a PS to support use of MF, and monitor fidelity to the guide throughout the study. All who agree to enroll will be referred to a study website, where they will be screened, provide informed consent, and complete baseline assessments of problem-solving skills and psychological health, which will include measures of quality of life, depression, anxiety, and PTSD. Participants will then be randomized to one of 3 conditions: a no-treatment control group, MF, or MF+PS. Participants in the two active intervention groups will be asked to complete the 8 MF modules over 4 weeks and spend an additional 4 weeks using MF. Mid-point and end-of-program assessments of problem-solving and psychological health will be completed, and use of the MF intervention will be objectively measured through the web site. Several indicators of feasibility and acceptability will be assessed to inform a large-scale RCT. User satisfaction, qualitative data on barriers and facilitators to use of MF and PS, and perceptions of usefulness of MF and PS will also be assessed. If results are encouraging, they will be disseminated and a Merit grant application for a large-scale RCT will be developed.
The population of Veterans with mental health (MH) care needs is large and is projected to continue growing for another 15 years, but many of these Veterans go without care due to stigma, logistical challenges, and a high value on self-sufficiency. VHA has developed online, evidence-based, interactive programs aimed at fostering MH that may be more acceptable than psychotherapy and has established a peer support program, but these programs have not been the focus of rigorous research. If an online program can improve MH and peer support can boost the program's use and effectiveness, peer support staff could be trained to coach a range of already available programs and deliver MH care to Veterans who decline other MH care. Results of this pilot study of feasibility and acceptability would inform a larger study of the impact on problem-solving and psychological health of a non-stigmatizing, online program - with and without peer support. If effective, peer supported online programs would improve the quality of care to Veterans with unmet MH needs.
