Psychological Services

Reducing veteran suicide is a high priority for the Veterans Health Administration (VHA). While dialectical behavior therapy skills groups (DBT-SG) may be as effective as comprehensive DBT in reducing suicide attempt, barriers and facilitators to this innovation in VHA are not well known. In preparation for a hybrid Type 1 effectiveness-implementation trial, we conducted individual semistructured qualitative interviews with 35 VHA staff (therapists, suicide prevention coordinators, local and national leaders) and identified themes using rapid qualitative analysis (Hamilton, 2013). Five themes emerged: (a) While leadership noted wanting innovative suicide prevention, (b) knowledge of DBT varied widely across respondents. (c) Implementation challenges, especially after COVID-19, included staff shortage and burnout. (d) DBT-SG may require adaptation to fit the diversity of the veteran population, including Indigenous, homeless, and urban veterans, and (e) virtual DBT-SG options hold promise for expanding reach and access and must be implemented with appropriate risk management. Enthusiasm for DBT-SG was high, and implementation challenges in a stressed health care system were noted. DBT-SG, especially delivered virtually, holds promise for VHA and will need to be implemented with attention to staffing, provider needs, and veteran diversity.

During deployments, Navy personnel have reported concerning levels of mental health symptoms, as well as suicidal ideation. Upstream efforts are needed to identify and mitigate symptoms, thereby, reducing the risk of suicide. Based on recent advances, research suggests that phone-based applications can be used to identify those at risk and facilitate treatment engagement. Toward this end, using a randomized controlled trial design, members of this study team: (a) evaluated the feasibility (application download/use and technical challenges) and acceptability (satisfaction) of the Cogito Companion phone application among a cohort of Naval personnel; (b) longitudinally characterized time to risk identification by cohort (Cogito/Active Control); and (c) identified patterns of symptoms (distress, depressive, posttraumatic, suicide-related thoughts, and mental and physical health functioning) over time and by study group. Two hundred seventy-nine Active Duty Navy personnel were enrolled and randomized, with 139 participants being randomized to Cogito and 140 to the Active Control arm. Findings suggested that those in the Cogito group were outreached more quickly than those in the Active Control group, highlighting the potential utility of employing technology to identify those at risk. However, there were significant feasibility issues in terms of implementing Cogito among Naval personnel on Active Duty. Interestingly, there were no significant differences in the proportion of serial self-report measures completed between those randomized to Cogito versus the Active Control, highlighting that, at present, implementing serial self-report measures may be a more feasible strategy to identify those at potential risk.

The high prevalence of major depressive disorder (MDD) combined with low treatment response supports continued research in this area. Electronic health records (EHR) are an important real-world data source for such MDD research, yet indicators of depression severity, a key confounder, are unreliably available. We examined the availability of depression severity indicators in the EHR and identified patient characteristics associated with having a severity indicator available for patients with an MDD diagnosis. We leveraged EHR data from academic health systems in Colorado and Utah from 2016 to 2021 to calculate the proportion of MDD encounters with a severity indicator from two sources in the EHR (diagnosis codes and Patient Health Questionnaire–9 total scores). We compared characteristics between patients with and without severity indicators using chi-square and t tests. We also estimated the proportional agreement between the two sources of severity. Among 1.55 million encounters with an MDD diagnosis from 2016 to 2021, 38% had a severity indicator available from the diagnosis code or Patient Health Questionnaire–9 total score. Availability increased from 28% in 2016 to 47% in 2021. Overall agreement was low at the MDD encounter level. Hispanic patients and those with anxiety, bipolar disorder, posttraumatic stress disorder, attention-deficit/hyperactivity disorder, and substance use disorder were more likely to have a severity indicator. While availability of depression severity in EHR data is increasing, it remains low. Researchers wanting to use depression severity data from the EHR should be cognizant of the potential impact of missing severity on their research and be cautious about using diagnosis codes and Patient Health Questionnaire–9 scores as indicators of severity in isolation.

