Steve Martino’s research while affiliated with Yale-New Haven Hospital and other places

Objective Dialectical behaviour therapy (DBT) is an evidence‐based psychological intervention (EBP) for reducing suicide behaviour. While DBT, like many EBPs, was developed and first evaluated in largely white samples in Western contexts, it is now broadly applied. This review assessed how DBT has been adopted or adapted when used with patient populations with minoritised identity constructs. Methods We conducted a PRISMA‐guided scoping review of articles using DBT with a minoritised patient population. We used an implementation science framework, Framework for Reporting Adaptations and Modifications‐Enhanced, to characterise adaptations to the content and context of DBT application. Through PubMed, Embase and PsycINFO, we identified 273 articles where the title or abstract mentioned DBT and described a minoritised adult patient population. Principle Findings We found 83.5% (228/273) articles reviewed reported adaptations to DBT content. Specifically, 66.3% (181/273), 44.6% (122/273) and 39.6% (108/273) of articles described reducing, expanding or changing DBT content, respectively. We found that 42.1% of articles (115/273) reported adaptations to the DBT context. Moreover, 57.5% of content adaptations and 65.3% of context adaptations did not specify a reason for adaptation. Conclusions This scoping review indicates that the majority of articles of studies using DBT with patients with minoritised identity constructs made adaptations to DBT, but few provided justification for these adaptations. We encourage clinicians and clinical administrators, researchers and policymakers to document adaptations and justifications thereof, and evaluate clinical and implementation outcomes.

To supplement the mental health programming offered to women veterans within the Veterans Health Administration, a retreat-based suicide prevention program could foster healing through social connection and holistic health. However, no study has investigated retreat-based suicide prevention program components relevant for violence-exposed women veterans. To address this gap, we conducted focus groups with women veterans and semi-structured interviews with interdisciplinary subject matter experts to examine perceptions, beliefs, concerns, and preferences related to a retreat-based suicide prevention program for women veterans. Emergent themes included interest and appeal, concerns about program execution, and program preferences. Findings suggest that both women veterans and experts agree that a retreat-based suicide prevention program for women veterans is a promising and welcomed prevention strategy that may reduce suicide risk. Both interest groups emphasized that programming should be trauma-informed with training for program facilitators and attention to group dynamics.

Background Preventing veteran suicide requires addressing mechanisms driving suicidal behavior, such as emotion dysregulation. Dialectical Behavior Therapy Skills Groups (DBT-SG) are well established for reducing emotion dysregulation, improving coping skills, and in some studies, reducing suicide attempt, but will require implementation support to deliver DBT-SG and to test its effectiveness within the Veterans Health Administration (VHA). Methods We conducted a mixed-method developmental formative evaluation of DBT-SG at four VHA medical centers, guided by the Integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework, as part of a hybrid effectiveness-implementation trial (Clinical trials ID, NCT05000749). Results Quantitative Organizational Reasons for Change Assessment data (n = 30 VHA staff) and qualitative data (n = 35 VHA staff) were merged, compared, and triangulated. Quantitative and qualitative data largely converged, showing favorable views of evidence supporting DBT-SG and strong enthusiasm for its potential to reduce veteran suicide attempt. Staff noted DBT-SG’s broad applicability to veterans. Staff were less optimistic about the inner context supporting DBT-SG implementation, commenting on how limited staffing could be a barrier despite leadership wanting to support suicide prevention. Conclusions Implementation barriers to DBT-SG at VHA include limited staffing, despite staff enthusiasm. The next phase of this project will evaluate DBT-SG effectiveness in a randomized controlled trial. Clinical trials registration https://clinicaltrials.gov/study/NCT05000749, identifier NCT05000749.

