Convenient Primary Care Reduces CV Risk Factors in Mentally Ill

by U.S. Medicine

September 6, 2012

Cardiovascular disease risk factors often are comorbid with serious mental illnesses (SMI) such as schizophrenia, schizoaffective disorder and bipolar disorder, yet these patients often don’t receive necessary care for those chronic conditions.

In fact, veterans with SMI have fewer medical visits than other VA patients, primarily seeking care for mental-health conditions rather than physician conditions. That led to efforts to provide primary-care services in the mental-health setting, according to a new study that documented the effectiveness of such a system.1

The study, “Benefits of a Primary Care Clinic Co-located and Integrated in a Mental Health Setting for Veterans with Serious Mental Illness,” was conducted by researchers from the Providence, RI, VAMC and published earlier this year in the Preventing Chronic Disease journal by the national Centers for Disease Control and Prevention.1

The authors noted that past efficacy trials have shown that medical care improved when primary care services were co-located in the mental-health setting and sought to find out if that was also the case for control of cardiovascular risk factors.

Using targeted chart review, they looked at two successive six-month periods in the year before and in the year following enrollment in the co-located primary-care clinic, identifying primary care and emergency department usage. They also took note of blood pressure levels, fasting blood lipids, body mass index (BMI) and, among patients with diabetes, hemoglobin A1c (HbA1c).

Compared with the period before enrollment, the 97 veterans enrolled in the clinic had significantly more primary-care visits over the second six-month period and had significantly improved goal attainment for blood pressure, low-density lipoprotein cholesterol, triglycerides and BMI. No significant changes were seen in reaching goals for high-density lipoprotein cholesterol and HbA1c.

“Co-location and integration of primary-care services in the mental-health setting is an innovation that may reduce some of the barriers to delivery and receipt of high-quality medical care among patients with SMI,” the authors noted, concluding, “Enrollment in a co-located, integrated clinic was associated with increased primary-care use and improved attainment of some cardiovascular risk goals among veterans with serious mental illness.”

  1. Pirraglia PA, Rowland E, Wu WC, Friedmann PD, O’Toole TP, Cohen LB, Taveira TH. Benefits of a primary care clinic co-located and integrated in a mental health setting for veterans with serious mental illness. Prev Chronic Dis. 2012 Feb;9:E51. Epub 2012 Feb 2. PubMed PMID: 22300871; PubMed Central PMCID: PMC3340211.

Survey Looks at Violent Behavior in Returning Veterans

What U.S. military veterans are at the greatest risk of demonstrating aggression when they return home, and how can the likelihood of violence be decreased among that group?

That is a question researchers from the Durham, NC, VAMC and the University of North Carolina at Chapel Hill sought to answer in a recent study.1

Based on a national survey, the study examined protective factors that are important in preventing violence, including employment, meeting basic needs, living stability, social support, spiritual faith, ability to care for oneself, perceived self-determination and resilience. Researchers found that veterans with these advantages were 92% less likely to report severe violence than veterans without.

“When you hear about veterans committing acts of violence, many people assume that post-traumatic stress disorder (PTSD) or combat exposure are to blame,” said Eric B. Elbogen, PhD, VA psychologist and research director of the Forensic Psychiatry Program at UNC. “But our study shows that is not necessarily true.”

In fact, the survey found that veterans who didn’t have enough money to cover basic needs were more likely to report aggressive behavior than veterans with PTSD. Other factors important to understanding violence potential were found to be alcohol misuse, criminal background, as well as veterans’ living, work and social circumstances.

“Our study suggests the incidence of violence could be reduced by helping veterans develop and maintain protective factors in their lives back home,” Elbogen said.

The survey included responses from 1,388 veterans who served in the Iraq and Afghanistan War era and theater after Sept. 11, 2001, and represented all military services and all 50 states. Study results were published this summer in the Journal of Clinical Psychiatry.

Minor aggressive behavior was reported by one-third of survey respondents, but 11% of the sample reported more severe violence.

“Although the majority of study participants did not report aggression, the potential for violence does remain a significant concern among a subset of returning veterans,” Elbogen noted.

  1. Elbogen EB, Johnson SC, Wagner HR, Newton VM, Timko C, Vasterling JJ, Beckham JC. Protective factors and risk modification of violence in Iraq and Afghanistan war veterans. J Clin Psychiatry. 2012 Jun;73(6):e767-73. PubMed PMID: 22795217; PubMed Central PMCID: PMC3399731.
Convenient Primary Care Reduces CV Risk Factors in Mentally Ill

Veterans Who Have Killed During War More Likely to Consider Suicide

Having killed someone during a war is strongly associated with suicidal ideation and should be considered when evaluating a veteran’s mental-health status, according to a recent study of Vietnam-era veterans.1

Researchers at the San Francisco VAMC and the University of California, San Francisco, found that veterans with more experiences involving killing were twice as likely to have reported suicidal thoughts as veterans who had fewer or no experiences.

For the study, investigators created four variables:

  • killing enemy combatants,
  • killing prisoners,
  • killing civilians in general and
  • killing or injuring women, children or the elderly.

A single composite score was developed for each veteran, and researchers found that the higher the score, the greater the likelihood that a veteran had considered suicide.

That relationship held, even after adjusting for variables such as post-traumatic stress disorder (PTSD), depression, substance-use disorders and exposure to combat.

The VA-funded study, published electronically this past spring in the journal Depression and Anxiety, used data from the National Vietnam Veterans Readjustment Survey, a comprehensive study of a nationally representative sample of Vietnam-era veterans.

“The VA has a lot of very good mental-health programs, including programs targeting suicide prevention. Our goal is to make those programs even stronger,” said lead author Shira Maguen, a clinical psychologist at the San Francisco VAMC and an assistant clinical professor of psychiatry at the University of California, San Francisco, campus. “We want clinicians and suicide-prevention coordinators to be aware that in analyzing a veteran’s risk of suicide, killing in combat is an additional factor that they may or may not be aware of.”

The only variable with a significant link to actual suicide attempts was PTSD; therefore, the link between having killed someone and suicide attempts was not as significant as the link between having killed someone and suicidal thoughts.

Maguen noted in a university press release that the mental-health impact of killing is neither formally evaluated as part of VA or DoD mental-health treatments nor usually considered when assessing suicide risk.

“We know from our previous research how hard it is to talk about killing,” she noted. “It’s important that we as care providers have these conversations with veterans in a supportive, therapeutic environment, so that they will feel comfortable talking about their experiences.”

The authors concluded, “Killing experiences are not routinely examined when assessing suicide risk. Our findings have important implications for conducting suicide risk assessments in veterans of war.”

Back to September Articles

1.    Maguen S, Metzler TJ, Bosch J, Marmar CR, Knight SJ, Neylan TC. Killing in
Combat May Be Independently Associated with Suicidal Ideation. Depress Anxiety.
2012 Apr 13. doi: 10.1002/da.21954. [Epub ahead of print] PubMed PMID: 22505038.

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