There is a dearth of information on wellness program preferences and influencing factors among Chinese health care professionals (HCPs). This study begins to establish a foundation for wellness programming for HCPs in China, especially during public health crises. It sought to (a) examine differences in wellness program preferences across the COVID-19 pandemic phases; (b) identify wellness program patterns and preferences; and (c) explore the influence of sociodemographic and psychological factors on these preferences. One hundred eighty participants (mean age of 33.1 ± 7.8 years) were HCPs from two hospitals in China who completed a battery of measures regarding preference for wellness programs (Wellness Programming Preferences Questionnaire), psychological symptoms (Patient Health Questionnaire–9; Depression, Anxiety, and Stress Scale–21), attitudes about professional help-seeking (Attitude Toward Seeking Professional Psychological Help–Short Form), and coping styles (Simplified Coping Style Questionnaire). Findings revealed that interactive and interpersonal wellness programs were preferred consistently throughout the pandemic. Peer support outreach (53.1%) and various onsite interactive programs, including wellness programming activities (50.6%), relaxation groups (46.7%), and in-person counseling (41.1%), were among the most preferred options. Further, HCPs with higher levels of help-seeking attitudes, t(145) = 3.28, p = .001, and positive coping styles, t(154) = 2.70, p = .008, endorsed higher preferences for an array of wellness programs. Our findings underscore the importance of developing and implementing interactive and interpersonally focused wellness programs to enhance the psychological well-being of Chinese HCPs. Future research should evaluate the effectiveness of culturally sensitive wellness programs for HCPs and compare wellness programming preferences worldwide.

Medication for opioid use disorder (MOUD) is an evidence-based treatment for opioid use disorder (OUD). However, only a small proportion of eligible patients receive MOUD, due in part to access barriers and the complex medical needs of this population. Provision of MOUD traditionally occurs in ambulatory opioid treatment programs that operate separately from other providers, making it difficult to address patient needs comprehensively during health care encounters. To alleviate these barriers to continuous care for individuals with OUD, The Ohio State Wexner Medical Center designed the System-Wide MOUD (SW-MOUD) program. The SW-MOUD program has two objectives, (a) expand access to MOUD across emergency, inpatient, and outpatient settings, and (b) coordinate care for patients across these settings using integrated program staff. This article describes the SW-MOUD program implementation in order to serve as a roadmap for the creation of similar care delivery mechanisms. In the program’s first 4 years, there were a total of 4,908 MOUD initiations. The implementation tools presented in this article include a patient flow model with an overall program structure, a detailed multilevel implementation timeline, and a table of implementation strategies used across three broad phases: preparation, rollout, and sustainability. The transformation of evidence-based treatments into systematic delivery approaches offers the potential to improve patient outcomes. Our experience is informative not only for health systems seeking to increase access to MOUD in their communities but also for those looking to expand access to care for any treatment modality by coordinating care across existing system silos.

Despite the advantages of integrated care for co-occurring chronic pain and posttraumatic stress disorder (CP + PTSD), barriers impede its implementation. In this qualitative study, we examined facilitators and barriers of integrated care for CP + PTSD at a single Veterans Affairs medical center. We used purposive sampling and snowball recruitment to identify key stakeholders. We conducted semistructured interviews (N = 38) via video teleconferencing between January and May of 2022. We analyzed interview data employing both thematic and matrixed analysis methodologies. We interviewed VA staff (providers [n = 11], clinic managers [n = 5], and administrators [n = 2]) and patients with CP + PTSD (n = 19). There were three main findings: (a) current models disconnect care for CP + PTSD and fail in fully addressing the intricacies of this comorbidity, (b) the interconnection of CP + PTSD symptoms supports the need to overcome barriers to integrated treatment, and (c) facility- and system-level barriers to implementation of integrated care include staffing and having an evidence-based protocol. Staff and patient stakeholders recognized growing momentum supporting the development of integrated, nonpharmacological treatments for CP + PTSD. However, interventions to address barriers are needed to increase wider adoption and implementation.

The Intensive Community Mental Health Recovery (ICMHR) services have been established by the Veterans Health Administration to provide veterans with high-quality mental health care. This study, for the first time, evaluates the association between ICMHR service initiation and change in psychiatric symptoms among veterans, to assess the effectiveness of these services. This retrospective observational study includes veterans who enrolled in ICMHR services during October 2018–September 2021, and had a Brief Psychiatric Rating Scale (BPRS) assessment at the time of ICMHR service enrollment (baseline), and at sixth and/or 12th month after enrollment. Multivariable random-effects linear regression was used to examine the change in BPRS scores over time during the first year after ICMHR service enrollment. Changes in the five clinically relevant BPRS domains were also examined. The study found a statistically significant decrease in BPRS scores during the sixth (adjusted change = −1.6; 95% CI [−2.2, −1.0]) and 12th month (adjusted change = −2.4; 95% CI [−3.0, −1.7]) follow-up after ICMHR service enrollment, as compared with the baseline score. The study also found that ICMHR service initiation was associated with considerable improvement in BPRS domains representing affect, activation, and negative and positive symptoms, but was not associated with changes to the domain representing resistance. These results suggest that ICMHR services were potentially effective in improving psychiatric symptoms, as measured by the BPRS scores, in veterans enrolled in these services. The services were not associated with improvement in all psychiatric symptoms, potentially indicating that additional services might be needed to manage symptoms that do not improve.