Objective The COVID-19 pandemic had profound effects on society, including those living with chronic pain. This study sought to examine pandemic impacts on individuals enrolled in pragmatic clinical trials focused on nonpharmacological treatments for chronic pain. Methods We evaluated responses to a questionnaire on COVID-19 impacts that had been administered to participants (n=2024) during study enrollment in 3 pragmatic clinical trials for chronic pain treatment. All trials were part of the National Institutes of Health (NIH)–Department of Veterans Affairs (VA)–Department of Defense (DOD) Pain Management Collaboratory. COVID-19–related impacts on access to health care, mental health, finances, ability to meet basic needs, and social support were assessed. Results Pandemic impacts were found in all domains assessed, including access to health care, mental and emotional health, ability to meet basic needs, finances, and social support. Impacts varied by demographic and clinical characteristics. The participants most negatively impacted by the pandemic were younger, Black or Latino, female, more educated, and unemployed and had screened positive for depression. No impact differences were found with regard to alcohol use disorder screenings or a prior history of COVID-19. Higher levels of pain were associated with worse pandemic impacts, and negative impacts declined over time. Conclusions Negative impacts of the pandemic on individuals living with chronic pain cut across aspects of life that are also central to effective pain management, including access to health care, social support, and mental and emotional health, with differential impacts found across key demographic and clinical factors. These findings should yield consideration of pandemic impacts in clinical practice and as moderating effects of treatment outcomes in clinical trials conducted during the pandemic.

Background Veterans transitioning to civilian life often have chronic pain from service-related musculoskeletal disorders (MSD) with higher risk for substance misuse. Many seek VA (Department of Veterans Affairs) compensation for MSD. Use of Screening, Brief Intervention, and Referral to Treatment for Pain Management (SBIRT-PM) by VA Post-9/11 Military2VA (M2VA) case managers presents an opportunity to engage these veterans in VA pain care and address substance misuse. Implementation facilitation might help case managers use SBIRT-PM and engage veterans in services to improve outcomes. Design This study is a 2-cohort multisite cluster-randomized hybrid type 2 effectiveness-implementation trial. Within 2 separate cohorts of 14 VA sites each, sites will be allocated to receive an implementation strategy through the use of a constrained randomization procedure: virtual implementation facilitation or training-as-usual. Sites and M2VA case managers will receive the assigned implementation strategy to support use of SBIRT-PM. Recently discharged veterans (n = 1848) claiming service-connected MSD will be recruited, with case managers blind to veterans’ study enrollment. The proportion of participants who receive any SBIRT-PM will be the primary implementation outcome. Veteran participants will complete baseline, 12-week, and 36-week assessments, irrespective of whether case managers conduct SBIRT-PM with them (intent-to-treat). Pain intensity and interference will be the primary clinical outcomes. The study emphasizes pragmatic over explanatory methodological features. Summary This pragmatic trial will examine implementation facilitation versus training-as-usual in implementing SBIRT-PM to promote veteran engagement in nonpharmacological pain services. Using innovative methods to train and support VA case managers in SBIRT-PM, study outcomes could have broad implications for case management systems of care across the VA.

Among persons with HIV (PWH), unhealthy alcohol use and polypharmacy contribute to bothersome symptoms (e.g., fatigue, dizziness, memory loss). However, effective risk communication targeting these associations is challenging. The HIV and Alcohol Research center focused on Polypharmacy (HARP) is conducting a pilot study that will generate feasibility and acceptability data on a clinical pharmacist-delivered counseling intervention targeting the modification of unhealthy alcohol use and polypharmacy in PWH. Counseling is guided by the Information-Motivation-Behavioral Skills-Motivational Interviewing (IMB-MI) model. Herein, we describe the study protocol. This pilot uses a one-group pre-test/post-test design. We will recruit 50 participants from those who participated in the consented cohort of the Veterans Aging Cohort Study. Participants must be prescribed ≥ 5 long-term medications, have a self-reported Alcohol Use Disorders Identification Test score > 0, and be living with HIV. We will exclude those with moderate-severe alcohol use disorder as identified by an Alcohol Symptom Checklist score ≥ 4. Data are collected using three self-administered surveys (baseline, immediately after booster intervention, and 30-days post-intervention), two PEth blood tests (baseline, 30 days post-intervention), and medication data from the electronic health record (baseline). The intervention includes a 60-minute IMB-MI-based counseling session followed by a booster session 2 weeks later. Some participants will also be asked to participate in a qualitative interview to provide feedback on the intervention. The pilot investigates the impact of an intervention on alcohol consumption and the use of multiple medications among PWH, exploring how best to reduce bothersome symptoms, communicate risk, and support behavior change in this population.