The U.S. Army’s Ask, Care, Escort (ACE) suicide gatekeeper training has been the annual requirement for all personnel since 2009; however, this training has never been formally evaluated. The present study evaluated three updated versions of ACE: a training for Army leaders (ACE-Suicide Intervention), a training for basic combat trainees (ACE for Basic Combat Training and One Station Unit Training), and a standard training for all personnel (ACE for the Force). Self-report surveys measured pre- to posttraining changes in objective and subjective knowledge and stigma, as well as preparedness, self-efficacy, and likelihood to engage in gatekeeper behaviors. Implementation outcomes, such as training acceptability, suitability, and usability were also assessed. Across these evaluations, participants reported that knowledge and gatekeeper behaviors significantly improved from pre- to posttraining. Implementation metrics revealed a high degree of acceptability and relevance for all three ACE trainings. Overall, the findings of these evaluations suggest important changes in key suicide prevention outcomes following the ACE suite of trainings. Further longitudinal assessment is needed to establish the full effectiveness of gatekeeper interventions in the Army.

Counselors often grapple with a lack of confidence and self-efficacy when conducting suicide risk assessments and treating individuals at risk of suicide. We conducted an online survey involving master’s-level clinicians and students (N = 132). The survey explored the association between perceived spiritual support (independent variable) and counselor self-efficacy (dependent variable) while also investigating the moderating role of four attitude constructs: avoidance of communication, suicide as common, suicide as acceptable, and preventability of suicide. When accounting for covariates, greater perceived spiritual support was associated with higher counselor self-efficacy scores. Of the total variation in self-efficacy scores, 4.3% can be explained by perceived spiritual support. Notably, three of the attitude constructs (common, acceptable, and preventable) did not significantly moderate the relationship between perceived spiritual support and self-efficacy. However, avoidance of communication attitudes surfaced as a moderator between perceived spiritual support and counselor self-efficacy, F = 12.964, p = .001. This finding suggests that mental health professionals who hold avoidance attitudes may experience a weakened connection between their perceived spiritual support and their self-efficacy in handling suicide risk assessments. This study sheds light on the complex interplay between perceived spiritual support, attitudes toward suicide, and self-efficacy in suicide risk assessment among mental health professionals. Implications for future research and practice are discussed.

Forensic psychologists conducting competence to stand trial evaluations may be at high risk of professional burnout (i.e., feeling exhausted, cynical, ineffective) due to the ongoing increase in demand for competence evaluations. The present study assessed the degree and potential consequences of burnout among 129 forensic evaluators conducting competence to stand trial evaluations in the United States. More than half of the evaluators (56%) reported being burned out and more than one third (39%) had considered leaving their jobs due to the demand of competence evaluations. Workload demands, feeling rushed while conducting essential job functions, understaffing, and class action lawsuits in the evaluator’s jurisdiction were predictive of burnout and thoughts of job exit. These findings draw attention to the critical number of forensic evaluators experiencing burnout and the need for changes to end the cycle of understaffing, increased workload demands, burnout, and job exit.

The Practical, Robust Implementation and Sustainability Model (PRISM) was utilized to develop an assessment for improving fit between implementation context, intervention, and implementation efforts. We present findings from the PRISM assessment used in seven military to Veterans Affairs clinics implementing eScreening to improve rate and time for the completion of mental health screenings for veterans and increasing referral to mental health treatment. Questions developed by Glasgow et al. (2020) were adapted to the study context covering the PRISM domains (six items) and reach, effectiveness, adoption, implementation, and maintenance (13 items) outcomes. Assessment results were summarized for each site graphically including comments and were presented in a discussion-based action-planning meeting. Group discussion involving implementation partners and research team members, including an external facilitator, focused on identifying ways to improve the implementation of eScreening. Participants across all sites identified areas of concern related to reach, adoption, and patient expectations. Survey data and comments on these concerns drove the team discussion and identification of implementation activities, which included (a) increasing communication of the value for veteran care, (b) standardizing minimum-effort workflows, and (c) increasing buy-in and collaboration with leadership and other facility services. In this study, the PRISM assessment was used as a one-time activity to enhance implementation across military to Veterans Affairs clinics. The assessment was feasible, and discussion yielded important data on alignment and potential adaptations of the implementation efforts within the dynamically changing local context. Recommendations are provided for those interested in applying the PRISM assessment in their studies.

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

The Veterans Health Administration (VHA) has committed to increasing health equity for all veterans, which is needed to address disparities in health care and outcomes experienced by Black VHA patients. In this cross-sectional retrospective observational study, we analyzed VHA operations data on all patients receiving mental health treatment at VHA in fiscal year 2021 (N = 1,602,865). Facility-level negative binomial regressions demonstrated that Black patients were disproportionately treated at large, complex, urban facilities in the Southern United States that had higher overall volumes of mental health care and staff but lower mental health staffing ratios and less care for each patient. Though they utilized facilities with lower visits and hours per patient, Black versus non-Black patients had on average more visits and hours per patient. Accounting for these gaps using patient-level Kitagawa–Oaxaca–Blinder (KOB) decomposition analyses, we found (a) negligible and small within-facility effects, (b) between-facility effects that demonstrated that Black patients would have received more treatment than non-Black patients had they utilized facilities in the same proportions as non-Black patients, and (c) excluded variables in unadjusted KOB and excluded variables and covariates (e.g., age, homeless treatment receipt) in adjusted KOB most strongly accounted for gaps. Combining facility-level analyses with novel use of patient-level KOB revealed nuance in the potential inequities experienced by Black VHA mental health patients while demonstrating the need for additional research to examine whether Black patients receive the proper treatments for their mental health conditions and at the optimum dose.

Detecting depression in primary care patients is suboptimal, especially among historically excluded populations. To improve depression screening rates, a primary care clinic integrated the Patient Health Questionnaire (PHQ) in the Electronic Health Record (EHR) and clinical workflow. Patients completed the PHQ on a tablet in the waiting room, and responses were available in real time for staff to review with patients. This study examined implementation science outcomes using the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework 3.0. First, we calculated the percentage of patients who completed a PHQ (“Reach”). Second, we examined “Inequitable Reach” by determining if demographic characteristics were associated with the probability of not completing a PHQ. Third, we conducted 13 interviews with care team members (three physicians, five staff) and the health system’s implementation team (two practice coaches, three EHR analysts) to identify barriers to Reach. Of the 8,765 patients seen in the clinic between November 2019 through September 2021, Reach was satisfactory at 71% (6,261/8,765 completed a PHQ) but inequitable because patients who did not complete PHQ screening (n = 2,502, 29%) had higher odds of being age 65+ (OR = 1.40), Black (OR = 1.37), or had Medicaid or no insurance (OR = 1.90; all p < .001). In interviews, barriers to Reach included inefficient EHR workflow, time constraints to help patients use the tablet and check if a PHQ was completed, and lack of clarity on how to talk with patients about PHQ responses. Our findings provide a roadmap for health systems to examine whether they have Inequitable Reach in depression screening.

Health care organization leaders are charged with patient safety, evidence-based practice, financial sustainability, capacity, and staff supervision in systems that are challenged by bureaucracy, fragmentation, mistrust, and limited interdisciplinary engagement. It is not known how leaders effectively address specific challenges of staff supervision, policies/mandates, difficult conversations, and staff burnout. This study collected strategies from high-performing leaders in the Veterans Health Administration to understand how they approach these challenges. Applying a positive deviance approach to examine organizational survey data across the entire administration, we first statistically identified Veterans Health Administration sites that, based on employee feedback, showed the greatest organizational health improvements from 2022. These sites’ chiefs of staff (N = 24) were then interviewed about how they approached four specific challenges. Findings indicate commonalities across these leaders’ best practices, including creating opportunities for dialogue, building a culture of learning and psychological safety, proactively addressing process improvements, supporting work–life balance, leading with grace and courage, and maximizing and protecting resources. Public sector health care leaders may benefit from this approach to learning from these highest performers.

The Practical, Robust Implementation and SustainabilityModel (PRISM) is an implementation science framework that incorporates multilevel contextual considerations and key implementation outcomes that can be used to support program planning, implementation, and sustainment. The PRISM has been applied to diverse populations, settings, and implementation strategies. Tools to rapidly assess the PRISM’s contextual determinants of implementation success are needed to support implementation efforts. The objectives of this study were to describe the development and preliminary psychometric and pragmatic properties of the PRISM Contextual Survey Instrument (PCSI) and to demonstrate its use to inform implementation and sustainment in health care settings. The 29-item survey was developed based on refinement of existing questions, expert feedback, and pilot testing. Three to six items were included for each of the six PRISM context domains, each rated on a 5-point Likert scale. Implementors completed the PRISM survey and quantitative measures of implementation outcomes (acceptability, feasibility, and appropriateness; Weiner et al., 2017) to establish concurrent validity. Survey results were used to tailor subsequent implementation efforts. The PCSI took 14 min on average to complete. The mean overall score across participants and sites was 3.95 (SD = 0.42). The PCSI exhibited good psychometric and pragmatic properties. Internal consistency for the subscales ranged from 0.53 to 0.82, and concurrent validity with the other implementation outcomes varied from r = 0.70 (p < .001) for feasibility to r = 0.80 (p < .001) for appropriateness. Pragmatic ratings ranged from the “minimal/emerging” to “excellent” category (Lewis et al., 2021), and provided examples illustrate the practical application of the survey results for implementation.

Chronic pain and alcohol use commonly co-occur and are associated with considerable functional impairment. Many patients with chronic pain present to primary care, and integrated primary care may be well-suited to provide brief, behaviorally focused treatment. Little is known about behavioral health treatment barriers and preferences among primary care patients with chronic pain and alcohol use. Veterans enrolled in Veterans Health Administration primary care with a chronic musculoskeletal pain diagnosis and past-year alcohol use were identified via electronic medical record review and mailed a survey with measures of alcohol use, pain severity/interference, treatment preferences, and treatment barriers. Chi-square tests were used to identify statistically significant treatment preferences. Generalized linear models tested for differences in treatment barriers based on alcohol risk, and pain severity was tested as a moderator using the PROCESS macro in SPSS. Patients expressed preferences for individual, face-to-face treatment in primary care. Participants reported they were overall receptive to behavioral health treatment, with the exception of treatment for alcohol, tobacco, or other drug use. Differences based on alcohol risk were observed for readiness to change alcohol use and beliefs about the relationship between pain and alcohol. Pain severity was a significant moderator of the relationships between alcohol risk and pain readiness, beliefs about pain and alcohol, and overall alcohol treatment barriers. Treatment preferences were largely aligned with models of integrated primary care. The impact of barriers on treatment engagement may vary by a patient’s degree of alcohol-related risk, and thus a range of treatment options should be considered.

Progress toward ending the HIV epidemic has been slowed by suboptimal utilization of effective biomedical interventions (e.g., HIV testing, pre-exposure prophylaxis), especially for populations with the highest incidence. In 2021, the New York City Health Department initiated a multilevel implementation strategy, focused on promoting the GOALS Approach to Sexual History and Health—an antistigmatizing, client-centered strategy for sexual history taking—as a lever for increasing HIV intervention adoption, reach, and equity. Project Partnership to Increase Access, Client-Centered Care, and Equity in HIV Services is a community–academic implementation science partnership designed to investigate the impact of strategy enactment on implementation outcomes, including changes in intervention utilization (HIV testing, sexually transmitted infection testing, pre-exposure prophylaxis) in practice over time. This article presents preliminary implementation outcomes collected from the 19 programs (client N = 8,865) funded to adopt GOALS. Data indicate the successful enactment of systems-level strategies (infrastructure development, service mandates), program-level strategies (staff training, learning collaboratives), and provider-level strategies (utilization of the GOALS). By Quarter 5, the GOALS was being utilized in a median of 84% of visits across programs (interquartile range: 54%–97%), and GOALS utilization was positively associated with provider adoption of HIV prevention interventions in practice. Programs that struggled with implementation had less buy-in from leadership and lower commitment to provider training; programs with upward implementation trends had less experience delivering sexual health care and used a phased approach to foster support, focusing on the positive reaction to the GOALS among their clients. These data suggest that a multilevel implementation strategy focused on delivery of antistigma, client-centered sexual histories may be a potent implementation strategy for enhancing HIV prevention intervention adoption.

This explanatory sequential mixed methods hybrid Type 1 study examined the efficacy and implementation of Connect2Test, a brief motivational enhancement intervention to increase SARS-CoV-2 testing among people experiencing houselessness and people who inject drugs. We conducted a randomized controlled trial with participants randomly assigned to Connect2Test (n = 105) or services as usual (n = 100). Most participants self-identified as male (65%), White (72%), and not Hispanic (87%). There were no intervention effects on immediate testing rates, χ²(1, n = 205) = 0.23, p = .6298, OR [95% CI] = 1.18 [0.61, 2.27], or at 1-month, χ²(1, n = 205) = 0.05, p = .8263, OR [95% CI] = 0.93 [0.51, 1.72], or 2-month follow-ups, χ²(1, n = 205) = 0.04, p = .8368, OR [95% CI] = 1.08 [0.52, 2.22]. We interviewed staff and volunteers (n = 17) affiliated with our community partner to examine implementation barriers and facilitators. Barriers included (a) intervention complexity, (b) no established relationship between the interventionist and participants, (c) Connect2Test’s misalignment with priorities of people experiencing houselessness, and (d) incompatibility with community partner resources. Facilitators included (a) congruency between motivational interviewing and harm reduction values, (b) collaboration with a trusted community partner, and (c) intervention alignment with the community partner’s mission. Although Connect2Test did not increase testing rates, our qualitative assessment highlighted barriers reflecting intervention and implementation failure. Facilitators highlighted Connect2Test adaptations to enhance efficacy. Juxtaposing qualitative implementation assessments with randomized controlled trials can discern implementation and intervention factors impacting efficacy to inform redesign.

Though the implementation of science frameworks has recently been expanded to understand determinants of health equity (Woodward et al., 2021), the application of these frameworks in safety net hospital settings is new. We applied the health equity implementation framework to (a) understand the determinants of implementation and equity and (b) develop an institution-wide implementation facilitation plan for three evidence-based practices (EBPs) for posttraumatic stress disorder. We utilized researcher field notes from clinical case consultation gathered during posttraumatic stress disorder treatment implementation initiatives (cognitive processing therapy, written exposure therapy, brief skills training in affective and interpersonal regulation) at the same safety net hospital (N = 94 meetings total, from 2020 to 2023) to assess determinants of implementation and equity. We developed a qualitative codebook based on the health equity implementation framework to specify determinants and then built an implementation facilitation toolkit for multi-EBP implementation. Similar determinants were found across clinics and EBPs (e.g., provider training gaps and misperceptions about manualized treatments; inefficiencies in identification, triage, and referral pathways; patient engagement barriers related to stigma, literacy, and mistrust) with additional nuance per clinic and EBP. Institution-wide facilitation strategies were then utilized to enhance implementation and equity and focused on enhancing both access and quality of services (e.g., training and consultation, refining referral pathways) and patient engagement (e.g., culturally responsive training, consultation, and treatment delivery). Implementation science has an important role to play in enhancing health equity. Our findings illustrate how pooling determinants across clinics and treatments can help implementation scientists engage with hospital leadership and advocate for system-level implementation facilitation strategies.

Women veterans (WV) present to Veterans Health Administration with mental health and medical treatment needs that differ from men and civilian women. Primary Care-Mental Health Integration (PC-MHI), which provides short-term, evidence-based mental health care, is often the first point of mental health assessment and intervention for veterans. Little research exists on gender-specific care, procedures, and impact for WV in PC-MHI, and many mental health providers feel ill-trained to address WV-specific concerns. This project aimed to identify the unique mental health necessities of WV within PC-MHI as compared with men, to support Veterans Health Administration Directive 1330.01 regarding providing gender-specific care, cultural competence among mental health providers, and underresearched areas for further exploration to make a valuable contribution to the mission of PC-MHI regarding training, education, and implementation of gender-specific procedures. Using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, nine sources published between 2005 and 2023 were included. Results were organized by gender comparisons, gender-specific care in PC-MHI, and mental health for WV. Preliminary sources indicate that WV present to PC-MHI with nuanced mental health concerns and utilize PC-MHI more than men. Subsequently, PC-MHI has promising potential to address gender-specific needs for WV. This review highlights the need for adaptation in mental health screening for WV in periods of increased mental health risk (e.g., postpartum) and across the lifespan. Findings emphasize the need for additional research on WV needs and gender-specific care in PC-MHI, as well as increased provider training, and establishment of evidence-based clinical guidelines and policies for WV in PC-MHI.

Veteran suicide is a public health crisis. Suicide rates for U.S. veterans have remained disproportionately higher than their nonveteran counterparts during the last 2 decades (White House, 2023; U.S. Department of Veterans Affairs, Office of Mental Health and Suicide Prevention, Community-Based Interventions for Suicide Prevention, 2022). Additionally, the majority of veterans who die by suicide are not engaged in care from the Veterans Health Administration (U.S. Department of Veterans Affairs, Office of Mental Health and Suicide Prevention, 2023). Veterans Health Administration’s Suicide Prevention 2.0 (SP 2.0) was developed to address this problem through a combination of clinical and community-based efforts that form a comprehensive public health approach for veteran SP (Carroll et al., 2020). In this article, the authors briefly outline the national, regional, and local program development of VA’s Community-Based Interventions for SP within SP 2.0. Then, they describe local-level program development and implementation of the Community Engagement and Partnership Coordinators. Community Engagement and Partnership Coordinators are tasked with developing and facilitating coalitions with local agencies and organizations aimed at reducing suicide risk among service members, veterans, and their families. The authors review the implementation of this program from 2020 to 2024 and then suggest directions for future program evaluation and research on the impact of this approach in preventing veteran suicide.

Department of Veterans Affairs (VA) clinicians are at elevated risk of patient suicide loss due to the high rates of suicide in the veteran population. Clinician support structures and administrative procedures following patient suicides vary widely across facilities. The present study examined how mental health clinicians’ experiences vary according to institutional responses to patient suicides. The authors disseminated an online survey to clinicians at 15 VA sites. Institutional responses such as supervisory support, postvention support services, and administrative postsuicide procedures were examined in relation to the clinicians’ emotional and professional practice outcomes. The multidisciplinary sample included 87 licensed mental health providers who had experienced a VA patient suicide. Most were experienced clinicians (licensed for 6 or more years) who worked daily to weekly with patients who were suicidal. After their patient’s suicide, over half of the participants reported self-doubt about their competency. Nearly three quarters of respondents reported changes in professional practice such as hypervigilance to suicide cues and an increased focus on documentation. Participants consistently described formal postvention supports and collegial outreach as constructive and helpful; however, experiences with supervisor outreach varied. Clinicians who experienced formal retrospective case reviews were more likely to report feeling blamed for the suicide, lengthier periods of emotional distress, reduced willingness to work with suicidal patients, and consideration of leaving their position. Strategic postsuicide procedures that include emotional and instrumental support for clinicians as well as thoughtful, nonblaming retrospective review policies may reduce negative clinician outcomes related to patient care and staff burnout and turnover.

Written exposure therapy (WET) is a brief psychotherapy for posttraumatic stress disorder (PTSD). Although WET is designed to be delivered in five sessions, implementation data collected from trained mental health care providers suggest that therapists sometimes add more sessions without sufficient justification. We conducted a mixed-methods examination to understand why therapists added WET sessions and whether adding sessions improved treatment outcomes. Participants were drawn from a larger trial where therapists were permitted to deliver five to seven WET sessions. This study included 77 client participants who were randomly assigned to receive WET and nine therapist participants who delivered WET during the trial. Results showed that PTSD symptom severity trajectories at follow-up assessment were not significantly different between client participants who received five sessions and those who received more than five. Only 15.7% of participants who received supplemental WET sessions displayed a clinically meaningful reduction in PTSD symptom severity, while 11.8% displayed a clinically meaningful increase in PTSD symptom severity. Qualitative interviews with therapists indicated that their decision to add sessions was largely driven by the client avoiding writing about the traumatic event in early treatment sessions or due to a very complex or lengthy traumatic event that required additional sessions to provide repeated exposure to the trauma memory. Taken together, the findings suggest that adding WET sessions is unnecessary most of the time, but therapists have a strong preference for having flexibility in adding treatment sessions.